a comparative evaluation of supportive apartments, group homes, and board-and-care homes for...

A COMPARATIVE EVALUATIONOF SUPPORTIVE APARTMENTS,GROUP HOMES, ANDBOARD-AND-CARE HOMESFOR PSYCHIATRICCONSUMER/SURVIVORS

Geoffrey NelsonWilfrid Laurier University

G. Brent HallUniversity of Waterloo

Richard Walsh-BowersWilfrid Laurier University

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In this research, we examined the processes and outcomes of supportivehousing for psychiatric consumer/survivors. To determine the relativeeffectiveness of supportive apartments (SA) and group homes (GH) operatedby non-profit mental health agencies, we used a longitudinal design with anon-equivalent comparison group of people residing in private, for-profitboard-and-care homes (BCH). A total of 107 psychiatric consumer/survivorscompleted an initial interview and a follow-up interview one year later. Bothquantitative and qualitative data were collected in the interviews. In termsof housing and social support processes, the residents of SA and GH weremore likely to have their own room, to spend less of their income on rent,and to have more control in decision-making in the residences than people

A R T I C L E

JOURNAL OF COMMUNITY PSYCHOLOGY, Vol. 25, No. 2, 167–188 (1997)© 1997 John Wiley & Sons, Inc. CCC 0090-4392/97/020167-22

This research was funded by the National Health Research Development Program of Canada and the OntarioMinistry of Health, Community Mental Health Branch. We thank the residents and staff of the different typesof housing for their participation in the research and the following people for their research assistance: Don-na Cameron, Gary Edwards, Lorie Fioze, Judy Gould, Karen Hayward, Janice McCarthy, Cari Patterson, KellyPeters, Ruth Slater, and Denise Squire. Special thanks to Leslea Peirson and Colleen Wiltshire for their helpwith coordinating the research and with data analysis. Direct inquiries for further information about this study to Geoffrey Nelson, Department of Psychology, Wilfrid Laurier University, Waterloo, Ontario, CANADAN2L 3C5.

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living in BCH. Residents of group facilities (GH and BCH) had more staffsupport, more emotional and problem-solving support, and less emotionalabuse than residents of SA. The outcome analyses showed that residents inall three types of housing increased their involvement in instrumental roles(e.g., work, education) over time, and residents of SA and GH reported morechanges in terms of personal growth and increased community involvementand showed increases in independent functioning, as rated by staff, thanresidents of BCH. However, none of the groups showed improvement overtime on measures of perceived control, resident-rated independentfunctioning, meaningful activity, positive and negative affect, and lifesatisfaction. The results are discussed in terms of previous literature andimplications for future research. © 1997 John Wiley & Sons, Inc.

In this paper we describe and interpret the process and outcome findings from a com-parative, one-year follow-up evaluation of three types of housing for psychiatric con-sumer/survivors: supportive apartments (SA), group homes (GH), and board-and-carehomes (BCH). While the philosophy (Hogan & Carling, 1992) and practice of support-ive housing for psychiatric consumer/survivors in both Canada (Trainor, Morrell-Bellai,Ballantyne, & Boydell, 1993) and the U.S. (Randolph, Ridgway, & Carling, 1991) haveshifted away from GH to SA, the bulk of the literature pertains to GH not SA. Severalfollow-up studies of GH for consumer/survivors have used comparison or control groupsand have found reduced rates of rehospitalization and/or improved employment (Dick-ey, Cannon, McGuire, & Gudeman, 1986; Fairweather, Sanders, Cressler, & Maynard,1969; Lamb & Goertzel, 1971, 1972; Lipton, Nutt, & Sabatini, 1988; Velasquez & Mc-Cubbin, 1980). A few evaluations of GH have shown improvement in social support andcapacity to meet basic needs (Okin, Dolnick, & Pearsall, 1983; Okin & Pearsall, 1993),independent functioning (McCarthy & Nelson, 1991, 1993; Velasquez & McCubbin,1980), and self-responsibility, self-esteem, social functioning, and social participation(McCarthy & Nelson, 1993; Velasquez & McCubbin, 1980).

In contrast, there have been very few evaluations of SA. In two small-sample studieswithout comparison groups (Boydell & Everett, 1992; Depp, Scarpelli, & Apostoles,1983), the only personal change reported over time was an increase in self-concept(Depp et al., 1983). On the other hand, Nelson, Hall, and Walsh-Bowers (1995) followedup a group of consumer/survivors one year after they had entered SA and found in-creases in instrumental role involvement and staff ratings of residents’ independent func-tioning; qualitative data revealed themes of personal growth and increased involvementin the community. In a large sample study, Hodgins, Cyr, and Gaston (1990) found nosignificant improvements in symptoms, rates of rehospitalization, social support, stress,or employment for residents of SA relative to those in a comparison group.

