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Listening to Consumer Perspectives to Inform Addictions and Housing-Related Practice and Research

Listening to Consumer Perspectives to Inform Addictions and Housing-Related Practice and Research by  Stephanie A. Farquhar, Marianne Ryder, Derek Henderlong, Robert A. Lowe, and Ted Amann

Author: Stephanie A. Farquhar, Marianne Ryder, Derek Henderlong, Robert A. Lowe, and Ted Amann

Abstract:

Stephanie A. Farquhar, Marianne Ryder, Derek Henderlong, Robert A. Lowe, and Ted Amann

The study, funded by the Northwest Health Foundation of Portland, Oregon and the National Institute on Drug Abuse (NIDA), was conducted as part of the HEARTH collaborative (Housing, Employment and Recovery Together for Health). HEARTH, established in 2010, is a community-academic partnership involving partners from Portland State University (PSU), Oregon Health and Science University (OHSU), and Central City Concern (CCC). Using the approaches of community-based participatory research (CBPR), these diverse stakeholders collaborated to co-develop research of direct relevance to the local community and to national academic and policy communities.

This study employed qualitative methods and community-based participatory research principles to solicit personal experiences with housing, employment, and recovery programs. We recruited interview participants via CCC-operated housing programs, including Alcohol and Drug Free Community Housing (ADFC), family housing, transitional housing, and non-ADFC (low barrier) housing units. The manuscript presents interview themes based on the five broad categories of interview questions: housing, employment programs, recovery programs, definitions of recovery, and definitions of success. Co-authors describe recommendations for practice and research protocol based on our findings. Our results highlight the importance of involving consumers in the development, data collection, and analysis of research, and present the unique perspectives of those who experience homelessness, recovery, and the programs designed to assist them.


Article:

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In the homelessness and addictions recovery literature, few research studies develop the data collection protocol and interpretation of research results with input from those who are experiencing homelessness or recovery (Coles, Themessl-Huber, & Freeman, 2012). This study was unique in that we worked closely with individuals who had accessed homelessness or recovery programs in order to identify the best data collection methods to solicit personal experiences with housing, employment, and recovery programs. We collected this information, along with definitions of “recovery” and “success” from among individuals who were in recovery and/or formerly homeless (referred to as consumers). First, we summarize the most relevant methods and results from past community-driven research studies with homeless or recovering individuals. Second, we describe our study with 16 individuals who accessed the homelessness and recovery programs of Central City Concern in Portland, Oregon. Study findings present the unique perspectives of those who experience homelessness and recovery, and highlight the importance of including their voices in the development of research and programs designed to serve them.

Community-based Participatory Research among Homeless and Recovering Population
Community-based participatory research (CBPR) scholarship draws attention to the distinction between community-placed (research conducted in a community or with community subjects) versus community-based or community-driven (research that is conducted in a power-sharing partnership between community and researchers) (Minkler & Wallerstein, 2008). The principal goal of CBPR is to apply knowledge and understanding of a given phenomenon to transform interventions and policy designed to create healthier conditions (Israel, Schulz, Parker, & Becker, 1998). A search of the literature conducted in consult with library faculty using MEDLINE, PsycINFO, Social Services Abstracts, and Web of Science revealed very few studies conducted with a truly CBPR approach that was grounded in shared decision-making and of equal benefit to all partners. Yet, search results suggested that some level of participation of homeless and recovering individuals in research programs can improve the quality and relevance of health promotion programs (Nyamathi et al., 2004).

Of the articles reviewed that drew upon CBPR principles, four addressed issues of homelessness and housing and included homeless individuals as members of the research team (Henwood et al., 2013; Greysen, Allen, Lucas, Wang, & Rosenthal, 2012; Greysen, Allen, Rosenthal, Lucas, & Wang, 2013; Nyamathi et al., 2004). Two of these studies described the procedures followed during discharge from a medical facility and transition to a shelter. Interviews with the discharged patients suggested that hospital providers should consider housing as a health concern (Greysen et al., 2012; Greysen et al., 2013). Over half of the interview respondents (56%) were not asked about their housing status upon discharge and data revealed patient concerns about stigmatization from disclosure of housing status (Greysen et al., 2013). Another study noted a lack of hospital-shelter communication and coordination that would help to place discharged patients into safe housing (Greysen et al., 2012).

In a third qualitative and CBPR study regarding homelessness, Henwood et al. reported the results from interviews with 15 tenants of a “housing first” program about management of chronic disease. Recommendations included the need for integrated services in addition to housing and a call for participatory methods to engage tenants in decision-making (Henwood et al., 2013). In the fourth study, Nyamathi et al.’s focus groups with homeless and low-income adults in Los Angeles investigated participation in HIV vaccine trials. Results highlighted the need for researchers to hear and address community concerns early in the research process in order to address distrust of government and funded research (Nyamathi et al., 2004).

