"The street will drive you crazy": why homeless psychotic women in the institutional circuit in the United States often say no to offers of help

The Experience of Psychosis in Psychiatric Inpatients During the COVID-19 Pandemic Among Unhoused Individuals

This research investigates the impact of Coronavirus-2019 on individuals without housing and experiencing psychosis using semi-structured qualitative interviews and a case study format. We found that for our participants, life in the pandemic was generally more difficult and filled with violence. Further, the pandemic seemed to impact the content of psychosis directly, such that in some cases voices referred to politics around the virus. Being unhoused during the pandemic may increase the sense of powerlessness, social defeat, and the sense of failure in social interactions. Despite national and local measures to mitigate virus spread in unhoused communities, the pandemic seemed to be particularly hard on those who were unhoused. This research should support our efforts to see access to secure housing as a human rights issue.

“It's no foundation, there's no stabilization, you're just scattered”: A qualitative study of the institutional circuit of recently-evicted people who use drugs

People who use drugs (PWUD) commonly experience housing instability due to intersecting structural vulnerabilities (e.g., drug prohibition, discriminatory housing policies), and prejudicial or illegal evictions are common. In Vancouver, Canada, evictions have proliferated in the Downtown Eastside, a historically low-income neighbourhood with high rates of drug use and housing instability, resulting in many PWUD being evicted into homelessness. This study characterizes housing trajectories of recently-evicted PWUD through the lens of the institutional circuit of homelessness, and explores how wider contexts of structural vulnerability shape experiences within this. Qualitative interviews were conducted with PWUD recently evicted in the Downtown Eastside (<60 days). Peer research assistants recruited 58 PWUD through outreach activities. All PWUD participated in baseline interviews on the causes and contexts of evictions. Follow-up interviews were completed with 41 participants 3-6 months later, focusing on longer-term impacts of eviction, including housing trajectories. Most participants were evicted into homelessness, remaining so at follow-up. Participants described patterns of residential instability consisting of frequent cycling between shelters, streets, and kin-based networks. While participants normalized this cycling as characteristic of their marginalized social positions, narratives revealed how the demands of the institutional circuit deepened vulnerabilities and prolonged experiences of homelessness. Experiences were framed by participants' (in)ability to navigate survival needs (e.g., shelter, drug use), with tensions and trade-offs between needs increasing participants' and their peers' risks of harms. Constructions of agency further shaped experiences; accounts highlighted tensions between the control inherent to indoor spaces and participants' need for autonomy. Findings demonstrate how the demands of the institutional circuit foregrounded structural vulnerabilities to perpetuate cycles of instability. Interventions that address survival needs and preserve agency will be necessary to mitigate risks within the institutional circuit, in tandem with upstream interventions that target housing vulnerability and broader social-structural conditions (e.g., poverty, affordability) that entrap recently-evicted PWUD in the institutional circuit.

Lessons in "Slow" Engagement From Staff and Administrators at a Prebooking Jail Diversion Program

OBJECTIVE

In this study, the authors elicited the perspectives of criminal justice and mental health stakeholders about a prebooking jail diversion program, the Judge Ed Emmett Mental Health Diversion Center, serving primarily individuals experiencing chronic homelessness and diagnosed as having a serious mental illness.

METHODS

The authors analyzed semistructured interviews with 19 participants and observational fieldnotes from 60 hours of ethnographic fieldwork, conducted from January to July 2020 and including five administrative-level meetings. They used qualitative coding to develop themes. Administrative data were also reviewed.

RESULTS

Engagement of clients in the program was a major theme. Barriers to engagement included clients’ fear of police involvement and strict rules around smoking. Facilitators to engagement included “slow” engagement, or gradual, gentle microengagements over time and across multiple visits, ideally with peer counselors.

CONCLUSIONS

To promote client use of services at this critical point of care, jail diversion programs might consider ongoing negotiations with clients to balance expectations between the criminal justice and mental health systems of care by using “slow” client engagement, limiting police involvement, and adopting trauma-informed and harm-reduction approaches.

The Psychiatric Nurse Care Coordinator on a Multi-disciplinary, Community Mental Health Treatment Team

Community mental health nurses sometimes join multi-disciplinary teams, but the role has not been defined and studied carefully. This article describes the psychiatric Nurse Care Coordinator (NCC)-a unique position created to support care management, facilitate systematic medication management, and coordinate medical care in the Social Security Administration's 30-site Supported Employment Demonstration. The authors reviewed the study's NCC manual, supervised and consulted with the NCCs weekly over nearly three years, and reviewed data on NCC activities. Although the 984 participants assigned to NCCs experienced numerous mental health, substance use, and chronic medical conditions, only 59% completed intake assessments and engaged over time with NCCs. For those 581 participants, NCCs spent approximately 51% of their time helping with mental health issues, 35% on medical care, and 12% on substance use conditions. The NCC was critically important for complex, high-need individuals.

