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AIMS We sought to identify person- and program-level factors distinguishing permanent supportive housing (PSH) residents with higher versus lower social integration; and higher versus lower instrumental functioning. METHODS Among 60 PSH residents at Los Angeles' VA, surveys and medical records captured person-level factors. Using a median split, we dichotomized participants with higher versus lower social integration; and higher versus lower instrumental functioning. Recursive partitioning (RP) identified variables that best-differentiated these subgroups. Interviews with 26 participants captured their perceptions on social integration and instrumental functioning. RESULTS Using RP, health-related quality of life, psychiatric symptoms and case management frequency best-differentiated the social integration subgroups. Few perceived that PSH affected social integration. RP did not yield a stable model to differentiate the instrumental functioning subgroups; participants perceived that PSH addressed most functional deficits. CONCLUSIONS Services that enhance social integration may benefit PSH residents with poor health; existing services may adequately address instrumental functioning.

Objective: Many persons with serious mental illness (SMI) who have experienced homelessness struggle to sustain stable and independent housing. We know little about determinants of this population's housing status. This study aimed to identify person-level determinants of housing status among homeless-experienced veterans with SMI, focused primarily on cognition. Method: We administered cross-sectional surveys and detailed cognitive assessments on a convenience sample of homeless-experienced veterans with SMI (n = 90); we also reviewed these participants' medical records. We captured person-level potential predictors of housing status (demographics, cognition, diagnoses, symptoms, and service utilization) and 2 years of retrospective housing history. Participants' housing status was conceptualized as the setting (stable housing, other sheltered settings, and streets) they lived in for >50% of the past 2 years. We used the chi-square test and analysis of variance to determine how potential predictors differed by housing status. We used recursive partitioning to identify the combination of potential predictors and corresponding scores that best-differentiated participants by housing status. Results: No between-groups differences (p < .05) in cognition, symptoms, or other person-level factors were found among participants grouped by housing status. Recursive partitioning did not yield a stable model to predict housing status from the potential predictor variables. Conclusions and Implications for Practice: These data suggest that clinical interventions addressing studied person-level factors (e.g., cognitive rehabilitation) may not affect housing status for homeless-experienced veterans. As housing is highly influenced by social determinants of health, policies, and practices that affect contextual factors (e.g., affordable housing supply) may be more likely to improve housing status. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

BackgroundLittle is known about the determinants of community integration (i.e. recovery) for individuals with a history of homelessness, yet such information is essential to develop targeted interventions.MethodsWe recruited homeless Veterans with a history of psychotic disorders and evaluated four domains of correlates of community integration: perception, non-social cognition, social cognition, and motivation. Baseline assessments occurred after participants were engaged in supported housing services but before they received housing, and again after 12 months. Ninety-five homeless Veterans with a history of psychosis were assessed at baseline and 53 returned after 12 months. We examined both cross-sectional and longitudinal relationships with 12-month community integration.ResultsThe strongest longitudinal association was between a baseline motivational measure and social integration at 12 months. We also observed cross-sectional associations at baseline between motivational measures and community integration, including social, work, and independent living. Cross-lagged panel analyses did not suggest causal associations for the motivational measures. Correlations with perception and non-social cognition were weak. One social cognition measure showed a significant longitudinal correlation with independent living at 12 months that was significant for cross-lagged analysis, consistent with a causal relationship and potential treatment target.ConclusionsThe relatively selective associations for motivational measures differ from what is typically seen in psychosis, in which all domains are associated with community integration. These findings are presented along with a partner paper (Study 2) to compare findings from this study to an independent sample without a history of psychotic disorders to evaluate the consistency in findings regarding community integration across projects.