The literature search for CBPR studies uncovered even fewer studies on addictions recovery and employment among homeless individuals. In the four databases searched, we identified two CBPR studies focused on addictions recovery and employment (Nyamathi et al., 2011; Rebeiro, Kauppi, Montgomery, & James, 2012). A study with 24 homeless young adult participants looked at the efficacy of art messaging to communicate the dangers of drug and alcohol use. Results of focus groups indicated that participants respond to messages that reinforce protective factors in addition to information about risks and consequences of drug use, and prefer content that is “personal, real, and truthful” (Nyamathi et al., 2011, p. 14). Rebeiro et al.’s research in Ontario examined employment as a contributing factor in recovery. Interview data emphasized the importance of collaborative partnerships between consumers, researchers, and service providers in an effort to create effective employment programs and improve health outcomes (Rebeiro et al., 2012).

In a separate and secondary review of literature, we searched for qualitative projects (removing “CBPR” as a search term) with homeless and recovering populations and found that qualitative methods varied widely with this population. Eight studies conducted semi-structured in-depth interviews; one analyzed secondary interview data previously conducted for a different study (Dodington et al., 2012); and one simply described “conducting interviews” (Nettleton, Neale, & Stevenson, 2012). Dashora, Slesnick, and Erdem (2012) conducted focus groups with homeless or recovering individuals. Two studies (Dordick, 2002; Stanhope, 2012) included participant observation along with the structured interviews, and one study (Dordick, 2002) included structured site visits.

One notable methodological consistency is that the interviews for the studies were conducted by researchers, generally including one or more of the article authors, research staff, graduate students, or paid interviewers. Only one study included interviews that were conducted by the consumers themselves, or the consumers accessing the housing or addictions programs (Lincoln, Plachta-Elliott, & Espejo, 2009). A summary of the reviewed studies suggests that intervention and program development for homeless and recovering individuals should: 1) allow homeless individuals to engage with and shape programs; 2) integrate psychosocial and lifestyle needs into programming, such as employment programs, housing and social support activities; and 3) tailor programs and services to fit individual needs.

The study presented here fills a gap in the literature by offering an alternative model for conducting qualitative research on homelessness and recovery in that the consumers co-developed the interview protocol and questions, conducted the interviews, and assisted with analysis and interpretation of interview transcripts. Given the dearth of qualitative and CBPR projects that truly partner with homeless and recovering individuals, the primary aim of this manuscript is to contribute to the limited literature on the methods used in consumer-driven studies and to increase our knowledge of consumer experiences. The primary research goals guiding this study included: 1) To understand how consumers describe “success” and “recovery” in their own words and using their own examples, and 2) To learn about the strengths and challenges of CCC programs and services from the consumers’ perspectives.

HEARTH: Community-based Partnership
HEARTH, established in 2010, is a community-academic partnership among partners from Portland State University (PSU), Oregon Health and Science University (OHSU), and Central City Concern (CCC). CCC is an internationally recognized organization that provides housing, employment, recovery and health-related services for persons experiencing homelessness or at risk of homelessness. Guided by the principles of CBPR, these diverse stakeholders collaborated to co-develop research of direct relevance to the local community and to national academic and policy communities. The primary objectives of HEARTH include: to build the research-community partnership, to develop the capacity for research at Central City Concern, and to better understand the interaction of factors that impact homelessness and the recovery process.

The impetus for this study grew out of the expressed interests of CCC staff and consumers. From 2011-2012, HEARTH project team members facilitated a series of meetings that involved other CCC staff, CCC consumers, and academic researchers. Through these meetings, the team gained the perspective of staff and consumers on drug and alcohol programs, housing, economic stability, social support and health. Less known was the way consumers defined and conceptualized success and recovery as they progressed through CCC programs. We agreed that additional qualitative information about consumers’ perspectives would help to inform local and national practices and policy.

Methods
This study, funded by the Northwest Health Foundation of Portland, Oregon and the National Institute on Drug Abuse (NIDA, grant #1RC4DA029988), was conducted as part of the HEARTH  collaborative (Housing, Employment and Recovery Together for Health). To assist with the project, two community research assistants (CRAs) were interviewed and hired from a group of CCC consumers who participated on the HEARTH consumer advisory board, a group established to guide HEARTH research projects. We selected the CRAs based on their first-hand experiences with CCC programs, their ability to work in a culturally competent and confidential manner, and their expressed interest in research and qualitative interview methods. The CRAs worked with project researchers and CCC staff to develop in-depth interview questions, recruit, schedule, and conduct interviews, and to assist with transcript analysis. The CRAs participated in a three-hour training facilitated by the research partner. Training covered interviewing skills, methods to reduce respondent bias, research ethics and confidentiality, and included time to practice asking, and being asked, the in-depth interview questions.

