There's no place like (a) home: Ontological security among persons with serious mental illness in the United States

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Abstract

As the homelessness ‘crisis’ in the United States enters a third decade, few are as adversely affected as persons with serious mental illness. Despite recent evidence favoring a ‘housing first’ approach, the dominant ‘treatment first’ approach persists in which individuals must climb a ladder of program requirements before becoming eligible for an apartment of their own.

Drawing upon the concept of ‘ontological security’, this qualitative study examines the subjective meaning of ‘home’ among 39 persons who were part of a unique urban experiment that provided New York City's homeless mentally ill adults with immediate access to independent housing in the late 1990s. The study design involved purposively sampling from the experimental (housing first) group (N=21) and the control (treatment first) group (N=18) and conducting two life history interviews with each participant. Markers of ontological security—constancy, daily routines, privacy, and having a secure base for identity construction—provided sensitizing concepts for grounded theory analyses designed to also yield emergent, or new, themes.

Findings revealed clear evidence of the markers of ontological security among participants living in their own apartments. This study expands upon previous research showing that homeless mentally ill persons are capable of independent living in the community. The emergent theme of ‘what's next’ questions and uncertainty about the future points to the need to address problems of stigma and social exclusion that extend beyond the minimal achievement of having a ‘home’.

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A sense of déjà vu accompanied the July 2006 announcement by New York City Mayor Michael Bloomberg that homeless encampments in the city would be cleared out and their occupants placed in supportive housing. Mayor Bloomberg's announcement was part of a keynote address delivered at the annual meeting of the National Alliance to End Homelessness, an organization that had earlier announced a plan to end homelessness by the year 2010 (National Alliance to End Homelessness, 2000). Dating back to the

Policies and services for the homeless mentally ill in the United States

The United Nations has ordained housing as a basic human right that should be secure, habitable, and affordable but this goal remains elusive for much of the world's population (United Nations, 1991). In the United States, the severe shortage of low-cost housing that began in the 1980s and continues to the present day set the stage for the ongoing homelessness ‘crisis’ (Lovell & Cohn, 1998).

Yet the fate of homeless mentally ill adults is also affected by policies designed to ensure that they

From a randomized experiment to a ‘natural’ experiment: The New York Housing Study (NYHS) and its successor, the New York Services Study (NYSS)

In the early 1990s, a consumer-centered approach emerged that fundamentally challenged the status quo. The ‘housing first’ approach separated treatment from housing, considering the former voluntary and the latter a fundamental human right (Carling, 1990; Ridgway & Zipple, 1990). As such, it removed the ladder continuum and made access to housing the first step and subsequent steps subject to consumer choice rather than coercion (Tsemberis, 1999).

The first implementation of a housing first

Ontological security and the treatment first vs. housing first philosophies

Conceptual fuzziness continues to surround terms such as ‘ontological security’ and ‘home’ in large part due to their contextual and subjective nature (Hiscock et al., 2003; Kearns et al, 2000; Mallett, 2004; Shaw, 2004). According to Dupuis and Thorns, the four ‘markers’ or conditions of ontological security are met when: (1) home is a place of constancy in the material and social environment; (2) home is a place in which the day-to-day routines of human existence are performed; (3) home is

Sampling and recruitment

Purposive sampling was used to select study participants (SPs) from the roster of subjects from the NYHS with the goal of selecting 40 for Phase 1 in-depth interviews. Persons in the earlier study had a documented DSM Axis 1 disorder and were referred for housing and services either from the streets or from hospitals; 90% also had substance abuse problems (Tsemberis et al., 2004).

As part of their final interview in the NYHS, SPs had been asked for contact information and permission to be

Characteristics of the sample

Study participants had a mean age of 48 years and were predominantly male (67%). In terms of race/ethnic composition, they were 41% African American, 41% white, and 15% Hispanic; one person was of Arab descent. The most common psychiatric diagnosis was schizophrenia (56%) followed by bipolar disorder (22%), and major depression (22%). A history of co-occurring substance abuse was common, with 33 of 39 reporting lifetime substance abuse. At the time of the interviews, none reported heavy use of

Themes

Themes that address the research questions as well as emergent or unanticipated themes are presented below. Participant identification numbers (NYSS ID numbers) follow each quote, along with the participant's previous status and any change in status by the time of the interview.

