Critical Characteristics of Housing and Housing Supports for Individuals with Concurrent Traumatic Brain Injury and Mental Health and/or Substance Use Challenges: A Qualitative Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Design
2.2. Participants and Recruitment
2.3. Data Collection
- Can you tell me about the challenges you experienced that affected your housing situation along the way?
- What helped you get into and settled into your current housing situation?
- What supports do you have that help you maintain this living situation?
- Is there anything else you wish you had help with?
- What are your hopes for the future regarding housing?
- What suggestions would you like to offer to improve housing for people with brain injury and [mental health and/or substance use] challenges?
- What supports does your organization provide to help individuals with TBI and [mental health and/or substance use] challenges find and maintain housing?
- What do you think are the major challenges that this group face in finding and maintaining housing?
- What are the challenges you face in providing housing supports for this group?
- What services and supports are in place or are needed to address these challenges?
2.4. Data Analysis
2.5. Rigor
3. Findings
3.1. Participants
3.2. Themes
3.2.1. Overcoming Structural Barriers to Housing
3.2.2. Enabling Engagement in Meaningful Activity and Social Connection
4. Discussion
Strengths, Limitations, and Future Directions
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Service Users (n = 16) | Service Providers (n = 15) | ||
---|---|---|---|
Demographic Characteristics | Total N (%) | Demographic characteristics | Total N (%) |
Age, mean (SD) | 50.6 (6.2) | Age, mean (SD) | 42.8 (11) |
Gender | Gender | ||
Man | 13 (81.3) | Man | 4 (26.7) |
Woman | 2 (12.5) | Woman | 11(73.3) |
Other | 1 (6.3) | Education | |
Education | Post-secondary degree | 7 (46.7) | |
Grade eight | 2 (12.5) | Some post-graduate work | 2 (13.3) |
Some high school | 5 (31.3) | Post-graduate degree | 6 (40) |
High school graduate | 2 (12.5) | Job Category | |
Some college/post-secondary | 3 (18.8) | Frontline (e.g., housing worker, crisis support worker, case manager) | 9 (60) |
Post-secondary degree | 3 (18.8) | Management (e.g., program coordinator, housing manager, clinical manager) | 6 (40) |
Some post-graduate work | 1 (6.3) | Experience in Population | |
Marital Status | 0–2 years | 1 (6.7) | |
Single, never married | 8 (50) | 3–4 years | 3 (20) |
Married or domestic partnership | 1 (6.3) | 5–9 years | 3 (20) |
Divorced | 5 (31.3) | 10+ years | 8 (53.3) |
Separated | 2 (12.5) | ||
Ethnicity | |||
White | 13 (81.3) | ||
Black | 2 (12.5) | ||
Asian | 1 (6.3) | ||
Living Situation | |||
Living alone | 8 (50) | ||
Living with others | 5 (31.3) | ||
Shelter/Other | 2 (12.5) | ||
Mental Health and/or Substance Use Diagnosis a | |||
Schizophrenia and other psychosis | 2 (12.5) | ||
Depression | 3 (18.8) | ||
Anxiety | 2 (12.5) | ||
PTSD | 3 (18.8) | ||
History of substance use | 3 (18.8) | ||
No diagnosis reported but receiving mental health supports | 5 (31.3) | ||
Traumatic Brain Injury | |||
Diagnosed | 8 (50) | ||
Self-reported | 8 (50) | ||
Mechanism/Context of Brain Injury b | |||
Assault | 9 (56.3) | ||
Fall | 5 (31.3) | ||
Vehicular accident | 3 (18.8) | ||
Struck by/against | 1 (6.3) | ||
Sports | 1 (6.3) |
Theme | Sub-Theme | Quotes |
---|---|---|
Overcoming structural barriers to housing | Limited housing supply in the context of high demand and affordability issues | […] But they recognize, you know, the mental health challenges…well, my shortcomings and the challenges the house presents to me, and how that affects my housing. A few of them have said you’ve got to move. If you can’t sleep, you can’t stay there. So I’m in the odd situation that I finally have long term stable housing but it’s almost like it’s not healthy for me so I’ve got to keep looking […] and then the challenge there, and this might be a systemic challenge, so okay, you’re in long term stable housing, subsidized. Why should we take you when there’s a homeless person applying for the same place?—Service user |
Attitudes towards and understanding of TBI | But certain landlords won’t even open the door for you. And you can explain… I’ve been in a situation where I was like, “Oh, hi. I’m so and so. I’m a case manager. I’m here to see this client. Can you please let me know… They’re expecting me.” It’s like, “No, she has to open the door herself.” … When I got access into the building, what I walked into was the client laying down in a pool of blood because she fell and cracked her head open. And had to go to the hospital and get 12 stiches across her forehead because she was drinking and she fell. …So it goes both ways. It’s like we’ve had lives saved because of great landlords who were very supportive, and could have potentially had lives lost because of the difficult landlords—Service provider | |