Social support and quality of life among chronically homeless patients with schizophrenia

This study aimed to describe the sociodemographic characteristics, social support received, and quality of life of chronically homeless patients with schizophrenia in China. A self-prepared sociodemographic questionnaire, the Social Support Rating Scale (SSRS), European Five-dimensional Health Scale (EQ-5D), and Eysenck Personality were administrated to 3,967 chronically homeless and 3,724 non-homeless patients from the Department of Xiangtan Fifth People's Hospital, Hunan, China, between April 2011 and October 2016. Results indicated that the homeless patients were more likely to live outside the city and be ethnic minorities compared with non-homeless patients. Although the married proportion was higher among homeless patients, they had a higher rate of being divorced or widowed. Notably, the homeless patients had higher employment rates before illness, despite significantly lower education (P < 0.001). Chronically homeless patients with schizophrenia showed a lower score in the SSRS (30.29 ± 7.34 vs. 26.16 ± 10.04, p < 0.001); they had significantly lower objective support, subject support, social support, and EQ-Visual Analog Scale, Eysenck Personality Questionnaire-Psychoticism, and Eysenck Personality-Neuroticism scores (p < 0.001). Homeless patients may be worse off, and could be assisted by providing accommodation, family intervention, medical services (such as pain medication), and other comprehensive measures.

Experiences of homeless women in accessing health care in community-based settings: a qualitative systematic review

INTRODUCTION

Homelessness among women is on the rise in the US and continues to be a concern globally. The challenges homeless women face are unique and vast, yet how they experience health care can greatly affect their desire to access health care in the future. The ability to shed light on what is meaningful to homeless women in their health care experiences can guide the changes necessary to provide appropriate patient-centered, impactful care with the goal of increasing access by this vulnerable population.

OBJECTIVE

This review aimed to identify, appraise and synthesize existing qualitative evidence on the experiences of homeless women when accessing community-based health care services.

INCLUSION CRITERIA

This review included studies on homeless women, both previously or currently, aged 18 or older. The phenomena of interest were homeless women's health care experiences, including perspectives, narratives and/or reflections, at any time during their period of homelessness. The review included health care services received by homeless women in community-based settings, shelter-based clinics and/or mobile clinics. Qualitative data including, but not limited to, the designs of phenomenology, grounded theory, ethnography, qualitative description, action research and feminist research were considered.

METHODS

Using a three-step search strategy, databases of published and unpublished articles were searched from database inception to 2018. All included studies were assessed by two independent reviewers for methodological quality, and data was extracted and pooled using the JBI System for the Unified Management, Assessment and Review of Information. Findings were rated according to their level of credibility, categorized based on similarity in meaning, and subjected to a meta-synthesis. Two reviewers utilized a meta-aggregative approach.

RESULTS

A total of 196 qualitative articles were identified of which 24 were included after critical appraisal. Meta-synthesis generated three synthesized findings: (1) Homeless women who access health care services at community-based settings feel as if their homelessness qualifies them as second-class citizens, which impedes future access; (2) Homeless women have an expectation of therapeutic communication from their health care providers, the lack of which can incite negative emotional responses, fear and knowledge deficits; (3) Homeless women with limited resources struggle to prioritize competing needs, such as transportation, time and money, which influences their ability to access health care. These synthesized findings were derived from 47 study findings that were subsequently aggregated into 10 categories. Of the 47 study findings, 32 were rated as unequivocal and 15 were rated as credible. The overall ConQual for each of the three synthesized findings was low due to common dependability issues across the included studies. A total of 454 participants were included. The included studies were published from 1997 to 2017.

CONCLUSION

The review identified that homeless women's experiences when accessing health care in community-based settings, particularly in the US, have been poor and have negatively affected their desire to access health care in the future. The synthesized findings illustrate clear indicators for use of cultural competence and addressing provider bias in the delivery of health care to homeless women. This review also highlights the importance of understanding clinical experiences of providing direct care for these women in order to shed light on the type of advocacy needed to ensure equitable access to health care services. While this review uncovered issues with some global health care systems, the predominance of system constraints within the US highlights the need for health policy reform to improve the experiences of homeless women when accessing health care.