Sample
The CRAs and CCC caseworkers recruited interview participants via CCC-operated housing programs, including Alcohol and Drug Free Community Housing (ADFC), family housing, transitional housing, and non-ADFC (low barrier or “housing first”) housing units. In keeping with standard qualitative data collection protocol, the number of participants interviewed was determined by two aims: (1) to include interviewees who are representative of the general CCC community in demographics and service experience, and (2) to interview a sufficient number of study subjects to achieve saturation. “Data saturation” in qualitative research refers to the point at which data collection produces no new information and the researcher stops collecting new data. We recruited participants who represented over a dozen different housing, health, recovery, and employment programs because one of the primary goals of the interviews was to learn about a diversity of experiences from a range of programs and services. The criteria used to identify the 16 consumer participants required that they had participated in at least two CCC programs or services and had participated in these programs or services for at least six months in the past two years. (Table 1 describes these CCC housing, employment, and recovery programs). Among the 16 participants, with roughly equal numbers of men and women, several participants had lived in more than one type of CCC housing and at least one person had lived in housing offered by another organization. The average age of the 16 interview respondents was 46 years.

Interview Protocol
Interviews were conducted between June-July 2012 at a CCC building or at a neutral location in downtown Portland as agreed upon by the interviewer and consumer. Before beginning the interview, CRAs described to the participants the purpose of the study, categories of interview questions, the benefits and risks of participation, and offered each participant a $25 gift certificate. Interviews lasted between 30 to 60 minutes, and were taped with permission and transcribed. Portland State University’s Human Subjects Research Review Committee approved interview questions and recruitment protocol.

There were five broad categories of interview questions: housing, employment programs, recovery programs, definitions of recovery, and definitions of success. Question categories and wording were guided by three sources: 1. the research goals described previously (e.g., to learn about consumers’ assessment of services and programs), 2. the review of literature that suggested that the strongest programs are integrative and tailored to consumer needs, and 3. input from the CRAs. Specifically, CRAs brainstormed with the co-authors general categories of inquiry and then helped the lead author refine interview questions to ensure they were clear and appropriate. Some of the questions included: 1. What were your goals when you first started the program (employment, housing, or recovery), 2. How did the program help you to meet your goals, 3. What are the barriers someone might face trying to finish the program, 4. What does “success” look like, and 5. How do you define “recovery”? Participants also provided recommendations for strengthening access or program implementation.

Analysis
The team used thematic analysis to review interview data and identify patterns of responses (Braun & Clarke, 2006). Thematic analysis involves reviewing transcripts, becoming familiar with the data, identifying patterns in the data, and then developing themes based on those patterns. Themes are ideas that occur numerous times across transcripts or data sets. In the research presented here, for example, one theme was the importance of integration of recovery, employment, and housing services. Co-authors performed an initial reading of the interview transcripts, named patterns and developed a preliminary coding scheme. At this point, we met to discuss the codes, refined code categories, and identified themes across interviews. The first author, with assistance from the co-authors, prepared and presented summary results at two HEARTH Advisory Committee meetings and invited responses to the results from CCC consumers, staff, and academic researchers. This method of member checking, or sharing results and soliciting responses, is common in CBPR projects and can strengthen the accuracy of data analysis (Patton, 2002). In the next section, we present the main themes from the 16 in-depth interviews, along with participants’ quotes that help to illustrate the themes.

Results
Recovery: “And for me, recovery meant changing everything.”

Participants were asked to discuss their recovery and to describe what recovery looked like for them. Generally, the respondents did not distinguish between recovery from mental health disorders and recovery from addiction, but rather emphasized that recovery means being honest and true to oneself. Most responses describing their experiences with recovery could be categorized as: actively participating in 12-step programs; making life changes and changing their ways of doing things; and working with or participating in CCC programs. Other common responses related to the benefits of successfully moving towards recovery included: being part of a community; experiencing a sense of freedom; and discovering personal capabilities that they didn’t know existed. One person described the recovery experience:

Recovery for me is not just abstaining from using…It’s more being honest. Not lying, like I was when I was in addiction. And just learning as much as I can, staying true to myself, so that I don’t have guilt, remorse and all that adding to it because that’s hard. Because when you start feeling bad, that’s when you start, well screw it, you know. But for me, it’s just continuing to work on myself because I think it’s a work in progress … It is just continuing to grow and to learn and to move forward, and to abstain.