Given the shift in philosophy from GH to SA, it would be useful to study the relativeeffectiveness of these two types of housing; yet, there have been no comparative evalua-tions of SA and GH to date. One limitation of extant research is that several of the eval-uations of supportive housing have either not used comparison groups or they have notclearly specified the types of housing of people in the comparison groups. Nelson andSmith Fowler (1987) recommended that investigators should specify the living arrange-ments of people in comparison groups or preferably select a homogeneous comparison

168 • Journal of Community Psychology, April 1997

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group in terms of type of residence. One suitable comparison setting is BCH. While GH,SA, and BCH all offer support and residence in community settings, BCH tend to havemore residents; they provide less control and power in decision-making; they offer lessprivacy; and the facilities may be less safe and physically comfortable than GH or SA(Blake, 1986; Capponi, 1992). Moreover, BCH are privately owned and are operated forprofit, whereas GH and SA are operated by non-profit organizations.

Evaluations of supportive housing also need to focus on process as well as outcome(Nelson & Smith Fowler, 1987). Presumed “therapeutic ingredients” need to be specifiedand examined to determine if SA and GH possess more of these desirable qualities thanBCH or other comparison group settings. Potential key process factors include bothhousing characteristics and social support. Important housing characteristics includehousing concerns (Earls & Nelson, 1988), privacy (Ittelson, Proshansky, & Rivlin, 1970),small program-size (Hellman, Green, Morrison, & Abramowitz, 1985; Nagy, Fisher, &Tessler, 1988), and resident control and a democratic staff-management style (McCarthy& Nelson, 1991, 1993).

Two types of social support, emotional and problem solving, may be importantprocess factors (Barrera & Ainlay, 1983; Gottlieb, 1978). Emotional support refers to ex-pressions of warmth, approval, care, and love, while problem-solving support is con-cerned with guiding or helping a person to understand and solve problems in living.There is also a need to examine negative network interactions, such as emotional abuseand avoidance-oriented support, because they too can be related to consumer/survivors’quality of life (Nelson, Hall, Squire, & Walsh-Bowers, 1992). Emotional abuse refers torejection, ridicule, and other forms of verbal abuse, while avoidance-oriented supportmeans encouraging a person not to face and deal with a problem (Billings & Moos, 1981).

Another limitation of research on supportive housing is the focus on rehospitaliza-tion and employment as outcome indicators. By themselves, these indicators are insuffi-cient for understanding consumer/survivors’ adaptation to community life. Additionalindicators, such as personal empowerment, community integration, and quality of lifeare needed. Personal empowerment refers to perceived and actual control over one’s lifecircumstances (Zimmerman & Rappaport, 1988). At the intrapersonal level, personal em-powerment means perceived control; while at the instrumental level, it means the abili-ty to function independently. Community integration refers to people’s participation incommunity life. Measures of involvement in instrumental roles in the community andthe meaningfulness of daily activities tap this dimension. Lastly, quality of life measuresof emotional well-being and satisfaction with various domains of life are needed to assessresidents’ subjective experiences (Baker & Intagliata, 1982).

Finally, with very few exceptions (e.g., Boydell & Everett, 1992; McCarthy & Nelson,1993; Nelson et al., 1995), evaluations of supportive housing have relied exclusively onquantitative methods, which effectively silences the voices of consumer/survivors (Lord,Schnarr, & Hutchison, 1987). Evaluation research also needs to use qualitative methodsto provide deeper understanding of consumer/survivors’ experiences and viewpoints.

In this research we tested the following hypotheses:1. Housing and Social Support Processes

a. SA and GH residents will report fewer housing concerns than BCH residents.b. GH and BCH residents will report more staff support than SA residents. We alsoexamined whether residents from the three types of settings differed with respect tofrequency of various types of positive and negative interaction with network members.c. SA and GH residents will report higher levels of resident control and democratic

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decision-making than BCH residents; SA residents will report higher levels of residentcontrol and democratic decision-making than GH residents.d. Proportionately more SA and GH residents will report having their own room com-pared with BCH residents.

2. Adaptational OutcomesSA and GH residents will show more improvement over time, compared with BCH

residents, on the following indices:a. personal empowerment (perceived control and independent functioning),b. community integration (instrumental role involvement and meaningful activity),andc. quality of life (positive affect, negative affect, and life satisfaction).