Insights from homeless men about PRISM, an innovative shelter-based mental health service

PRISM (Projet Réaffiliation Itinérance Santé Mentale-mental health and homelessness reaffiliation project), is a new shelter-based mental health service in Montreal, Canada. It offers short-term residential services in a shelter with the aim of housing and connecting the person to the appropriate services in the community. This qualitative research project was designed to gain a rich understanding of service-user experience within this program, and to apply these impressions to a broader reflection concerning how to best serve the needs of homeless people living with severe mental illness. We conducted in-depth interviews with 20 clients from the all-male PRISM-Welcome Hall Mission at program intake and departure between May 2018 and March 2019. We used methods stemming from grounded theory to analyze themes emerging from the interviews. Analysis revealed three core aspects endorsed by PRISM clients as helpful to their recovery: first, the community-based and flexible PRISM structure allows for continuity in daily routine through the preservation and expansion of the client's existing informal resource network; second, the secure environment is conducive to improving one's physical and mental health; and third, the multimodal mental health and social service approach used at PRISM is appreciated and stands in contrast to what most have experienced during other inpatient experiences. This led us to reflect more broadly on the benefits of a shelter-based intervention, as a catalyst to the achievement of longer-term goals such as housing, as well as flexible care adapted to the specific needs of these individuals. Even though this study took place in a specific program in Quebec, it sheds light more broadly on how to best meet the needs of individuals with mental illness living in homeless situations and contributes to the growing literature on men's mental health.

Necropolitics in the "Compassionate" City: Care/Brutality in San Francisco

In San Francisco in the United States, the urban precariat is governed simultaneously by two logics of intervention that are highly contradictory: compassion and brutality. In this article, I explore the contours of violence embedded in humanitarian governance for unstably housed/homeless women who use drugs as they navigate care systems for their health and well-being. I use Mbembe's concept of necropolitics to examine how women embody an anticipation of death, at the same time as they manage their risk for actual death in engagements with care in a city paradoxically known for its progressive, compassionate principles of intervention for those who are most marginalized.

Merging Intentional Peer Support and Dialogic Practice: Implementation Lessons From Parachute NYC

This ethnographically informed implementation analysis of Parachute NYC between 2012 and 2015 documents the obstacles that can impede disruptive innovations in public mental health. Parachute combined family-based dialogic practice with peer-staffed crisis respite centers and mixed teams of clinicians and peers in an ambitious effort to revamp responses to psychiatric crises. This Open Forum reviews the demands posed by formidable contextual constraints, extended trainings in novel therapeutic techniques, and the effort to ensure sustainability in a managed care environment. It cautions that requiring innovations to produce evidence under the structural constraints that Parachute endured hobbles the effort and thwarts its success. The dialogic embrace of ordinary people and the use of peer labor as active treatment agents promote a slower and more participatory approach to psychiatric crises that offers extraordinary promise. However, a better prepared and more receptive context is needed for a fair trial of the comparative effectiveness of this approach.

Coping amidst an assemblage of disadvantage: A qualitative metasynthesis of first-person accounts of managing severe mental illness while homeless

WHAT IS KNOWN ON THE SUBJECT?: Understanding what strategies individuals use to cope with serious mental illness is vital for enhancing their quality of life, mental well-being and recovery, and effective use of services; An episode of homelessness can be a profoundly disruptive event that often leads to chronic stress, social isolation, a negative belief about oneself and restricted access to care, among other adverse experiences; WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: In contrast to existing reviews of qualitative research focusing on escaping homelessness, managing problem substance use and growing resilience, the current review offers an in-depth, interpretive account of coping with serious mental illness during an episode of homelessness; This paper integrates evidence showing the diverse and intricate processes via which homelessness can impede an individual's ability to successfully cope with life stressors and with chronic mental illness; Despite experiencing severe social disadvantage, many individuals demonstrate positive adaptation and coping, and even personal growth; WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is important to be aware of the many ways in which coping with serious mental illness can be influenced by adverse environmental factors such as poverty, homelessness, traumatic life experiences and institutional discrimination; Nursing practice should recognize that coping efforts by individuals facing multiple forms of social disadvantage may be shaped by acute adverse life events and institutional interactions, as well as by the stresses and strains of living on the streets; Nursing practice should focus not only on reducing clients' mental illness symptoms and facilitating positive coping behaviours, but also on helping create the conditions that aid clients in leveraging inner resources for personal growth and constructive meaning-making. Abstract Introduction An evidence gap persists concerning the impact of extreme socio-structural disadvantage, such as homelessness, on the nature and effectiveness of coping with severe mental illness (SMI). While existing reviews of qualitative research into homelessness have focused on processes such as escaping homelessness and managing concurrent problem substance use, as well as on the experiences of specific vulnerable groups such as women and youth, no analogical review has been dedicated to understanding the management of SMI during an episode of homelessness. Aim/Question A qualitative metasynthesis of first-person accounts was conducted to understand how individuals cope with SMI when experiencing homelessness. Method The systematic search strategy yielded 481 potentially eligible sources. Following the team-based full-text screening and the two-tiered quality appraisal, 14 studies involving 377 participants with lived experience were synthesized following Noblit and Hare's metaethnographic method. Results Seven third-order concepts were derived capturing the complex nature and processual character of coping, as well as the web of contextual influences upon coping strategies. The resultant line-of-argument synthesis reveals the dialectical relationship between the two higher-order constructs-"the continuum of coping" and "the assemblage of disadvantage." Discussion Despite the profoundly adverse impacts of biographical and socio-structural conditions, many individuals mobilized internal and external resources to enable various coping processes. Coping in the context of multiple disadvantage is not a monolith but rather a multidimensional, contingent and fluid phenomenon. Implications for practice Nursing practice should espouse a humanizing, structurally competent, and strength- and meaning-oriented approach in order to meet the complex and multifaceted needs of such multiply disadvantaged persons.