Recovery was described as “freedom” – freedom to make clear decisions, and to be involved in other CCC programs, to maintain employment, and to get “a better apartment,” per one respondent. Another person described recovery as freedom from any type of addiction: “I’ve been sober now over three years, which is great…it’s a freedom. It’s not having that ball and chain of an addiction that can just take your life away from you. It kills yourself, mentally, physically and spiritually. And that’s for any addiction, drug, alcohol, whatever. You name it.”

In addition to getting clean, many participants were interested in getting into housing, and for some, getting into housing programs required that they participate in recovery programs. Some participants mentioned that people who took part in certain programs just to get housing were not likely to be successful. However, two participants who made this type of comment noted that they had taken part in programs only to get housing, and their goals changed as they became more involved in CCC programs and maintained their recovery. One participant described his experience in a comprehensive recovery program that included housing, employment, and mental health services.

Well, they supplied housing for me. You know, they gave me a housing voucher. And that was a major thing because of my homelessness. And it really began to make me feel a little bit more normal. It made me feel more grateful, I think. And it began to give me hope that….going back to school was possible.

Many participants reported changing goals over time and as they participated in various programs. In general, participants’ goals became more ambitious as people achieved their immediate goals of finding a safe place to live, employment, and then realizing that there were many other resources available. A respondent discussed how success in recovery expanded his perspective of what was possible.

Well, initially it was just to not drink, to stay sober. Now that I’ve been in it for a while my goals are now to get employment, and to get out of this housing and into my own apartment so I can have my son.

When discussing how recovery programs helped them meet their goals or supported recovery, several consumers reported that CCC recovery programs gave them “the tools” to pursue recovery. Most referenced specific 12-step programs including Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). Those who mentioned 12-step programs talked about “working the steps” and staying sober and clean one day at a time. Some participants mentioned other mechanisms such as counseling, acupuncture and treatment for physical and mental health issues in relation to recovery.

And then also the programs they have, like the acupuncture, the Healing Power, the Qigong. And I also want to do like the art journal…. and you just can’t lose in there. Everybody, from the pharmacist to the people that answer the phones, I think somebody special picks them out for that place because they’re all awesome.

Several participants mentioned that the caseworkers involved in recovery and medical clinics were very helpful. Caseworkers and CCC staff helped participants learn about available programs, access programs, and offered caring and compassionate treatment. Some participants sought help from CCC to address other mental and physical health issues in addition to addiction issues. The consumer participants were generally satisfied with the treatment they received and the range of programs available.

They gave me tools. You know what I mean? They gave me an understanding that there could be a life without drugs. The one-on-one counseling that I got over there, the group counseling that I got over there. Again, this is my first recovery program and I came in very, very confused but very, very willing…they gave me a way out.

Comments were positive about the programs, yet a few consumers mentioned that the programs could be stricter and that they could recruit more staff to reduce wait time. The suggestions for improvement mirrored those offered while discussing housing and employment: “I think the (recovery program) needs to be a lot more strict. I think it’s too forgiving.”

Housing: “To have a place to shower, a place to eat, a place to sleep, a place to just feel comfortable”

While we did not collect additional demographic data on our interviewees in an effort to protect their anonymity, we present demographic and self-report data from a recent CCC Consumer Census Survey to provide the reader with a general description of the CCC client base from which participants were recruited (see Table 2).

When CRAs asked consumers about their initial goals when they entered their housing program(s), some of the participants mentioned that their goal was to simply get into housing and get off the streets. Yet, participants most frequently mentioned the goal of “staying clean and sober” and recovering from addiction. Participants who had lived in or were living in clean and sober housing felt that living in this type of housing facilitated their recovery. When discussing how a particular housing program helped meet their goals towards recovery, participants noted a variety of factors, including: having a place to live and getting away from the influences of the streets; living in a clean and sober environment; the importance of rules and accountability for behavior; and, the support they received from caseworkers, CCC staff, and other community members. A longer term goal was to get permanent housing outside of CCC facilities. Some of the frequent responses, or themes, are further described below.

Several people mentioned the necessity of “getting off the streets” and discussed how difficult it was to find a job, to start or maintain recovery, or to avoid being depressed without having a decent place to live. This was described as:

You can’t do much living on the street, you know, because...living in the street, you’re going to probably never stay clean or dry because it’s depressing… and if people get depressed and down about that…they can’t be successful without housing.

