Mental Health and Housing Research: housing needs and sustainable independent living.

• Author: Peace, Robin

Abstract

Research to quantify the extent of independent housing need and homelessness and transience among people who experience mental illness, undertaken by the Ministry of Social Development, was commissioned as part of an interdepartmental work programme established by the Ad Hoc Committee on Mental Health in April 2000. Questions of affordability, adequacy and sustainability of housing form the core of the research. A key outcome from the research was the development of a typology focused on the idea of "sustainable housing" for consumers/tangata whai ora. The discussion of the framework provides a backdrop for the presentation of the research findings in which the extent and nature of housing are discussed, the role of support services in the retention of housing summarised, and information about specific groups affected by housing need is put forward. The evidence from the research suggests that there is a need for systematisation of support services for consumers/tangata whai ora and that developing a coordinated inter-agency strategic framework for resource allocation and service provision to this group is a necessary step towards ensuring the sustainability of independent housing.

INTRODUCTION

This paper summarises research undertaken by the Research Unit of the Ministry of Social Development (MSD) between July 2000 and August 2001. The research responded to a Cabinet directive to quantify the independent housing need, and homelessness and transience of consumers/tangata whai ora. (2) Although the immediate function of the research was to inform Government and the initial audience for the findings was government officials, the outcomes from the research have relevance for a wider audience.

An extensive review of the literature (3) identified several key New Zealand documents:

* the Mental Health Commission (MHC) publications establishing the MHC Blueprint for Mental Health Services in New Zealand (1998) and related publications updating progress with service provision;

* the 1998 report, Housing and Housing Support for People with Mental Illness, by Paine;

* the MHC's 1999 discussion paper, Housing and Mental Health: Reducing Housing Difficulties for People with Mental Illness; and

* Bennion's (2000) report, Planning Processes for Providing Supported Accommodation for People with Mental Illness.

The New Zealand research into the experience of mental illness and the effectiveness of services available to consumers/tangata whai ora has taken place in the context of findings that the experience of mental illness and housing difficulties are linked. The widespread acceptance of the link between the two is exemplified by the Mental Health Commission in its 1999 Discussion Paper.

Recovery [from mental illness] requires specific housing arrangements that combine support, a quality physical environment and suitable local environment. These arrangements may include:

* coordination of support, clinical services and housing;

* assistance to make "wise housing choices";

* help from time to time in managing the day to day responsibilities of housekeeping, budgeting and maintaining a house;

* being handy to shops, community facilities, support services and clinical services;

* availability of social support networks (friends and relatives and community);

* meeting needs for living alone or with others;

* empowerment to choose living arrangements; and

* physical comfort, safety and privacy. (Nelson et al. 1998)

The recovery requirements described above were used in conjunction with the Kearns et al. (1991, 1992, 1993) housing stressors, to shape the MSD national survey of 800 mental health service providers paid by the District Health Boards (DHBs). This paper focuses on the findings from this national survey of providers and the group interviews with 190 consumers/tangata whai ora and providers, which together comprised the research fieldwork.

In the following section, we discuss the main challenges presented by the project, the methodological constraints, key concepts and terms, and introduce the conceptual framework for subsequent discussions of sustainability. The next section furthers the discussion and application of the sustainability framework. This is followed by the research findings, and then a concluding section.

MAIN CHALLENGES AND METHODOLOGICAL CONSTRAINTS

A range of challenges had to be met in the research. These included identifying the research population, addressing ethical issues and processes, developing a research strategy, clarifying definitions and terms, and addressing specific methodological constraints.

Identifying the Research Population

The population focus for research on consumers/tangata whai ora depends on whether the research aims to include all people who experience mental illness of any degree, only those who experience "serious, ongoing and disabling" mental illness, or only those who receive mental health services. It is estimated that 20% of the national population has a diagnosable mental illness (including alcohol and drug disorders) at any one time. The Mental Health Commission (1998) reports that around 3% of people have serious, ongoing and disabling mental illness requiring treatment from specialist mental health and alcohol and drug services. Not all of these people are receiving treatment, however, and recent estimates, including one made in the course of this research, suggest that the numbers receiving services are fewer than anticipated (MHC 1998 and MHC 2000 online). We estimate that only about 1.2% of the population are receiving services, and our research draws on information from and about this group. The research paid particular attention to the circumstances of Maori and Pacific peoples and examined the impact of gender issues on housing and mental health. Current data collection and mental health funding criteria made it particularly hard to identify issues in relation to youth, older people and ex-prisoners, but it is important to note that these groups are also significantly affected by mental health and housing issues.

Addressing Ethical Issues and Processes

Ethical issues are complex because people who experience mental illness are considered to be a vulnerable group, potentially open to exploitation. Although the ethical issues are not discussed in any detail in this paper, particular efforts were made to ensure the safety of research participants. Extensive consultation, not only with consumers/tangata whai ora but also with Maori and Pacific communities, was undertaken during the scoping phase for the research. Ethical approval from the Association of Social Science Research was sought and obtained for the project. Informed consent was obtained for all interviews and for survey participation.

Developing a Research Strategy

The project team settled on a research strategy designed to obtain information from a range of sources, using a mix of quantitative and qualitative methods. Twenty-three consumers/tangata whai ora from around the country took part in a one-day workshop as part of the scoping of the research. The main data collection tools were a national survey of 800 mental health service providers and group interviews with 190 consumers/tangata whai ora undertaken between March and July 2001. This empirical work was preceded by an extensive review of relevant New Zealand and international literature.

There were a number of specific methodological constraints produced by the nature and resourcing of the research and discussed in greater detail in the report (Ministry of Social Development forthcoming). An important issue was that, in order to respond to the Cabinet directive to quantify housing need, it was necessary to undertake empirical work since no currently available statistics were suitable for this purpose. It was not considered feasible to conduct a survey of consumers/tangata whai ora, because of the lack of an appropriate sampling frame, and also because of concerns about privacy. Instead, mental health service providers were asked to furnish estimates of the numbers of their consumers who were having housing difficulties of some sort. (4)

It was recognised that this would not be a precise source of data, because some providers would know little about the housing circumstances of the consumers/tangata whai ora using their services. Nevertheless, it was considered that this would permit a rough estimate to be made of the level of housing difficulties they were experiencing.

Clarifying Definitions and Terms

A number of terms and concepts required clarification. This was undertaken systematically throughout the research, and is discussed in more detail in the section below on developing a conceptual framework. The terms around which there is confusion and debate include: clients, consumers, customers, people with mental illness, tangata whai ora; and adequate housing, sustainable housing, unmet housing need, living independently, living independently in the community and supported housing. In order to resolve the issue of definitions for this research, specific interpretations of the concepts were developed on the basis of consultation with mental health service providers, in a series of telephone interviews, and with 23 consumers/tangata whai ora from around the country in a one-day workshop.

An important question in the research revolved around the interpretation of the phrase "independent housing needs", referred to in the Cabinet directive. Because of the difficulty of developing a direct measure of "housing needs", it was decided to use the alternative concept "housing difficulties", which would be more amenable to measurement.

The concept of housing difficulties refers to the whole range of housing and related service-access issues that consumers/tangata whai ora face. Important dimensions of housing difficulties are "adequacy", "suitability", "affordability", and the "sustainability" of housing arrangements, defined...