Keeping it together: Idioms of resilience and distress in Thai Buddhist mindlessness

Mindfulness is increasingly lauded as a mark of well-being around the world, but less often is its opposite, mindlessness, articulated in discussions of mental health. In Thailand, where people follow the kinds of Theravāda forms of Buddhism that have inspired today's global mindfulness movement, "mindlessness" is understood as a culturally salient mark of distress. In this article I address what mindlessness looks like for people in and around the Northern Thai city of Chiang Mai, where mindlessness can be thought of as ephemeral and passing as a fleeting forgetfulness that necessitates re-reading a page in a book, or as long lasting and powerful as a destabilizing condition to be treated in the in-patient ward of a psychiatric hospital. I emphasize local meanings and contexts of mindlessness, and their entanglement with broader discourses in the mindfulness movement, in order to point to mindlessness as a type of local and potentially international idiom of distress. I do this to argue for both the continued importance of cultural concepts of distress in our psychiatric nosology, and for further study into the slippages that can occur when local idioms like mindfulness go global.

Surviving Violence in Everyday Life: A Communicative Approach to Homelessness

In this narrative review, the author synthesizes the literature on homelessness across various disciplines (e.g., public health, social work, sociology, and communication) to demonstrate how the experiences of homelessness can be created, maintained, and reinforced through communication, including interpersonal interactions and public discourse. By conceptualizing homelessness as a culturally constructed and socially situated phenomenon, the author examines (a) the complex conceptualization of homelessness, (b) everyday violence faced by people who are homeless, and (c) coping strategies of people who are homeless. In summary, homelessness is a complex social phenomenon, involving tensions between individuals, families, and social systems, all of which are situated in the larger sociocultural and sociopolitical contexts of a specific time and place.

Relevance of a subjective quality of life questionnaire for long-term homeless persons with schizophrenia

BACKGROUND

Increasing numbers of programs are addressing the specific needs of homeless people with schizophrenia in terms of access to housing, healthcare, basic human rights and other domains. Although quality of life scales are being used to evaluate such programs, few instruments have been validated for people with schizophrenia and none for people with schizophrenia who experience major social problems such as homelessness. The aim of the present study was to validate the French version of the S-QoL a self-administered, subjective quality of life questionnaire specific to schizophrenia for people with schizophrenia who are homeless.

METHODS

In a two-step process, the S-QoL was first administered to two independent convenience samples of long-term homeless people with schizophrenia in Marseille, France. The objective of the first step was to analyse the psychometric properties of the S-QoL. The objective of the second step was to examine, through qualitative interviews with members of the population in question, the relevance and acceptability of the principle quality of life indicators used in the S-QoL instrument.

RESULTS

Although the psychometric characteristics of the S-QoL were found to be globally satisfactory, from the point of view of the people being interviewed, acceptability was poor. Respondents frequently interrupted participation complaining that questionnaire items did not take into account the specific context of life on the streets.

CONCLUSIONS

Less intrusive questions, more readily understandable vocabulary and greater relevance to subjects' living conditions are needed to improve the S-QoL questionnaire for this population. A modular questionnaire with context specific sections or specific quality of life instruments for socially excluded populations may well be the way forward.