For many, moving off the street and into housing was their primary goal for getting involved with CCC programs. A participant in family housing, in which children can reside with their parents who are at risk of homelessness or in recovery, noted:

(It) helped us to have a place to shower, a place to eat, a place to sleep, a place to just feel comfortable…we tried (doing these things) when we were homeless, you know… but it’s so hard when you don’t have a place to shower and have your clothes clean, and have a place to eat and a place to just be comfortable and get adequate sleep, and just be fully rejuvenated through your day and everything. So it’s really helped us to feel comfortable and…and be ready for our day every day.

Participants mentioned that housing provided a sense of safety or a stable foundation from which to begin their recovery process. Feeling safe also translated as feeling supported by other residents and the housing community.

You know, it’s a very controlled environment and I like that. So that didn’t bother me a lot. But I loved it because it was just very safe to me. And I felt safe. And I felt like I could let go. And I felt like I could explore, you know, get to explore who I am there. Also, some of the other women that I was in treatment with were in the building so it provided a good atmosphere of support.

Some participants had been in relationships with users, or had been living in home environments where other people were using, and they did not feel that they could maintain recovery in these environments. One person noted: “I came from a place...a crack house, a place where they were shooting heroin on a daily basis. I made it the first seventy days in my recovery there. Had it not been for supportive (clean) housing … I don’t know if I would have stayed clean.” The fact that CCC provided clean and sober housing arrangements helped many people maintain recovery, as did being held accountable for certain behaviors in those particular units.

…having the accountability (in family housing) of who I was interacting with as a way to limit my associations or any temptation present. I felt really safe because it was so controlled. There were so many rules. So I definitely wouldn’t change anything about the rules.

Interview respondents described the important role of case managers who live in the buildings in terms of the on-site support and encouragement they provided.

Case managers, I think, are very important for this program to be successful. They’re usually right in the building where you live. Housing and those case managers, I think are the base, the roots for success because I don’t think…you can have housing, but I don’t think without a case manager, and having the follow up program, I don’t think many people would be successful.

Although all of the participants noted that they were grateful for the CCC housing options, and few offered suggestions for improving housing programs, there were areas that participants identified as barriers to participation or that could be strengthened. These responses ranged from finding some way to reduce the waiting lists for housing to being unhappy about other people breaking the rules or using alcohol/drugs where they were not allowed.

But like, I’ll come home at night and there will be like homeless people just hanging out outside, and like people getting drunk and yelling. And it’s like; you can’t do that in a normal house. In a normal apartment, you can’t be like outside drunk and drinking and being disruptive. So I don’t understand why it should happen here.

One participant called for stricter consequences for people who broke the rules and felt that there were not enough restrictions: “(It could be better) if the staff watched people and if they were more strict on like what was allowed here.”

Employment: “I’m starting to pay back some of my wreckage.”

Not surprisingly, the primary goal of employment program participants was to find work. Many also stated that their goals were to learn how to find and apply for paid work, because they had been out of the job market or did not own the equipment needed for job searching.

Okay, my goal was to work, for sure. It was just to work. I had looked for jobs. I’d been looking for about three months. I was very discouraged. I hadn’t worked in five or six years, probably more. You know, throughout my addiction, I never had a steady job. So I had a big gap to explain, and I wasn’t finding nothing. I was really discouraged…my goal was to work… just to work, obtain employment.

Some participants modified their goals and their approaches to employment after having some success in recovery or employment programs. A few participants reported that finding work and gaining some control over their finances and working situations provided them with an enhanced sense of self. This, in turn, increased their broader career or life ambitions.

So I started, you know what I mean, becoming a productive member of society…I pay rent. I’m starting to take care of my fines. I’m starting to pay back some of my wreckage. I’m starting to learn how to manage money. I like never missed a day. You know what I mean? So I mean, it was great…It started the ball rolling of all those fears you have when you’re just coming alive again.

All participants in job programs appreciated the range of support available and the assistance and instrumental support provided by the job counselors. This assistance included working with the participant to identify job possibilities and help with resumes, following up with potential employers after the participant completed an interview, providing referrals to a program, and finding clothing suitable for job interviews. When discussing how jobs programs helped them meet their goals or support recovery, participants noted a variety of factors, including the following: learning how to search for work; access to equipment and supplies; assistance from counselors with job search activities; and their own expanded ambitions.

Several discussed the positive experience of mentored work opportunities with a public sanitation and safety service.

CCC employment programs provided access to the equipment that participants needed to conduct successful job searches, including computers, printers, faxes, phones or a number for potential employers to call and leave messages.

Well, first I was using their (employment program) computer, right, because they had computers there and you could access…employment job listings. And I didn’t have a computer. So I’d go there and use the computer, and you could pull up some lists.