OBJECTIVES: The experience of homelessness for young people can impact social, emotional and physical development, resulting in poorer physical and mental health outcomes. To reduce rates of homelessness in youth, a better understanding of both risk and resilience is needed to inform future intervention development. This article presents a systematic review of published research reporting risk or resilience factors related to homelessness in young people in Western countries, and integrates this information into a provisional developmental model of homelessness risk in youth. Clinical implications of this model on service development are discussed, and a model for monitoring homelessness risk and resilience factors (HOME) is proposed. METHODS: After thorough examination for inclusion criteria, 665 abstracts of peer-reviewed quantitative examinations of risk or resilience factors for homelessness in young people (aged 0–25), including an adequate comparison group (e.g., non-homeless) were selected and, following abstract and full text screening, 16 articles were included in this review. Using a primary prevention framework, an explanatory model for the onset of homelessness using risk and resilience factors is proposed. RESULTS: Common risks for youth homelessness identified by this research included difficulties with family, mental health or substance use problems, a history of problem behaviors, a history of foster care, homelessness as a child, or running away. Common protective factors included a supportive family, a college education and high socioeconomic status. CONCLUSIONS: Factors impacting homelessness risk in youth differ from adults, with family, foster care and schooling playing a much more important role. This highlights opportunities for youth homelessness prevention strategies, and monitoring.

Background Only 7% of individuals with co-occurring mental health and substance use disorder (COD) receive services for both conditions. We implemented and evaluated maintaining independence and sobriety through systems integration, outreach and networking-Veteran's edition (MISSION-Vet), an evidence-based manualized psychosocial intervention for Veterans with CODs. This paper identifies the generative mechanisms that explain “how, for whom, and under what conditions” MISSION-Vet adoption, implementation, and fidelity work when applied in a complex adaptive system with facilitation support. Methods Within two VA healthcare systems (Sites A and B), a hybrid III trial tested facilitation to implement MISSION-Vet. We conducted a two-site case study based on 42 semi-structured consolidated framework for implementation research (CFIR) guided interviews with site leadership, implementers (social workers, peer specialists), and team members (facilitators, site leads). Interviews were coded and CFIR constructs used to generate “Context + Mechanism = Outcome” configurations to understand the conditions of MISSION-Vet adoption, implementation, and fidelity. Results Site A was low, and Site B was high in adoption, implementation, and fidelity. Adoption hesitancy/eagerness (outcome) resulted from the interaction of “external policy” (context) dampening/encouraging a “tension for change” (mechanism). Implementation intensity (outcome) was based on how “peer pressure” or practice culture (context) activated staff “self-efficacy” (mechanism) to engage with MISSION-Vet and appraise its “relative advantage” over current practices (mechanism). Fidelity relied on how “staffing structure and availability” (context) activated/muted “facilitation” (mechanism) to result in strategy and intervention adaptation (outcome). Conclusions We delineated how specific contexts activated certain mechanisms to drive the different stages of implementation of a multi-faceted COD treatment intervention. Trial registration ClinicalTrials.gov, NCT02942979. Plain language abstract Implementation is inherently dynamic and influenced by interdependent factors operating at the individual, organizational, and system levels. This is especially true for complex interventions addressing co-occurring mental health and substance use disorders because such interventions involve multiple treatment modalities delivered simultaneously, in busy practice settings, with challenging populations. This paper pairs consolidated framework for implementation research (CFIR) constructs with a realist evaluation approached to generate configurations important to the adoption, implementation, and adaptation stages of a highly complex intervention addressing the behavioural health and housing needs of a vulnerable population. Each configuration describes how contextual factors trigger mechanisms to generate implementation outcomes and answers “what works for whom, in what circumstances and in what respects, and how?” These findings further our understanding of possible mechanisms of change and push us to be more precise about identifying causal relationships among constructs that contribute to the success of implementing complex interventions. This work also moves us to think theoretically and methodologically in a more dynamic fashion, thereby leading to more responsive implementation practice.