But it’s very hard to convince those landlords to take people that are not working because they can easily get $1000 for the room from a person who’s working […] There’s many reasons […] but the stories I hear from the landlords [are], “No, the last guy I had in here was in here drinking and had all his buddies here, and keeping me and my wife up all night. And I don’t want to have another person in my basement like that.” […] Or “No, I don’t want someone who’s home all day and all night because they’re going to use all my hydro.” You know, they have all these reasons. But it’s hard, you know. […] Like with the rent [supplement], we can negotiate. We can say, “Yes, but they can afford now to pay for the hydro.” So there’s a little buffer when you have a rent [supplement] When you don’t have a rent [supplement], it’s next to impossible. They would much rather get a student who’s paid direct from one of the student placement agencies. So there’s such competition out there right now.—Service provider | ||
So after a while, he just disappeared from the house. He left his key there and he told his housemates he was leaving. So I think this person will end up homeless again just because he didn’t really have any… Well, I think he had supports but he would not accept, right. He just decided… And again, I don’t know if he decided or because he was confused. I don’t know if he knows what he was doing. But I believe he will wind up again homeless just because of his confusion. So in this situation, it’s hard to provide support. Like even though support is there, the person is not accepting. There is not much we can do.—Service provider | ||
What happens is I found 1) they come in and out of service because of the way the service is provided. It’s not the service itself, it’s the way the service is provided. Because people with a brain injury require different methods on how you engage them, on how you work with them, and how you continue to work with them and how you follow-up with them. […] So their social skills are very bad usually because almost all brain injuries are frontal lobe. So you end up with people with poor social skills. They’re rude, they’re loud, they’re aggressive, they fly off the handle really easily. They don’t understand. And people don’t take the time in order to work through those pieces to help people who have a brain injury. Because they don’t know they have a brain injury. They don’t understand. They can’t identify it. And so giving service providers education on how to help somebody with a brain injury, identify somebody with a brain injury, you’re miles ahead of what’s happening right now.—Service provider | ||
Fragmented system | I didn’t know anything. I didn’t know all the rules. I’d hear little tidbits from say [social worker] or whoever. But I’m like I just… I don’t know, I just felt like I was on my own. […] So I don’t know, like knowing who to talk to and knowing what to say and what to ask for, etc. Things like that.—Service user | |
Critical characteristics of housing supports | Service coordination through navigation and facilitation | Well, I’ve had situations where I can sense that somebody is not doing well. So I try to help them finding let’s say a case worker or a case manager or… Yeah, I’ve gone above and beyond my job description to try to help someone maintain their housing […] in this case, I had to go through the Access Point application process, to fill out for her. So that’s something I can do. It’s in my job description. But beyond that, I went with her to doctor’s appointments to make sure she was attending. I went with her to the case worker’s meetings to make sure she would go. So those things I went beyond. So I had to ask my manager for permission. Because I was aware that if I didn’t go with her, she would probably miss the appointment and that would cause her…you know, there would be consequences. So that was something I did beyond my job description.—Service provider |
Education and awareness raising | I thought like I’m really under-resourced in terms of expertise. So we don’t know… What is it that I don’t know–it’s a hard question to answer. […] I think it would just be have more of an awareness. Like I know mental health, there’s illnesses, for example, and I know kind of the symptoms of those illnesses. So when a person presents this way, chances are it could be this or it could be that. You have a frame of reference. With [TBI], I don’t have that. I really don’t know what’s a sign, what do I look for to know that things are getting worse, things are getting better. Like I don’t know what that baseline is and what those points of reference are.—Service provider | |
