Independent Supported Housing Versus Institutionalised Residential Rehabilitation for Individuals with Severe Mental Illness: A Survey of Attitudes and Working Conditions Among Mental Healthcare Professionals

Adequate and stable housing conditions are a human right and a public health priority (World Health Organization WHO, 2021). Since deinstitutionalisation, housing rehabilitation has become an important component of psychosocial care for people with severe mental illness (SMI) and housing support needs (Farkas & Coe, 2019). In Western countries, various forms of housing rehabilitation have evolved. Traditionally, housing rehabilitation consists of a continuum of various institutionalised residential care facilities (RCFs), which are organised like a ‘stepladder’: individuals live in more or less intensively supported RCFs, and, as their level of functioning and housing skills improves, they move on to more independent living arrangements and eventually to their own apartments (Ridgway & Zipple, 1990). However, this linear continuum model does not work as intended, and a significant proportion of individuals remain in RCFs (Killaspy et al., 2019; Richter et al., 2016). In contrast, Independent Supported Housing (ISH) provides outreach housing rehabilitation based on the ‘Housing First’ approach and thus directly supports independent and autonomous living for people with SMI (Ridgway & Zipple, 1990). Under this approach, individuals live in their own apartments and are supported by a mobile team for an indefinite period of time.

ISH interventions clearly outperform institutionalised housing rehabilitation for homeless individuals in terms of their effectiveness, especially regarding increased housing stability and reduced hospitalisations (Tsai, 2020). However, with respect to non-homeless individuals, the current evidence does not reveal superiority of either housing rehabilitation setting (McPherson et al., 2018; Richter & Hoffmann, 2017a). Recent effectiveness studies suggest that ISH is similarly effective as or non-inferior to traditional RCFs (Dehn et al., 2022; Mötteli et al., 2022). Despite this, treatment guidelines recommend outreach support in an individual's own home as the first choice in housing rehabilitation, as it enables greater participation in the community and more self-determination for people with SMI than institutionalised RCFs (Gaebel et al., 2012; Gühne et al., 2019; World Health Organization WHO, 2021). The guidelines thus meet the requirements of the UN Convention on the Rights of Persons with Disabilities (UN CRPD) for social inclusion and the right to self-determination of people with SMI (United Nations, 2006). The lagging implementation of the UN CPRD (United Nations, 2022) is also reflected in the supply of housing rehabilitation services. Despite widespread support for ISH interventions, in many countries, the residential rehabilitation standard still consists of RCFs.

ISH is consistent with the preferences of individuals with SMI; most individuals strongly prefer independent living over residential institutions (Richter & Hoffmann, 2017b; Tanzman, 1993). In contrast to affected individuals, their family members as well as professionals tend to recommend assisted RCFs (Minsky et al., 1995; Piat et al., 2008). In a more recent study, caregivers' beliefs about the most appropriate living arrangements for their service users appeared to be so strong that they hindered the conduction of the study (Killaspy et al., 2019). Despite the clinical equivalence of institutionalised and outreach housing rehabilitation, many mental healthcare professionals (MHCPs) assumed different levels of support and supervision. However, neither these perceptions nor the degree of institutionalisation in the respective housing rehabilitation setting seem to reflect the severity of the service users’ illness and functional impairment (Valdes-Stauber & Kilian, 2015).

With the present study, we aimed to explore from a MHCPs’ perspective why the implementation of ISH interventions has been lagging despite the strong preferences among individuals with SMI and urgent recommendations from policies and treatment guidelines. For this purpose, we conducted a survey among MHCPs in outreach (ISH) and institutionalised (RCFs) housing rehabilitation settings and compared different work-related and attitudinal factors such as preferences for either housing rehabilitation approach (‘continuum’ vs. ‘Housing First’ approach), attitudes toward mental health and recovery, as well as working conditions or job demands between MHCPs working in ISH and RCFs. In addition, we aimed to examine obstacles MHCPs face and factors they perceive as important for successful housing rehabilitation of service users and to compare these between the two settings.

An online survey was conducted among MHCPs in psychiatric housing rehabilitation settings in the three largest German-speaking cities in Switzerland: Bern, Basel and Zurich. All three cities offer ISH interventions and different RCFs, such as residential care homes, and assisted/supported group homes for people with SMI (see Table 1). Heads of facilities and services were targeted via email for participation. In October 2021, all MHCPs were asked to participate in a survey on challenges and attitudes concerning their work on housing rehabilitation for individuals with SMI. The survey was conducted in German and took 10–20 min to complete. Responses were collected anonymously using Unipark survey software. A total of 117 MHCPs responded to the survey, giving an estimated response rate of 33%. Of these, five persons were excluded from the analyses (four did not belong to a caregiving group, and one subject had many missing values, including the rehabilitation setting). The survey included questions concerning MHCPs’ preferences, attitudes, stress and strain at work, factors perceived as obstructive or important for successful housing rehabilitation and sociodemographic variables. Ethical approval was not required as confirmed by the Ethics Committee of the Canton Zurich, Switzerland (Req-2022-00714).