To address homelessness among Veterans, a growing proportion of permanent supportive housing units supported by the U.S. Departments of Housing and Urban Development and Veterans Affairs Supportive Housing (HUD-VASH) program are allocated to programs where multiple Veterans with a history of homelessness live in a particular building, referred to as single-site housing. This mixed-methods study-including administrative data from Veterans who moved into HUD-VASH housing and qualitative data from focus groups with services providers at 10 single-site programs-describes the characteristics and needs of Veterans who moved into single-site HUD-VASH programs, the rationale for developing single-site HUD-VASH programs, and the services provided in single-site programs that are responsive to Veterans' needs. Based on quantitative analyses, Veterans who were older and had chronic medical and mental health conditions and sought related care were at increased odds of receiving single-site housing. Qualitatively, we found that HUD-VASH programs developed single-site programs for two reasons: to ensure that the most vulnerable Veterans remained housed through the provision of supportive services and to increase housing options for hard-to-house Veterans, including those who require more support because of medical, mental health, or substance use disorders; physical disabilities; or lack of ability to live independently for other reasons. Due to the high needs of Veterans served by single-site programs, development of these programs should consider both space and staffing needs. Future research should assess the relationship between assignment to housing type and health and housing outcomes for participants as well as service enhancements to address Veterans' needs. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Objective Resilience is broadly defined as the ability to respond adaptively to challenges or adversity. It is unclear which clinical and cognitive factors are most closely related to resilience. Also, the dimensions that comprise resilience may differ among different groups, such as those who are homeless. The purpose of this study was to understand the relationships between resilience and clinical, cognitive, and functional variables among homeless veterans and to determine independent predictors of resilience. Method One hundred homeless veterans completed measures of resilience, defeatist beliefs, negative symptoms, psychotic and mood symptoms, social and nonsocial cognition, and community functioning. We examined associations between resilience and clinical, cognitive, and functional measures. We performed regression analyses to determine independent contributions of the variables to resilience. Results Resilience was correlated with negative symptoms, defeatist beliefs, depression/anxiety symptoms, and social cognition. There were no significant correlations with nonsocial cognition or psychotic symptoms. Stepwise multiple linear regression showed that defeatist beliefs, motivational negative symptoms, expressive negative symptoms, and depression/anxiety symptoms made independent contributions. Resilience was correlated with community functioning in the domains of work, independent living, and social and family relationships. History of psychosis moderated the relationship between resilience and defeatist beliefs, which was stronger in those who had experienced psychosis. Conclusions and implications for practice These findings suggest that resilience is an important construct to consider in homeless veterans, is related to other clinical factors such as defeatist beliefs and negative symptoms, and could be a valuable treatment target with the goal of improving functioning. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

OBJECTIVE: By combining supportive services with independent housing, permanent supportive housing (PSH) programs effectively address homelessness. Yet, many persons with serious mental illness struggle to attain and retain housing in these programs. Social skills—which facilitate social interactions and instrumental tasks—predict premature exit from PSH. This project aimed to build consensus on a set of social skills that supports independent housing attainment and retention among homeless persons with serious mental illness, with a clinical focus on PSH programs. METHODS: Guided by the RAND/University of California, Los Angeles, appropriateness method, the set of social skills was developed by using literature review; key informant interviews (N=12), a national consensus panel of experts in psychosocial rehabilitation and homelessness (N=11), and two focus groups with homeless persons with serious mental illness (N=17). RESULTS: These methods identified 24 social skills in seven domains: finding and renting an apartment, using one’s time well, getting closer to people, managing finances, avoiding problems with drugs and alcohol, solving interpersonal problems, and managing one’s health. Expert panelists and focus group participants agreed that these social skills were feasible for inclusion in social skills training and could strongly affect housing outcomes in PSH settings. CONCLUSIONS: Consensus was reached about a set of social skills relevant to housing attainment and retention for persons with serious mental illness engaged in PSH. Next steps include modifying social skills training interventions to this skill set, making contextual modifications relevant to the setting and context of PSH, and studying the effectiveness and implementation of the adapted intervention in PSH.

Introduction Unsheltered homelessness is a strongly debated public issue. The study objective is to identify personal and community characteristics associated with unsheltered homelessness in veterans and to test for interactions between these characteristics. Methods In a 2018 national survey of U.S. veterans with homeless experiences; investigators assessed unsheltered time; psychosocial characteristics; and community measures of shelter access, weather, and rental affordability. Associations between these characteristics and unsheltered status were tested in July–August 2020. This study also tested whether the count of personal risk factors interacted with community characteristics in predicting unsheltered status. Results Among 5,406 veterans, 481 (8.9%) reported ≥7 nights unsheltered over 6 months. This group was more likely to report criminal justice history, poor social support, medical and drug problems, financial hardship, and being unmarried. Their communities had poorer shelter access and warmer temperatures. The likelihood of unsheltered experience rose with risk factor count from 2.0% (0–1) to 8.4% (2–3) and to 24.2% (4–11). Interaction tests showed that the increase was greater for communities with warmer weather and higher rents (p Conclusions Among veterans experiencing homelessness, unsheltered experiences correlate with individual and community risk factors. Communities wishing to address unsheltered homelessness will need to consider action at both levels.