No predictions are made about the differential effectiveness of SA and GH.

METHOD

Settings

Members of the research team initially met with housing directors, staff, and mentalhealth workers to ask for their participation in the research. Before this study was con-ducted, two pilot studies were completed, one of GH (McCarthy & Nelson, 1991, 1993)and one of SA (Nelson et al., 1995). These pilot studies permitted us to develop rela-tionships with the settings and participants, to test our procedures, and to determine im-portant factors to study. A total of 14 supportive housing programs (eight GH and sixSA) operated by eight different non-profit organizations in southwestern Ontario par-ticipated in the main study reported here. All of the organizations that we approachedto be involved in the research cooperated with us, although one of the organizations par-ticipated only in a pilot study. Hence, our data are drawn from all of the government-funded supportive housing programs for this population that operate in seven cities.

Fifteen separate BCH, which operate on a profit-making basis, were also involved inthe research. The recruitment process for people residing in BCH was different than thatfor the SA and GH. In most cases, we contacted staff from mental health agencies whoprovide support to people in BCH. These workers described the study to the people theysupported and asked if they would be interested in participating. Thus, we did not usu-ally go directly to the housing operators in our recruitment process. As a result of thisdifferent procedure, many BCH in one particular city were not sampled.

All 29 settings provide housing for people with severe and long-term psychiatric dis-abilities, with the exception of individuals who are violent or who have a recent historyof drug or alcohol abuse. Since several different housing units (e.g., a particular grouphome) are nested within each of the three main types of housing, it is possible that res-idents in particular housing units showed more improvement over time than residentsof other units. However, we could not directly examine this possibility because of smalland unequal sample sizes for the housing units.

The goals of the SA and GH, according to directors and coordinators, are to providestable housing, reduce symptoms, and promote community integration, independence,and well-being. Moreover, goals are flexible and individualized. Staff identified peer sup-port and staff–resident relationships as the most influential aspects of their programs forresidents. In one organization, which operates several SA and GH, the helping processconsists of different stages, moving from meeting basic needs initially, to increased com-petence and integration within the setting, then to increased competence and integra-


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tion within the community. The role of staff is to coach residents through this processand to encourage peer support. The GH and SA are seen as part of a residential con-tinuum, with GH providing high levels of support to people early in their recoveryprocess. As residents recover, they “graduate” to more autonomous SA.

The BCH provide accommodation, meals, and, in some cases, recreation. The BCHdo not have explicit rehabilitation goals or methods. Rather, they aim to provide com-fort and support. If residents wish, they can avail themselves of support from externalmental health workers, who could help them to improve their life skills and access so-cial-recreational or employment opportunities in the community.

Residences vary with respect to size, physical environment, and level of staff support.The GH house 8 to 12 people; they are physically comfortable; and the amount of staffsupport ranges from 8 to 24 hours per day. The SA accommodate one to three peopleper apartment; they are also physically comfortable; and staff support is flexible (week-ly to “on call”). In SA, the amount and type of support provided by staff is negotiated onan individual basis, according to each resident’s needs and desires. The BCH house 8 to28 people; they tend to be more crowded and variable with respect to physical comfort;and they have around-the-clock staffing. The average number of people residing in eachof the three types of settings, according to participants, are: 2.3 in SA, 6.5 in GH, and16.3 in BCH. SA and GH residents had fewer people sharing their residence than BCHresidents, t(102) 5 15.9, p , .001, and SA residents had fewer living companions thanGH residents, t(102) 5 5.5, p , .001. Most residences are in urban and suburban neigh-borhoods; some SA and GH, but no BCH, are in new buildings. Finally, while this studywas conducted in Canada, the types of housing and issues are very similar to those in theU.S. and other western nations.

Research Design

A pre-test, post-test, non-equivalent comparison group design was used (Cook & Camp-bell, 1979). The two intervention groups were SA and GH, while BCH functioned as thecomparison group. While we attempted to match the three groups as closely as possibleon age, gender, and other variables to minimize the problem of selection, the partici-pants in the three groups differed on several characteristics described in the next sec-tion. We also only interviewed participants in SA and GH who had been living in themfor a short time (e.g., a few months at most). We tried to use this criterion with residentsof BCH, but insufficient numbers of people moved into BCH during our study. Partici-pants completed an Adaptation to Community Living Assessment and a Social NetworkAssessment at the initial interview (T1), and they completed these two assessments anda Housing Environment Assessment at the one-year follow-up interview (T2). The inter-views were conducted between 1988 and 1993. We combined participants from a pilotstudy with the participants who were interviewed for the larger study to increase samplesizes for the three groups.