Diversity Within the Psychotic Continuum

There has been great interest in the hallucination-like events experienced by the general nonclinical population. Many psychiatric scientists have come to identify these as part of a "psychotic continuum" and have begun to ask what we might learn from these experiences that will enable us to better understand and treat psychosis. While sympathetic to this goal, this paper argues that many of these events in the nonclinical population may be associated with the attention to inner imagery characteristic of much religious practice like unscripted prayer. Many of these hallucination-like events are phenomenologically distinct, culturally salient, and are predicted both by a measure of absorption, which probes for an interest in inner imagery, and by inner sense cultivation practice. These observations suggest that rare, brief, and positive sensory events may not be associated with psychotic vulnerability. They also suggest there may be an absorption-dissociation pathway, with or without trauma, for more frequent hallucinations.

"Not Homeless Yet. I'm Kind of Couch Surfing": Finding Identities for People at a Homeless Shelter

The meanings of homelessness are fluid and socially constructed, providing resources and limitations for individuals to negotiate their identities and relationships in everyday life. In this study, we examine the strategies and corresponding resources utilized by people who are homeless to cope with the labeling of a homeless identity and to redefine their identities. We used constant comparative analysis to examine in-depth interviews with 16 participants (male = 11, female = 5) who access a local homeless shelter in the southwest United States for resources. We identified three strategies that homeless people adopt to cope with the labeling of homeless identity: (a) differentiating oneself from others who are homeless, (b) prioritizing certain aspects of life, and (c) embracing the status of homelessness. Although these strategies have been identified in previous literature, the authors extend this line of research by identifying the common resources people who are homeless utilize when adopting these strategies, which entail important implications for theory development and practical implications.

"No One Ever Even Asked Me that Before": Autobiographical Power, Social Defeat, and Recovery among African Americans with Lived Experiences of Psychosis

Our article draws on ethnographic research with African American males diagnosed with a psychotic disorder in a high-poverty urban area of the northeastern United States. Our participants frequently described the ways public mental health services led them to experience a paralyzing erosion of autobiographical power, which we define as the ability to tell one's own story and be the editor of one's own life. We identified three important points when the loss of autobiographical power seemed to perpetuate social defeat or a sense of social powerlessness (Luhrmann 2007) for our participants during their interactions with public mental health care. We invite further inquiry into the loss of autobiographical power in settings of public mental health care, the sense of social defeat it seems to perpetuate, and the impact of these on mental health recovery, especially for people living in contexts of persistent social adversity.

Social Relationships of Dually Diagnosed Homeless Adults Following Enrollment in Housing First or Traditional Treatment Services

OBJECTIVE

Strong and effective social support is a critical element of mental health recovery, yet social support is often lacking for adults experiencing homelessness. This study examines differences in the social networks of participants newly enrolled in programs that use either a Housing First (HF) approach (i.e., provides immediate access to permanent housing with ongoing consumer-driven support services) or a treatment first (TF) approach (i.e., traditional clinician-driven staircse model that requires temporary or transitional housing and treatment placements before accessing permanent housing).

METHOD

We use a mixed-methods social network analysis approach to assess group differences of 75 individuals based on program type (HF or TF) and program retention.

RESULTS

Quantitative results show that compared with TF, HF participants have a greater proportion of staff members in their network. TF participants are more likely than HF participants to maintain mixed-quality relationships (i.e., relationships with elements of support and conflict). As compared with participants who remain in a program, those who disengage from programs have a greater proportion of mixed relationships and relationships that grow distant. Qualitative analyses suggest that HF participants regard housing as providing a stable foundation from which to reconnect or restore broken relationships. However, HF participants are guarded about close relationships for fear of being exploited due to their newly acquired apartments. TF participants report that they are less inclined to develop new relationships with peers or staff members due to the time-limited nature of the TF programs.

CONCLUSIONS

These findings suggest that HF participants are not more socially isolated than those in traditional care. Implications for practice, policy and future research are discussed.

Putting meaning into medicine: why context matters in psychiatry

Mainstream psychiatry emphasises controlling symptoms by taking medications. This approach ignores the role of context in shaping illness experiences and how people engage with mental health professionals. The focus on symptom control and medication management also narrows the function of the psychiatrist. This editorial argues that knowledge of patients' lives is important for providing empathic care that is oriented to the outcomes that matter to patients. In addition, care that attends to the person-in-context motivates and sustains mental health providers by putting meaning back into medicine. Truly patient-centred care demands pushing back against the reductionism of contemporary psychiatry to thoughtfully engage with the complexities of patients' lives.