Job counselors helped participants write resumes, provided references, and in some cases even took participants to job interviews. They provided information on educational and vocational programs and provided job leads when participants successfully completed job training programs. One participant described how a counselor, “hooked me up with this guy … took me for an interview to a couple places…and he helped me find a job.” Another participant described his experience with the Employment Access Center, a resource center with specialized programs to assist homeless individuals by identifying and teaching the vocational and social skills needed to find and sustain full-time employment.

You get that specialist that works just specifically with you. And they’re really good about, hey, let’s build your resume. And you can be like, well, I don’t have anything to put on a resume. I don’t have any work history. And they’re like, oh, yes you do. You know, so they really get to know you and build on the tools that you don’t even realize that you have, or the skills that you don’t even realize that you have.

Consumers’ responses to questions about employment services and programs were overwhelmingly positive, but there were some suggestions for improvement. A couple of participants mentioned that some programs were too lenient and didn’t consistently hold workers accountable or expect high performance.

Okay, so some of the people just think of it as like a freebie job, you know. And that was hard for me because they didn’t take it seriously, or they didn’t do work. Or they didn’t work at all…and the way the program is set up, they just kind of watched. You know what I mean? You’ve got to do something pretty heinous or bad to get fired, or to get reprimanded.

Success: “Just that feeling of happiness, and just knowing that you’re going to be okay and your family is going to be okay.”

Interview participants were asked to discuss personal “successes” and to define what this term meant to them. Responses fell into the following categories: achieving goals, finding a job, or going to school; recovery and maintaining sobriety; feeling happy and safe; and, possessing a willingness to change. One person noted that: “Success for me right now would be to stay clean and to become employed. And find a job that I like and that I can support myself and my son in an apartment, and my dog.” It became clear that all participants agreed that in order to be “successful” or find “success” they must be in recovery or taking steps towards recovery:

You can’t have success without recovery. Recovery is the foundation, the cornerstone, the anchor, the framework, the roof, everything. And success can build on and around that. But that, at the very least, is the most important thing. How much money I have, how much food I have doesn’t matter. Where I live doesn’t matter. I got to stay in recovery and stay sober so I have a happy life. And success, for me again, is going back to that, be willing to learn and be willing to be willing.

Another person mentioned the relationship between recovery and success, “I think that if I had stayed clean and not used for a day then I’m super successful.”

Feeling safe, housed, and less vulnerable to dangerous situations was another common theme mentioned when participants talked about what success felt like. “Success has many faces, but most of all success is just peace of mind, for me. You know, having a safe place to live is… just acknowledging that it’s a safe place and that I need it, is successful for me. I lived my life very dangerously for a long time, and didn’t value myself and didn’t value life.”

Most of the 16 interview participants noted that CCC’s integration of services and programs contributed to their success. For example, they described being safely housed in a CCC housing site while accessing employment assistance and getting medical and dental care from a CCC clinic. Participants stressed their gratefulness for the multiplicity and integration of programs that CCC offered and the range of services provided.

Despite the recognition that external circumstances or conditions may make it difficult for some to be successful, when discussing what is required for success the most common responses included reference to two individual-level traits: “being willing to change” and “personal motivation.”

People who don’t blame others and accept their faults, try to fix them and move on. People who are willing to change, because we obviously…weren’t doing such a good job before.

Discussion
Despite the consistency in themes across interviews, consumers shared very different personal stories to illustrate their experiences of recovery and success. What became apparent during analysis of the transcripts was that participation in CCC (or other) programs and services is one small step towards a lifetime of self-work and growth. For one respondent his initial goal was simply “to stay sober” and now his goals are “to get employment…and (get) into my own apartment.” Others shared that recovery is a liberating move towards a better life, but that the better life required a lot of patience and, at times, felt unattainable. The discussion section highlights four core features that should be considered when developing programs and policy designed to foster consumer success: type of housing, structured programs and staff support, integrated care, and personal experiences of recovery.

Type of Housing
One of the central threads throughout the interviews was the important role of housing in recovery and feeling successful. Interview results suggested that regardless of the type of housing (e.g., family, transitional, ADFC), simply having shelter and feeling safe can lead to an increased sense of self-worth and the ability to maintain employment, recovery, re-integration, ties to family, and so forth. Two of the studies reviewed highlighted similar findings as they expanded their definition of “homelessness” beyond categories of place or time to include the psychosocial effects of being homeless. Power and French (1999) described homelessness as more than just the lack of a safe and secure accommodation. They argued that homelessness has as much to do with social exclusion as with bricks and mortar. In this regard, housing has the potential to provide social connections and a sense of security that enables individuals to pursue loftier goals and maintain sobriety.