Partnerships and collaboration | Well, I think part of the fragmentation is caused by the system. I think how we’re funded is an issue. I think how agencies are structured is an issue […] But in order to move forward, we need to create real partnerships and we need to work together to mitigate like fragmented treatment outcomes […] So as an example, with one of the clients who has severe cognitive impairments, he was receiving community-based addiction support. Which is great. But he was getting nothing from it because of the cognitive impairments. So it was only when we would both literally be there together, working side by side, were we actually able to obtain any results.—Service provider | |
Enabling engagement in meaningful activity and social connection | Finding something to do with their time | I wish I had help more with like having a schedule like during the day. Like things to keep myself occupied. […] I think it would help me a lot because I’d have things I’ve got to do every day. If you’ve got a schedule, okay, I’ve got to do this, I’ve got to do this, I’ve got to do this, I don’t have time to sit at home and look at the wall and do drugs or do…you know, drink and stuff. If I’ve got my time occupied, I don’t have time to do that kind of stuff, right. Because if you’ve got a schedule, it keeps you in line, right. It keeps you, okay, I’ve got this I’ve got to do, I’ve got that that I’ve go to do. You’re not going to have time to be doing stupidity. That’s what I need, is a schedule.—Service user |
Living independently and comfortably in housing | But they need a safe place. They need a place where they don’t have to look over their shoulders, where they don’t have to hear their neighbour screaming at their son or something like that. You know, that’s really the biggest thing. Loud noise is not a helpful thing for anybody with a brain injury […] So that’s the whole thing about it, is they’ve got to have a safe place.—Service user | |
Need for social connection | So I don’t know, the home? Just a nice, safe, quiet, comfortable location but also amongst people of like mind. Like a community.—Service user | |
Critical characteristics of housing supports | Creating opportunities for engagement in activity and social interaction | And another thing I think the team does well is supports people going to programs. So like they’ll walk them to the community centre. We often need like maybe 10 times with that warm handover and then finally the client will start going on their own. But taking the time to sort of…to go with them and integrate into different community programs, I think is […] something that’s really important–in supporting people in connecting with the different like community social, recreational activities—Service provider |
Training and skills development | So that’s life skills, right. So that’s understanding how to be clean. Like you can’t pluck somebody from the street and have an expectation that they’re going to know how to cook, and they’re going to know how to clean, and they’re going to know how to budget. So we offer them life skills in the ADLs. So what we call activities of daily living […] So understanding how to budget, you know, and how to budget food. You know, you make leftovers, and this is how you can cook […] So we do those things.—Service provider | |
Design and features of home and neighborhood environments | So our building […] feels like a home. It doesn’t feel like… You know, it doesn’t feel temporary. It doesn’t feel like a hospital, you know. And I think that, you know, having access to privacy, having access to security, those are really important things that clients highlight when they come. You know, like having privacy is…like they really love that. And knowing that they’re in a safe place. Those are two really, really important things.—Service provider |
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Estrella, M.J.; Kirsh, B.; Kontos, P.; Grigorovich, A.; Colantonio, A.; Chan, V.; Nalder, E.J. Critical Characteristics of Housing and Housing Supports for Individuals with Concurrent Traumatic Brain Injury and Mental Health and/or Substance Use Challenges: A Qualitative Study. Int. J. Environ. Res. Public Health 2021, 18, 12211. https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph182212211
Estrella MJ, Kirsh B, Kontos P, Grigorovich A, Colantonio A, Chan V, Nalder EJ. Critical Characteristics of Housing and Housing Supports for Individuals with Concurrent Traumatic Brain Injury and Mental Health and/or Substance Use Challenges: A Qualitative Study. International Journal of Environmental Research and Public Health. 2021; 18(22):12211. https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph182212211
Chicago/Turabian StyleEstrella, Maria Jennifer, Bonnie Kirsh, Pia Kontos, Alisa Grigorovich, Angela Colantonio, Vincy Chan, and Emily Joan Nalder. 2021. "Critical Characteristics of Housing and Housing Supports for Individuals with Concurrent Traumatic Brain Injury and Mental Health and/or Substance Use Challenges: A Qualitative Study" International Journal of Environmental Research and Public Health 18, no. 22: 12211. https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph182212211