Time seizures and the self: institutional temporalities and self-preservation among homeless women

This article documents temporalities of homelessness as experienced by many homeless people today, those living in the midst of an urban "services ghetto"-where social service organizations abound, but such organizations fail to coordinate the provision or timing of services, producing an incoherent multiplicity of offerings and schedules. I analyzed distinct but related temporal modes by which institutional timetables controlled homeless women's existence, what I call empty time and overscheduled time. The paradoxes of institutionalized waiting and strict yet inconsistent timetables exacted profound material and psychological tolls. For homeless women in Chicago, many of whom experienced symptoms of severe mental illness, simply securing their daily needs was such a time-consuming endeavor that they had to focus on short-term self-preservation rather than seeking stable employment or housing. Using anthropological theories of self and subjectivity, I argue that what was at stake for many women was more than the exhaustion of shelter life-negotiating institutional timetables also threatened their sense of dignity and humanity. Through the everyday patterning of women's time, non-profit agencies whose stated aim was to eliminate homelessness paradoxically frustrated women's efforts to escape life on the streets. I conclude the analysis with policy suggestions to address these problems.

Exploring psychosis and bipolar disorder in women: a critical review of the qualitative literature

BACKGROUND

The experiences of women with severe mental illness warrant particular consideration to identify the strategies they use to facilitate recovery. This review systematically examined women's experiences of psychosis and bipolar disorder.

METHODS

Following an extensive database search, 13 studies met inclusion criteria. Noblit and Hare's metasynthesis approach was used to synthesise these qualitative studies exploring the experiences of 250 women, of which 78 (31.2%) were also mothers.

RESULTS

Twelve sub-ordinate themes were identified and categorised into three overarching themes: 1) women's beliefs about illness, 2) perceived consequences of illness, and 3) strategies used to cope with illness. Contextual factors and spiritual beliefs were found to be important in these women's illness appraisals. Women incorporated diagnosis-related information into illness models if it was concordant with their existing beliefs.

CONCLUSIONS

Women reported negative illness consequences relating to stigma, loss of self-determination and changes to relationships. They employed various strategies in order to cope with illness. Barriers to strategy use and clinical recommendations are presented.

Homelessness, behavioral health disorders and intimate partner violence: barriers to services for women

Homeless women comprise a significant portion of the homeless population and may encounter multiple life stressors including mental illness, substance abuse, and trauma. Women who are homeless may experience difficulty gaining access to resources such as shelter and health care. In addition, the interaction of behavioral health problems with intimate partner violence (IPV) may create extraordinary barriers to their engagement in services. This paper explores the co-occurrence of homelessness, behavioral health problems, and IPV and lessons learned through a gender-specific homeless services program designed to reach women who are unengaged in traditional services. Recommendations for providing gender-responsive services are discussed.

How people with serious mental illness seek help after leaving jail

In this study, I examined how people with serious mental illness defined and prioritized their service needs when released from jail and how these service priorities shaped the sequencing of help-seeking activities after their release. Data included ethnographic observations and interviews with the staff and clients of a mental health reentry program and responses to an open-ended questionnaire that was given to the program's clients (N = 115). Sixty-three percent of the clients identified housing and 35% identified financial assistance as one of their two most important service needs, whereas only 12% selected treatment services. These service priorities reflect a hierarchy in help-seeking activities postrelease in which clients' access to treatment services was predicated on their ability to first find sustainable economic and material support. I conclude that reentry programs need to have the resources required to meet both the basic and treatment needs of people with serious mental illness leaving jail.

Single room occupancy (SRO) hotels as mental health risk environments among impoverished women: the intersection of policy, drug use, trauma, and urban space

BACKGROUND

Due to the significantly high levels of comorbid substance use and mental health diagnosis among urban poor populations, examining the intersection of drug policy and place requires a consideration of the role of housing in drug user mental health. In San Francisco, geographic boundedness and progressive health and housing polices have coalesced to make single room occupancy hotels (SROs) a key urban built environment used to house poor populations with co-occurring drug use and mental health issues. Unstably housed women who use illicit drugs have high rates of lifetime and current trauma, which manifests in disproportionately high rates of post-traumatic stress disorder (PTSD), anxiety, and depression when compared to stably housed women.

METHODS

We report data from a qualitative interview study (n=30) and four years of ethnography conducted with housing policy makers and unstably housed women who use drugs and live in SROs.