Most of the 112 participating housing rehabilitation MHCPs from ISH and RCFs for individuals with SMI favour the ‘Housing First’ approach over the conventional continuum of different RCFs. The so far tentatively implemented ISH interventions therefore not only correspond to the preferences of individuals with SMI (Richter & Hoffmann, 2017b) and to current policies (United Nations, 2006) and guidelines (Falkai, 2012; Gaebel et al., 2012; World Health Organization WHO, 2021), but also receive endorsement from MHCPs in both settings. The MHCPs’ preferences for a certain housing rehabilitation approach in general does not seem to contribute to the lagging implementation of ISH interventions. Also, MHCPs’ attitudes toward recovery did not show relevant differences between the settings. However, MHCPs’ attitudes in RCFs showed higher levels of stigmatisation toward persons with SMI. In addition, RCF workers mentioned service users’ characteristics as an important barrier for successful rehabilitation, which was not the case for ISH workers. These results may reflect a more protective and restraining attitude in RCFs than in ISH in line with current policies and guidelines, which state a higher potential of ISH interventions in the promotion of service users’ social inclusion and participation in the community (Gühne et al., 2019; United Nations, 2006; World Health Organization WHO, 2021).

Work-related satisfaction and health did not differ between the two settings. In ISH, MHCPs reported higher job demands, more opportunities for development, and greater influence at work than professionals in RCFs. Having influence and opportunities for development can contribute to employees’ satisfaction and health (Nübling et al., 2006). ISH therefore appears to be associated with more opportunities for independent, preference-based decision-making than RCFs, not only for service users (World Health Organization WHO, 2021) but also for MHCPs. In addition, MHCPs in both settings most frequently agreed with the statement that individuals with SMI best acquire housing skills when living independently with outreach support. Noteworthy, the majority of MHCPs working in RCFs agreed with this statement. This indicates that the traditional continuum approach is being increasingly evaluated critically not only in the literature (Fakhoury & Priebe, 2007; Priebe et al., 2005; Richter et al., 2016) but also during the practical everyday lives of housing rehabilitation professionals.

In both housing rehabilitation settings (ISH and RCFs), MHCPs showed remarkably high recovery orientation and open-mindedness toward individuals with SMI. This is of high relevance because the attitudes of MHCPs are crucial to the success of rehabilitation interventions (Richter et al., 2016). The importance of a strong recovery orientation of the supporting professionals was also emphasised by them in the qualitatively evaluated open questions. This, together with the availability of low-threshold support services, was highlighted by MHCPs in both settings as central factor in enabling persons with SMI to live in a stable and equitable manner.

Regarding obstacles to successful housing rehabilitation, however, MHCPs were faced with different problems between the settings. In RCFs, characteristics of service users (e.g. limited personal resources), of the support process (e.g. MHCPs’ lack of resources and flexibility regarding time and content), and contextual circumstances (especially the lack of affordable accommodations) were stated as obstructive factors with equal frequency. In ISH, on the other hand, characteristics of the service users do not seem to be an obstacle in the rehabilitation process. However, based on the available data, one cannot determine to what extent service users of the two settings differed in terms of their symptoms and functioning, despite the comparable indications of the services regarding service users’ level of impairment or functioning. Other research shows differences in diagnosis and gender of service users between different housing rehabilitation settings (de Heer-Wunderink et al., 2012; Dehn et al., 2022; Martinelli et al., 2019; Nordentoft et al., 2012). However, there is some evidence that questions a clear association between disease severity and the degree of institutionalisation (de Heer-Wunderink et al., 2012; Valdes-Stauber & Kilian, 2015). Thus, it remains a question of further research if service users in RCFs have actually more severe impairments, or if the view of service users’ non-readiness for independent living reflects the traditional continuum approach, which aims to first train and prepare service users before considering them competent to live independently. According to the surveyed MHCPs, outreach housing rehabilitation is mainly obstructed by social and environmental conditions. In particular, a lack in affordable accommodation, financial and regulatory hurdles and the social stigmatisation of individuals with SMI impede outreach housing rehabilitation and the social inclusion of service users.

The generalisation of the results might be limited. Data was collected only in one country and in a limited number of sites. In two of the three sites, the rehabilitation providing institutions each provide both settings and no fidelity assessment of the participating services was conducted. This could pose the risk that the institutions follow specific policies and do not explicitly follow normative guidelines of good services. Because the study was conducted as an online survey, generalisability may further be limited by participants’ self-selection. Despite the considerable response rate of 33%, participants may differ from non-participants, for example in their interest in the issue. In addition, response patterns might be biased toward social desirability.

The results of this study indicate that MHCPs’ preferences, attitudes or working conditions seem not to substantially contribute to the lagging implementation of the strongly preferred and widely recommended ISH interventions. MHCPs of both housing rehabilitation settings (ISH and RCFs) gave stronger endorsement of the ISH approach. However, the findings of this study show that societal and political conditions constitute major barriers. Therefore, successful housing rehabilitation in terms of an independent, self-determined life as a participating member of the community would be almost impossible for people with SMI without the support of housing rehabilitation professionals.