Individuals attending residential rehabilitation programs for substance misuse are particularly vulnerable to treatment disruptions spurred by the novel coronavirus disease 2019 (COVID-19) pandemic. We describe adaptations to services within a large residential rehabilitation program for under-resourced veterans, report veterans' experiences with these changes, and outline successes and challenges encountered throughout adjustment to the pandemic. Data collected from two focus groups with nine veterans engaged in this program during the pandemic highlight experiences of inconsistent communication about residential policies, interruptions to medical and addiction services, and feelings of confinement and social isolation. Overall, these findings suggest the need for health systems to support clients in taking an active role in communications, provide additional technical and social support in transitioning to virtual health services, and offer alternative means for clients to maintain social connection during a pandemic. Understanding clients' perspectives can inform strategies to promote continuity of care and enhanced care experiences.

BackgroundIn an initial study (Study 1), we found that motivation predicted community integration (i.e. functional recovery) 12 months after receiving housing in formerly homeless Veterans with a psychotic disorder. The current study examined whether the same pattern would be found in a broader, more clinically diverse, homeless Veteran sample without psychosis.MethodsWe examined four categories of variables as potential predictors of community integration in non-psychotic Veterans: perception, non-social cognition, social cognition, and motivation at baseline (after participants were engaged in a permanent supported housing program but before receiving housing) and a 12-month follow-up. A total of 82 Veterans had a baseline assessment and 41 returned for testing after 12 months.ResultsThe strongest longitudinal association was between an interview-based measure of motivation (the motivation and pleasure subscale from the Clinical Assessment Interview for Negative Symptoms) at baseline and measures of social integration at 12 months. In addition, cross-lagged panel analyses were consistent with a causal influence of general psychiatric symptoms at baseline driving social integration at 12 months, and reduced expressiveness at baseline driving independent living at 12 months, but there were no significant causal associations with measures of motivation.ConclusionsThe findings from this study complement and reinforce those in Veterans with psychosis. Across these two studies, our findings suggest that motivational factors are associated at baseline and at 12 months and are particularly important for understanding and improving community integration in recently-housed Veterans across psychiatric diagnoses.

Homeless persons with psychosis are particularly susceptible to unsheltered homelessness, which includes living on the streets, in cars, and other places not meant for human habitation. Homeless persons with psychosis have distinct barriers to accessing care and comprise a high-need and hard-to-serve homeless subpopulation. Therefore, this study sought to understand unsheltered homelessness in persons with psychosis and its relationship to cognitive impairment, clinical symptoms, and community functioning, examined both categorically and dimensionally. This study included 76 homeless participants with a history of a psychotic diagnosis who were enrolled in a supported housing program but had not yet received housing. This study used two different housing stability thresholds (literally homeless at any point vs. literally homeless >20% of days) for comparing homeless Veterans with psychosis living in sheltered versus unsheltered situations on cognition, clinical symptoms, and community integration. Dimensional analyses also examined the relationship between percentage of days spent in unsheltered locations and cognition, clinical symptoms, and community integration. Sheltered and unsheltered Veterans with psychosis did not differ on clinical symptoms or community integration, but there was an inconsistent group difference on cognition depending on the threshold used for determining housing stability. In the unsheltered group, cognitive deficits in overall cognition, visual learning, and social cognition were related to more days spent in unsheltered locations. Rehabilitation efforts targeting specific cognitive deficits may be useful to facilitate greater access to care and successful interventions in this population.