What we learned during this study was that regardless of how one defines homelessness, and regardless of the criteria used to decide whether someone qualifies as “homeless”, there is consistency in the lived experiences and emotional states associated with being without safe, accessible, and permanent shelter. Of the qualitative studies reviewed most of the definitions provided drew upon the basic definition that Kidd (2003) provided in his study of street youth as having “no fixed address.” Tsemberis and Asmussen’s (2008) definition described homeless people as occupying specific places and referred to persons “who live on the streets, parks, subway tunnels, and other uninhabitable public places” (p. 114). In their study of coping strategies among a rural homeless population, Hilton and DeJong (2010) used a more inclusive definition that included people who are living outdoors, in public places, in cars or other substandard dwellings, in shelters or other homeless service programs. Regardless of the location, participants generally reported similar experiences with homelessness.

Much of what we discovered in the housing and recovery literature (and then probed for in our interviews) addressed the comparative effectiveness of housing first versus treatment first programs (Lincoln et al., 2009; Padgett, Stanhope, Henwood, & Stefancic, 2011). The treatment first approach typically provides temporary housing or shelter, with the requirement that consumers take part in treatment programs in order to be placed into more permanent housing arrangements (Lincoln et al., 2009). This housing model has been criticized for creating additional hardship for homeless people unable to maintain sobriety; in response, some advocate for the housing first approach, which does not require participation in treatment programs as a condition for long-term housing (Lincoln et al., 2009; Padgett et al., 2011). One study that compared the outcomes of consumers reported that treatment first participants were more likely to have higher rates of substance use than housing first participants (Padgett et al., 2011), and that housing first participants were more likely to remain in their programs and used fewer substance abuse services. The authors concluded that a housing first approach can help support housing stability for those suffering from serious mental illness because they are not at risk of losing housing due to substance use.

Results from the study presented here identified housing as a key variable in successful recovery. For some, housing is a means to recovery. Although consumers who were interviewed for this study generally favored Alcohol and Drug Free Community Housing, consumers on the HEARTH advisory committee were more divided, a controversy reflected in the literature. The research literature and national conversations about types of housing and recovery generally focus on the dichotomy of housing versus treatment first, while CCC specifically emphasizes the importance of community by referring to their clean & sober housing as Alcohol and Drug Free Community housing. CCC does not require sobriety to access employment, housing, acupuncture, or other types of services that could benefit a sober or non-sober individual. In CCC’s experience, there are people who are not in treatment but who feel safer in ADFC housing. Other people may be coming off the street seeking housing with a specific goal of getting off drugs and alcohol. For them, their housing first choice is to be in ADFC housing because it gives them the extra support they need to succeed. The CCC Executive Director often refers to a “housing choice” model that focuses on what the individual consumer is trying to achieve rather than the model the program identifies with. Whether sobriety or housing happens first is up for debate and consumers argue that there is no one path that fits all.

Importance of Structured Programs and Staff Support
Throughout the interviews, participants discussed how CCC programs’ structure and rules supported their recovery and promoted personal accountability. Participants frequently mentioned the benefits of carefully “working the steps” of AA and NA-type programs, and six of the participants referred to their participation in a 12-step recovery program. Very few residents resented the rules and structure of programs and residents of clean and sober housing, for example, wanted more enforcement of the rules and structure. These findings somewhat contradict Lincoln and colleagues’ (2009) study on Safe Haven residents, which suggested that successful programs include “rules and nonrules, respect for independence, and staff treating residents as adults” (Lincoln et al., 2009, p. 240). The authors reported that residents felt the rules limited independence and had “concerns about feeling supervised by staff” (Lincoln et al., 2009, p. 240). Some CCC participants noted that the rules provided them with a sense of safety:

…having the accountability (in family housing) of who I was interacting with as a way to limit my associations or any temptation present. I felt really safe because it was so controlled.

In addition to a call for structure, a related recurring theme was appreciation for the quality and consistency of support from CCC staff, including on-site case managers, employment counselors, and health providers. This is similar to a typology presented in White and Kurtz (2006) that listed the various roles of the addictions recovery support specialist to include outreach worker, motivator, ally and confidant, truth-teller, role model and mentor, planner, problem solver, resource broker, companion, advocate, educator, community organizer, lifestyle coach, and friend. Padgett and Henwood (2012) recommend that providers “meet clients where they are,” and discussed that staff respect and pay attention to individual stories and personal traumas. This type of tailored and healthy connection between staff and consumers was mirrored in interview transcripts.