RESULTS

Women in the study lived in a range of SRO built environments, from publicly funded, newly built SROs to privately owned, dilapidated buildings, which presented a rich opportunity for ethnographic comparison. Applying Rhodes et al.'s framework of socio-structural vulnerability, we explore how SROs can operate as "mental health risk environments" in which macro-structural factors (housing policies shaping the built environment) interact with meso-level factors (social relations within SROs) and micro-level, behavioral coping strategies to impact women's mental health. The degree to which SRO built environments were "trauma-sensitive" at the macro level significantly influenced women's mental health at meso- and micro-levels. Women who were living in SROs which exacerbated fear and anxiety attempted, with limited success, to deploy strategies on the meso- and micro-level to manage their mental health symptoms.

CONCLUSION

Study findings underscore the importance of housing polices which consider substance use in the context of current and cumulative trauma experiences in order to improve quality of life and mental health for unstably housed women.

Coping in plain sight: work as a local response to event-related emotional distress in contemporary U.S. society

This article examines how middle-class psychotherapy clients in Southern California use work as a coping strategy in the aftermath of distressing life events. It begins by arguing why all such distress in the aftermath of unbidden and unanticipated events are "local" distresses, embedded in particular social and interpersonal contexts, and then discusses the various ways in which people may use cultural resources, including ordinary, mundane, everyday routines and practices, such as work, to express and cope with emotional distress. Three case studies are used to illustrate how work can be used to avoid emotional distress, to conceal it, and also to acknowledge and heal it.

Making God real and making God good: some mechanisms through which prayer may contribute to healing

Many social scientists attribute the health-giving properties of religious practice to social support. This paper argues that another mechanism may be a positive relationship with the supernatural, a proposal that builds upon anthropological accounts of symbolic healing. Such a mechanism depends upon the learned cultivation of the imagination and the capacity to make what is imagined more real and more good. This paper offers a theory of the way that prayer enables this process and provides some evidence, drawn from experimental and ethnographic work, for the claim that a relationship with a loving God, cultivated through the imagination in prayer, may contribute to good health and may contribute to healing in trauma and psychosis.

Social defeat in recovery-oriented supported housing: moral experience, stigma, and ideological resistance

Drawing from ethnographic observations and interview data gathered during 6 months working as a home caregiver at the Pinewood Apartments, a recovery-oriented supported housing community in Texas, I demonstrate how stigma and social defeat were moral and social processes that pervaded life for all involved, including service providers. Yet, because of the extreme power differentials that characterized tenant-staff relationships, the assault of stigma and social defeat was much more frequent, existentially intense, and morally and materially consequential for certain tenants, whose attempts at ideological resistance were delegitimized by service providers, including myself, who were backed by the authority of dominant psychiatric and moralistic discourses concerning the inherent irrationality and irresponsibility of people with severe mental illness. Nevertheless, due to the indeterminate and at times inharmonious nature of moral experience, it is not my intention to portray tenants as wholly defeated. Rather, individual tenants often exhibited defeat and resistance simultaneously.

The zone of social abandonment in cultural geography: on the street in the United States, inside the family in India

This essay examines the spaces across societies in which persons with severe mental illness lose meaningful social roles and are reduced to "bare life." Comparing ethnographic and interview data from the United States and India, we suggest that these processes of exclusion take place differently: on the street in the United States, and in the family household in India. We argue that cultural, historical, and economic factors determine which spaces become zones of social abandonment across societies. We compare strategies for managing and treating persons with psychosis across the United States and India, and demonstrate that the relative efficiency of state surveillance of populations and availability of public social and psychiatric services, the relative importance of family honor, the extent to which a culture of psychopharmaceutical use has penetrated social life, and other historical features, contribute to circumstances in which disordered Indian persons are more likely to be forcefully "hidden" in domestic space, whereas mentally ill persons in the United States are more likely to be expelled to the street. However, in all locations, social marginalization takes place by stripping away the subject's efficacy in social communication. That is, the socially "dead" lose communicative efficacy, a predicament, following Agamben, we describe as "bare voice."

Missing link in community psychiatry: When a patient with schizophrenia was expelled from her home

Treatment and disposition of homeless patients with schizophrenia represent a great challenge in clinical practice. We report a case of this special population, and discuss the development of homelessness, the difficulty in disposition, their utilization of health services, and possible applications of mandatory community treatment in this group of patients. A 51-year-old homeless female was brought to an emergency department for left femur fracture caused by an assault. She was diagnosed with schizophrenia about 20 years ago but received little help from mental health services over the decades. During hospitalization, her psychotic symptoms were only partially responsive to treatment. Her family refused to handle caretaking duties. The social welfare system was mobilized for long-term disposition. Homeless patients with schizophrenia are characterized by family disruption, poor adherence to health care, and multiple emergency visits and hospitalization. We hope this article can provide information about the current mental health policy to medical personnel. It is possible that earlier intervention and better outcome can be achieved by utilizing mandatory community treatment in the future, as well as preventing patients with schizophrenia from losing shelters.