OBJECTIVES Little research has assessed the nature of veterans' departures from permanent supportive housing (PSH), which may be of positive valence (e.g., moving into more independent housing). This study aimed to identify participants appropriate for "graduation" from PSH and how to support their transitions. METHOD This mixed methods study used qualitative data from PSH program staff, 445 PSH participants' responses to a survey assessing their experiences and administrative records, and qualitative data from a subsample of 10 participants who graduated from the program. Participants were classified as "stayers" (retained in PSH for at least 600 days); "graduates" (exited with improvement in community integration); or "involuntary leavers" (exited for reasons of negative valence). Template analysis of qualitative data from PSH staff described graduation processes; qualitative data from participants were analyzed using a thematic analysis approach. The study compared veterans' characteristics using chi-square and analysis of variance (ANOVA) tests; a multinomial logistic regression assessed correlates of graduates' and involuntary leavers' exits from PSH. RESULTS Approximately one half of participants who exited the program were graduates. Processes used by program staff to identify potential graduates varied. Participants' self-report of substance use and mental health problems was associated with involuntary leaver status. Frequency of case management, a trusting relationship between participant and case manager, and participants' receipt of compensation related to disability incurred during military service were associated with graduation. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE To support successful transitions from PSH, programs should focus on providing high-quality case management that may respond flexibly to participants' varying recovery needs. (PsycINFO Database Record

Permanent, community-based housing with supportive services ("supported housing") has numerous favorable outcomes for homeless-experienced consumers. Little is known, however, about consumers who attain but subsequently lose their supported housing. Using mixed methods, we compared persons who retained their supported housing for at least 1 year ("stayers") with those who lost their supported housing within 1 year of move-in ("exiters"). Among persons housed through the VA Supported Housing (VASH) program at the VA Greater Los Angeles between 2011 and 2012, we queried VA homeless registry data to identify stayers (n = 1,558) and exiters (n = 85). We reviewed the medical records of 85 randomly selected stayers and all 85 exiters to compare demographics, homelessness chronicity, era of service, income, presence or absence of a serious mental illness, and health service utilization. From this subsample, we purposively selected 20 stayers and 20 exiters for semistructured, qualitative interviews, and more detailed medical record review. We also performed qualitative interviews and focus groups with VASH staff/leadership (n = 15). Recursive partitioning identified quantitative variables that best-differentiated stayers from exiters. Thematic analyses were performed on qualitative data. Interrelated factors were associated with exiting supported housing: chronic homelessness; low intrinsic motivation; unmet needs for mental health care, substance abuse treatment, and independent living skills; poor primary care engagement; frequent emergency department use; and recent mental health hospitalizations. These findings suggest the value of clinical interventions that address these factors-for example, motivational interviewing or social skills training-adapted to the setting and context of supported housing. (PsycINFO Database Record

Homelessness is a major public health problem, and serious mental illness (SMI) is highly prevalent in the homeless population. Although supported housing services-which provide permanent housing in the community along with case management-improve housing outcomes, community integration typically remains poor, and little is known about the underlying determinants of poor community integration postresidential placement. The general SMI literature has indicated that motivational and cognitive ability factors are key determinants of successful community integration, which provides a foundation for examining this issue. This study evaluated whether interview- and performance-based assessments of motivation, nonsocial and social-cognitive ability, and psychiatric symptoms were associated with community integration indices in 2 samples of homeless veterans either with (N = 96) or without (N = 80) a psychotic disorder who had recently been admitted to a supported housing program but who had not yet attained housing. Motivation indices, including experiential negative symptoms and defeatist performance attitudes, stood out as the most robust correlates (rs = -.30 to -.69) of community integration across both samples, particularly for social role participation. Demographics, general psychiatric symptoms, and nonsocial cognition showed generally weak relations with community integration, though social cognition showed a few relations. The consistent findings across samples point to the importance of motivational factors for understanding the determinants of poor community integration in this complex population. Further, interventions that target motivational challenges may have widespread usefulness for enhancing community integration outcomes beyond obtaining housing. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Community integration is recognized as a meaningful goal that is highly relevant to the long-term success of supportive housing programs. Research to date highlights concerns that some individuals in permanent supportive housing remain socially isolated and have limited success in other domains of community integration. However, we know little about what factors impact formerly homeless veterans’ ability to achieve community integration. To identify factors associated with community integration among homeless veterans housed through the Department of Veterans Affairs’ (VA’s) Supportive Housing program (HUD-VASH), we performed secondary database analyses of Veterans (n = 560) housed via HUD-VASH in the VA Greater Los Angeles Healthcare System from 10/1/14–9/30/15. We conducted ordinal and logit regressions to examine associations between baseline HUD-VASH participant characteristics, supportive housing voucher type, health service utilization in the year post-housing, and three types of community integration outcomes (i.e., change in community adjustment, status of housing stability, and change in employment). Data were obtained from HOMES (VA’s homeless registry) and Corporate Data Warehouse (CDW) (VA’s a national administrative dataset of VA inpatient and outpatient care). Mental health service utilization was negatively associated with community adjustment, housing stability, and employment. Employment at baseline was positively associated with housing stability and employment. Also, substance use disorder visits was positively associated with employment, and combined medical and substance use disorder diagnoses was positively associated with change in community adjustment. We considered 29 variables and found relatively few were associated with community integration. Consistent with previous research, our study highlights the importance of mental health needs, and suggests that utilization of mental health services is an important indicator of improvements in community adjustment, housing stability, and employment.