Sample Selection and Final Sample

Potential participants were identified by housing staff or mental health workers. The in-terviewers explained the purpose of the study, what participation would entail, and therights of participants (i.e., confidentiality, refusal to answer questions, withdrawal at anytime) to those residents who expressed interest. While we do not have figures on how


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many people were approached to participate, it is our impression that most of those res-idents of SA and GH who were eligible agreed to participate. On the other hand, re-cruitment of residents of BCH was more difficult with a lower percentage of those whowere approached agreeing to participate.

Although 173 people completed the T1 interview, only 107 completed both T1 andT2 interviews, representing an attrition rate of 38%. The reasons for not completing theT2 interview were: 33 people moved; 19 withdrew; eight were rehospitalized; four died;one was evicted; and one was too disoriented. We then compared the 107 participantswith the 66 people who completed only the T1 interview on age, education, gender, typeof residence, monthly income, marital status, types of medication taken, measures ofemotional well-being, social network size, perceived control, and independent function-ing. Only two variables showed statistically significant differences. Proportionately moreof the 107 participants were taking oral anti-psychotic medication (39%), compared withthe 66 within the attrition group (20%), x2(1,N 5 173) 5 6.2, p , .01; on the other hand,proportionately more of the 66 were taking minor tranquilizers (27%) than the 107 par-ticipants (14%), x2(1,N 5 173) 5 4.0, p , .05. Accordingly, the findings presented be-low are based on the 107 people.

Characteristics of the participants in the three types of housing are presented inTable 1. There were 52 people residing in SA, 30 in GH, and 25 in BCH. While most(45) of those in the SA group resided in apartments managed by mental health housingagencies, seven people lived in private residences, usually an apartment, and receivedsupport from a mental health agency. Both the residential environments and the formalsupport of these seven participants were very similar to the 45 in SA and thus justifiedtheir inclusion in the SA group.

Compared with BCH participants, SA and GH participants were younger, t(103) 54.6, p , .001, had lived in the residence for less time, t(88) 5 6.7, p , .001, and hadcompleted a higher level of education, x2(4,N 5 106) 5 13.8, p , .01, at the T1 inter-view. Compared with GH and BCH participants, SA participants were more likely to havebeen married, x2(2,N 5 107) 5 7.9, p , .05, and less likely to have been involved in daytreatment, x2(2,N 5 104) 5 8.1, p , .05. The three groups did not differ significantlyon social network size, gender, monthly income, source of income, or taking medica-tions. Overall, the participants were White, tended not to be married, had very low in-come, and were taking psychotropic medication.

Interview Process

The interviewers gave participants a letter explaining the study and asked them to signa consent form if they agreed to participate. At the end of the interview, the interview-ers also asked the participants if they would consent to having staff provide informationon their level of independent functioning. Participants were paid $10 for interviewschedules they completed (see below).

Roughly two-thirds of the interviews were conducted by two women, both with anM.A. in Community Psychology. The remaining interviews were conducted by sevenwomen and men, all of whom have a degree in Psychology or Social Work. The inter-views were conversational in style and took place mainly in the residences, but on someoccasions in nearby coffee shops or mental health offices. The interviewers attempted tomake the respondents feel as comfortable as possible and in control of what they choseto share. A few participants required reassurance that there were no “right” answers. Ingeneral, the interviewers observed that the interview process enabled the participants to


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reflect on the personal progress they were making. Many residents were glad that some-one cared to ask their opinions about their housing situation and hoped that the resultswould be used to effect change.

The T1 interview began with open-ended questions and were followed by the Adap-tation to Community Living Assessment and Social Network Assessment measures whichused fixed-response formats. Once the T1 interviews were completed, all the participantsand housing staff were sent an interim report on the findings. T2 interviews (includingthe Adaptation to Community Living, Social Network, and Housing Environment assess-ments) were conducted one year after the T1 interview, following the same procedure.