Control and self-determination

Having one's own apartment offered both ‘freedom from’ and ‘freedom to’ opportunities (Kearns et al., 2000). One man noted:

Int: What did you like about it being your own apartment? 108: Just having it… Stay over anytime you wanted to. You know, things like that. Go shopping. You don’t have to…. People can’t tell you what to do in your own place. You have your own say-so. What goes on in your own apartment. Things like that. #108 (Pathways group, who had moved to supervised treatment setting at

Routines of daily life: ‘The simple things’

Study participants spoke with pride of the seemingly minor but deeply gratifying aspects of having a home, whether it was doing the laundry or taking a walk in the park.

… that's what makes me feel good at times, the simple things. To be able to get up and know that I got two new shirts, a clean pair of jeans, clean socks and I can feel good about myself. I explain that to my peers too. That's what part of recovery's about. #144 (Pathways Group)

You get your own room, you mind your business, you

Privacy and freedom from supervision

Participants viewed their apartments as havens from the noise and stress of urban life, particularly after spending months or years on the streets or in shelters where privacy was not possible. As one older woman commented:

Sometimes it gets stressful. But I manage because I got a home to come home to and relax. #118 (Pathways group)

This contrasted with earlier experiences in transitional housing where monitoring of residents was part of daily life. One man noted:

I don’t think I ever really

Identity construction (and repair)

As mentioned earlier, ontological security is enhanced by having a ‘home’ as a secure base around which identities can be constructed. For study participants, this meant self-reflection and repairing identities damaged along the way. A woman recalled a childhood very different from her adult years.

It wasn’t until I got with Pathways that I started straightening up, like, learning how to stop using, you know, taking a good look at me, and realizing who I really am. You know… I grew up in a

The ‘what's next’ of having a home

One of the more salient themes in this study was the existential ‘what's next?’ question that can emerge after leaving the survival mode of the streets and having the ‘luxury’ to contemplate a future.

I have to either get myself a job, a volunteer position, or something… I have to be doing something constructive. In other words, go back into society, you know what I mean. I just got this apartment…the goal is to reintegrate you back into society. Int: What does that mean? 128: Kind of like, you

Staying in transitional housing

Some study participants reluctantly accepted the need for residential treatment, even if it was not their optimal situation.

… I miss it. I wish that I can get my apartment back and start all over again. It’d be nice. But, I told my social worker that I’d rather stay here, just in case I get sick again. Then I don’t have to go through all the trouble again. Of going through the hospital and-starting all over again, and have to work from the bottom. #108 (Pathways group, who had moved to

Discussion

Findings from this and previous studies affirm that formerly homeless individuals with serious mental illness can live on their own without the need for on-site supervision and monitoring (Tsemberis et al., 2004; Greenwood, Shaefer-McDaniel, Winkle, & Tsemberis, 2005). Findings specific to this report demonstrate that they can also enjoy the benefits of a ‘home’. Markers of ontological security were clearly in evidence for those living in their own apartments—a sense of control, reassuring

Conclusion

Ontological security was originally developed within the mental health field where the emphasis was on the breakdown in ontological security experienced by those with schizophrenia. The treatment approach for such persons reflects the belief that ontological security cannot be regained until the mental illness is addressed. Research in the housing and health field, including this study, suggests that housing can provide a fundamental building block for ontological security, thus lending support

Acknowledgments

This project was supported by Grant #R01-MH69865 from the National Institute of Mental Health. The author is deeply grateful to the study participants for graciously sharing their lives. While the analyses and interpretations for this specific study are my own, I wish to thank New York Services Study staff members Andrew Davis, Courtney Abrams and Ana Stefancic for their assistance in interviewing and early coding of transcripts. Finally, I would like to thank Kim Hopper and the two anonymous

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