Few interventions train homeless consumers in housing-related independent living skills. To inform the development of such interventions for the Department of Veterans Affairs' Supported Housing consumers with serious mental illness, we examined these consumers' problem-solving skills and deficits. We performed semistructured interviews and cognitive tests with 20 consumers who retained housing for ≥1 year ("stayers") and 20 consumers who lost housing in

Objective Research suggests that social supports are associated with housing retention among adults who have experienced homelessness. Yet, we know very little about the social support context in consumers find and retain housing. We examined the ways and identified the junctures in which consumers' skills and deficits in accessing and mobilizing social supports influenced their longitudinal housing status. Method We performed semi-structured qualitative interviews with VA Greater Los Angeles consumers (n = 19) with serious mental illness, substance use disorders, and a history of homelessness; interviews explored associations between longitudinal housing status (categorized as: stable, independent housing; sheltered housing, continually engaged in structured housing programs; and unstable housing) and social supports. We compared data from consumers in these 3 mutually exclusive categories. Results All participants described social support as important for finding and maintaining housing. However, participants used formal (provider/case managers) and informal (family/friends) supports in different ways. Participants in stable housing relied on formal and informal supports to obtain/maintain housing. Participants in sheltered housing primarily used formal supports, for example, case management staff. Unstably housed participants used formal and informal supports, but some of these relationships were superficial or of negative valence. Interpersonal problems were prevalent across longitudinal housing status categories. Conclusions and implications for practice Social context, including patterns of formal and informal support, was associated with participants' longitudinal housing status. Within interventions to end homelessness, these findings suggest the value of future research to identify, tailor, and implement practices that can help consumers improve their social resources. (PsycINFO Database Record

Community integration is integral to recovery for individuals with severe mental illness. This study explored the integration of individuals with severe mental illness into mental health and non-mental health communities and associations with mental health service intensity.Thirty-three ethnically diverse participants with severe mental illness were categorized in high-intensity (N=18) or low-intensity (N=15) mental health service groups. Community integration was assessed with measures of involvement in community activities, social capital resources, social support, social network maps, and subjective integration.Although participants rated themselves as being more integrated into the mental health community, their social networks and social capital were primarily derived from the non-mental health community. The high-intensity group had a higher proportion of members from the mental health community in their networks and had less overall social capital resources than the low-intensity group.The findings suggest opportunities and possible incongruities in the experience of community integration.

Author(s): Gabrielian, Sonya; Hamilton, Alison B; Gelberg, Lillian; Hellemann, Gerhard; Koosis, Ella R; Johnson, Axeline; Young, Alexander S | Abstract: IntroductionSupported housing-which offers permanent, community-based housing and supportive services-effectively addresses homelessness. Yet, many persons with serious mental illness (SMI) struggle to retain housing in these programs. Social skills-which facilitate social interactions and instrumental tasks-predict premature exits from supported housing. Though social skills training effectively improves social skills and functioning for persons with SMI, this intervention is essentially absent from supported housing initiatives.MethodsThis study will use literature review, key informant interviews and an expert panel to adapt social skills training for supported housing, aiming to improve housing retention among SMI persons in these programs. In the Department of Housing and Urban Development-VA Supported Housing program (HUD-VASH) at VA Greater Los Angeles, we will conduct an effectiveness-implementation hybrid type I trial of the adapted intervention. Baseline and 6-month assessments (measuring social skills, mental health status, healthcare utilization, social networks, money management, and housing outcomes) will be conducted with intervention participants (n = 30) and a usual care control group (n = 20). We will use the generalized linear mixed model (GLMM) to compare change over 6 months between groups, capturing the intervention's effectiveness on factors strongly associated with housing retention. Qualitative data and surveys with staff, leadership, and participants will gather data on factors relevant to the intervention's future implementation in routine care.DiscussionFew effective psychosocial interventions for persons with SMI have been adapted or studied in supported housing initiatives. To our knowledge, this is the first study to adapt and study the effectiveness and implementation of social skills training in supported housing programs.