Perceived competency and resolution of homelessness among women with substance abuse problems

Using a metasynthesis approach, our aim was to articulate new insights relating to the most efficient and effective means of helping homeless women with substance abuse problems to enhance their well-being and become more stably housed. Distorted perceptions of competency, which are shaped by dysfunctional relationships and mental health problems, make it challenging for women with substance abuse problems to resolve homelessness. Women with particularly low or high levels of perceived competency tend to grapple with challenges related to structure and control, trust, and hopelessness. Therapeutic strategies for approaching these women include careful assessment, caring, personalized structure and control, development of interpersonal trust, instillation of hope, and the targeted use of psychotherapeutic agents and counseling. Framing care for homeless women within the context of perceived competency offers a new way of understanding their plight and shaping interventions to more expeditiously move them toward healthy and stable lives.

Culture, stress and recovery from schizophrenia: lessons from the field for global mental health

This cultural case study investigates one U.S. psychosocial rehabilitation organization's (Horizons) attempt to implement the recovery philosophy of the U.S. Recovery Movement and offers lessons from this local attempt that may inform global mental health care reform. Horizons' "recovery-oriented" initiatives unwittingly mobilized stressful North American discourses of valued citizenship. At times, efforts to "empower" people diagnosed with schizophrenia to become esteemed self-made citizens generated more stressful sociocultural conditions for people whose daily lives were typically remarkably stressful. A recovery-oriented mental health system must account for people diagnosed with schizophrenia's sensitivity to stress and offer consumers contextually relevant coping mechanisms. Any attempt to export U.S. mental health care practices to the rest of the world must acknowledge that (1) sociocultural conditions affect schizophrenia outcomes; (2) schizophrenia outcomes are already better in the developing world than in the United States; and (3) much of what leads to "better" outcomes in the developing world may rely on the availability of locally relevant techniques to address stress.

Becoming homeless, being homeless, and resolving homelessness among women

The purpose of this investigation was to more comprehensively articulate the experiences of homeless women and make evidence-based inferences regarding optimal social services. This study was conducted using qualitative meta-synthesis methods. As youth, homeless women experience challenging circumstances that leave them ill-prepared to prevent and resolve homelessness in adulthood. Resolution of homelessness occurs in iterative stages: crisis, assessment, and sustained action. To enhance forward progression through these stages, nurses are encouraged to promote empowerment in concordance with the Transtheoretical and Harm Reduction Models. Services that are highly valued include physical and mental health care and child care assistance.

Disengagement from mental health services. A literature review

This paper reviews the literature on disengagement from mental health services examining how the terms engagement and disengagement are defined, what proportion of patients disengage from services, and what sociodemographic variables predict disengagement. Both engagement and disengagement appear to be poorly conceptualised, with a lack of consensus on accepted and agreed definitions. Rates of disengagement from mental health services vary from 4 to 46%, depending on the study setting, service type and definition of engagement used. Sociodemographic and clinical predictors of disengagement also vary, with only a few consistent findings, suggesting that such associations are complex and multifaceted. Most commonly reported associations of disengagement appear to be with sociodemographic variables including young age, ethnicity and deprivation; clinical variables such as lack of insight, substance misuse and forensic history; and service level variables such as availability of assertive outreach provision. Given the importance of continuity of care in serious mental disorders, there is a need for a consensual, validated and reliable measure of engagement which can be used to explore associations between patient, illness and service related variables and can inform service provision for difficult to reach patients.

Crisis engagement in mental health: a New Zealand Māori contribution

The active engagement of clients in mental health services offers far greater chances of successful outcomes. When clients do not actively engage in treatment, their risk of becoming part of the population of 'high users' is greater. The 'high users' consume a disproportionate share of health resources, which may prevent other potential clients from accessing services. Engagement can be particularly challenging in crisis situations, which is how many clients attracting psychotic diagnoses first enter the service. New Zealand Māori bring a transcendent quality to the idea of 'respect for Other', which would make it sacrilegious to overpower Other in most situations. This paper reviews a growing body of literature indicating how we might integrate an enhanced respect or reverence of Other into clinical practice. This includes the idea of engaging more frequently with the social network when building rapport with an individual is particularly challenging. There is some evidence that services adopting this kind of approach are more economical.