Integrated Care
Nationally, CCC programs are recognized for their innovation in bridging addiction treatment, housing, and employment services. As a community-academic partnership, HEARTH has started to explore why CCC programs work, and what it is about integration of services that can help facilitate consumers’ sense of success and recovery. In addition to the study reported here, the partnership is pursuing funding to examine the many dimensions of self-sufficiency among consumers, the association between acupuncture and recovery, the role of housing in facilitating maintenance of chronic disease, and the physiological effects of stress associated with homelessness.

It seems that there is a momentum -- perhaps a transformative movement -- to provide a more integrated model of care and services to homeless and recovering individuals (Kurtz, in press). White and Davidson (2006) argue that we are witnessing a push for programs that include recovery, housing, peer support, mental health, and employment services. Several major national reports, including the Institute of Medicine report on Improving the Quality of Health Care for Mental and Substance-use Conditions (2006), make a case for conjoining services into a more comprehensive model of care.

Subjective vs. “Objective” Quantified Experiences of Recovery
This study presents consumers’ perspectives using their own words, which are not always consistently (or, accurately) captured in quantitative surveys or via provider records. By asking about, and listening to, consumer experiences and suggestions, we gain a richer understanding of needs and the types of policies or programs that are likely to support recovery and success. Dordick (2002) examined the attitudes toward recovery held by staff and residents in a transitional housing program. They reported that staff and residents felt strongly that recovery was more accurately measured by “attitude and outlook” rather than by any standard objective measure such as consecutive months or years of not using substances. When consumers were asked to define success, answers included meeting subjective criteria related to personal goals, recovery, housing, jobs, family, self-sufficiency, safety, peace of mind, and just being alive. These results are similar to Kidd’s (2003) study of street youth, which reported dimensions of recovery that included social support, self-worth, decreased reactivity to others, hope, pride, decreased anger, non-conformity and spirituality. Furthermore, defining recovery is more complicated than simply eliminating use of a substance.

Recovery as supported in the mental health and addiction literature, and further supported by the participants’ comments, is about finding purpose, hope, and community (White & Davidson, 2006). It should be noted that CCC uses the term “recovery” very broadly and often uses the term “recovery model” to include all CCC services that contribute to a healthy and functioning individual. The underlying principle with this broad definition is that regardless of whether the condition is addiction, mental illness, or a medical condition, people can recover from any condition that has hindered their ability to function at their highest level.

Conclusions
There are several mechanisms through which a consumer and CCC staff-driven project transforms individuals, organizations, and practice. At the individual level, participation in HEARTH has the potential to give consumers an opportunity to verbalize their stories and influence the project partners to study what matters to them. At the organizational level, this study can serve to remind service providers and policy makers that housing programs do more than get people off the street – they provide a base level of security that people require to seek bigger, bolder personal change. For those who work with people with addictions, this study offers different ways to think about “success” and “recovery;” the processes are complicated and this study challenges us to think beyond dichotomist definitions (e.g., you’re homeless or you’re not).

Finally, the principles of CBPR as applied in this study have the power to democratize research with homeless and recovering populations by including them in each phase, and it offers an alternative way of assessing consumers’ realities and priorities. We were able to demonstrate that it is certainly possible and even desirable, to conduct consumer-driven research while retaining high academic and ethical standards. Rigorous, academic, theory-driven research and community-based principles that call for inclusion and shared power are not at odds. Rather, the consumers’ experiences and perspectives strengthened all aspects of the research process—from developing the initial research questions, to finalizing the language used to collect data, to analysis and interpretation of results.

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Author

Stephanie A. Farquhar, Marianne Ryder, Derek Henderlong, Robert A. Lowe, and Ted Amann Stephanie A. Farquhar, Marianne Ryder, Derek Henderlong, Robert A. Lowe, and Ted Amann

Stephanie A. Farquhar, PhD, is Associate Professor at Portland State University School of Community Health, Portland, OR, USA. Email: farquhar@pdx.edu, Phone: 503.725.5167, Fax: 503.725.5100

Marianne Ryder, PhD is an independent researcher and writer in Portland, OR, USA. Email: marianneryder@gmail.com, 503-453-4778

Derek Henderlong, is a student of Classical Chinese Medicine at the National College of Natural Medicine Portland, OR, USA. Email: derekhenderlong@gmail.com

Robert A. Lowe, MD, MPH is with the Department of Medical Informatics and Clinical Epidemiology, Department of Emergency Medicine, Department of Public Health and Preventive Medicine, and the Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, OR, USA. Email: RobertALoweMDMPH@gmail.com, 503 494-7134

Ted Amann, MPH, RN, is a Community Research Associate at Central City Concern, Portland, OR, USA. Email: ted.amann@ccconcern.org, 503-200-3917


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Keywords: Recovery, success, housing, integrated services, community-based research, gjcpp, community psychology practice