Community integration is recognized as a crucial component of recovery from serious mental illness. Although the construct of community integration can be measured with structured instruments, little is known about the subjective and experiential meaning of community and community involvement for persons with serious mental illness.In 2010, 30 individuals with serious mental illness treated in two public mental health clinics completed semistructured interviews that elicited the places and people that they associate with the experience of community and the larger meaning of community in their lives.Participants described four experiences as integral to their concepts of community: receiving help, minimizing risk, avoiding stigma, and giving back. Participants looked for communities that provide reliable support, and they described the need to manage community contact in order to protect themselves and others from their symptoms and from discrimination. Most participants experienced communities centered on mental health treatment or mentally ill peers as providing opportunities for positive engagement.The experience of having a serious mental illness shapes preferences for and perceptions of community in pervasive ways. Participants described community involvement not as a means to move away from illness experiences and identities but as a process that is substantially influenced by them. Mental health communities may help individuals with serious mental illness to both manage their illness and recognize and enjoy a sense of community. The findings indicate the need for further research on the relationship between community integration and outcome in serious mental illness.

Kohlberg’s moral stage scale is but one of a number of “Piagetian” developmental scales proposed during the latter part of this century. Kohlberg claimed that his moral stages fulfilled the criteria for “hard” Piagetian stages—invariant sequence, qualitative change, and structured wholeness. He also argued that his scoring system measures a dimension of thought with a unique structure. To explore these contentions, we compare the concepts that define Kohlbergian stages with those associated with orders of hierarchical complexity as determined with the Hierarchical Complexity Scoring System, a generalized content-independent stage-scoring system. We conclude that the sequence of conceptual development specified by Kohlberg generally matches the sequence identified with the Hierarchical Complexity Scoring System, and that contract and authority concepts identified with a methodology that employs the Hierarchical Complexity Scoring System match the concepts that define theoretically analogous Kohlbergian stages above Kohlberg’s stage 2. However, we argue that Kohlberg’s stages 1 and 2 do not accurately describe the development of moral concepts in young children.

ObjectiveWe sought to understand the housing trajectories of homeless consumers with serious mental illness (SMI) and co-occurring substance use disorders (SUD) and to identify factors that best predicted achievement of independent housing.MethodUsing administrative data, we identified homeless persons with SMI and SUD admitted to a residential rehabilitation program from December 2008 to November 2011. Our primary outcome measure was independent housing status. On a random sample (N = 36), we assessed a range of potential predictors of housing outcomes, including symptoms, cognition, and social/community supports. We used the Residential Time-Line Follow-Back (TLFB) Inventory to gather housing histories since exiting rehabilitation and to identify housing outcomes. We used Recursive Partitioning (RP) to identify variables that best differentiated participants by these outcomes.ResultsWe identified 3 housing trajectories: stable housing (n = 14), unstable housing (n = 15), and continuously engaged in housing services (n = 7). In RP analysis, 2 variables (Symbol Digit Modalities Test [SDMT], a neurocognitive speed of processing measure, and Behavior and Symptom Identification Scale [BASIS-24] Relationships subscale, which quantifies symptoms affecting relationships) were sufficient to capture information provided by 26 predictors to classify participants by housing outcome. Participants predicted to continuously engage in services had impaired processing speeds (SDMT score < 32.5). Among consumers with SDMT score ≥ 32.5, those predicted to achieve stable housing had fewer interpersonal symptoms (BASIS-24 Relationships subscale score < 0.81) than those predicted to have unstable housing. This model explains 57% of this sample's variability and 14% of this population's variability in housing outcomes.ConclusionsBecause cognition and symptoms influencing relationships predicted housing outcomes for homeless adults with SMI and SUD, cognitive and social skills training may be useful for this population.