Process Assessment: Housing and Social Support

Housing Environment Assessment. We designed a 15-item measure of Housing Concerns totap perceived physical comfort of the residence, taking several items from the Multi-


Table 1. Characteristics of Participants by Type of Residence at T1

Type of Residence

Supportive Group Board-and-CareCharacteristic Apartment Home Home

Age (M) 34.1 32.5 45.0Months in residence (M) 2.3 2.8 39.1Social network size (M) 13.3 14.4 11.7

Gender n (%) n (%) n (%)

Men 31 (60%) 20 (67%) 11 (44%)Women 21 (40%) 10 (33%) 14 (56%)

Marital statusMarried 7 (13%) 0 (0%) 0 (0%)Single, separated, divorced or widowed 45 (87%) 30 (100%) 25 (100%)

EducationPartial high school or less 19 (37%) 11 (37%) 18 (75%)High school graduate 9 (17%) 4 (13%) 3 (12%)University/community college 24 (46%) 15 (50%) 3 (12%)

Monthly income,$750 32 (65%) 26 (87%) 16 (73%)$$750 17 (35%) 4 (13%) 6 (27%)

Sources of incomeEmployment 18 (35%) 8 (27%) 3 (12%)General welfare 4 (8%) 5 (9%) 1 (4%)Family benefits 32 (62%) 22 (73%) 21 (88%)Unemployment insurance 4 (8%) 0 (0%) 1 (4%)Other 13 (25%) 4 (13%) 5 (21%)

MedicationsNone 7 (13%) 1 (3%) 1 (4%)At least one 45 (87%) 29 (97%) 23 (96%)

Day treatmentNo 33 (65%) 10 (33%) 10 (43%)Yes 18 (35%) 20 (67%) 13 (57%)

Note. Not everyone answered all of the questions, so there are some missing data (as many as three missing cases per type ofhousing). Also, participants could indicate more than one source of income, so these percentages do not sum to 100%.

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phasic Environmental Assessment Procedure (MEAP) (Moos & Lemke, 1979). The itemswere answered “yes” or “no.” Estimated reliability of this measure was .73, using Cron-bach’s alpha.

We used a 10-item modified version of the MEAP Resident Control measure. Resi-dents rated the extent to which they were involved in decision making (e.g., selectingnew residents) on a three-point scale: “staff control” (1), “shared control” (2) and, “res-ident control” (3). This measure had an alpha of .88.

We adapted the MEAP Tolerance for Deviance scale to assess Staff ManagementStyle. Residents were asked which style staff would use to respond to potential problemsinvolving residents. Democratic style refers to staff engaging residents in problem solv-ing, Authoritarian to staff intimidating or threatening residents, and Permissive to staffsaying or doing nothing. Each resident had a score for Democratic, Authoritarian, andPermissive. The alpha for Democratic style was .72.

Positioned before the quantitative scales were the following open-ended questions:(a) “How would you describe your relationships with your living companions? Are theresome people you really enjoy being with? Are there some people that you find annoyingor bothersome?”; (b) “Overall, how would you describe the amount of control or influ-ence you have over your living environment? Do you feel that it is your home and thatyou can do what you want in the residence?”; and (c) “Describe the positive and nega-tive aspects of your housing situation. How has the residence helped or harmed yourhealth and well-being?” Interviewers also asked participants whether they had their ownroom, their proportion of rent to income, how well they knew their neighbors, and thetype of neighborhood in which they lived.

Social Network Assessment. We used a measure of Socially Supportive and Unsupportive Ac-tions with four subscales: Positive Emotional Support, Positive Problem-solving Support,Emotional Abuse, and Avoidance-oriented Support. The items for the first two subscalescame from Barrera and Ainlay (1983), while we created the items for the latter two sub-scales. Each subscale has seven items. Residents rated items on frequency of occurrencein the past month on a five-point scale from “not at all” to “about everyday.” The alphasfor the subscales at T2 were as follows: Positive Emotional Support–.80, Positive Prob-lem-solving Support–.77, Emotional Abuse–.86, and Avoidance-oriented Support–.84.

We constructed a seven-item scale of Staff Support for residents. Residents wereasked on a “yes” or “no” basis whether they had received help from staff within the pastfew weeks with activities such as household chores, meal planning, and preparation. Thealpha for this scale was .65.

At the beginning of this interview schedule, participants were asked the followingopen-ended questions about their relationships: “How have you been feeling about thequality of your relationships with other people?” and “How have your relationshipschanged in the past few months? Describe both positive and negative changes that haveoccurred.” Participants were also asked to list the people who were important to themin the following network segments: family, living companions, friends, and professionals(including housing staff).

Outcome Assessment:Adaptation to Community Living

Personal Empowerment. We used Pearlin and Schooler’s (1978) Mastery scale to assess theextent to which a person perceives control over her or his life circumstances. This sev-


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en-item scale is rated on a four-point scale from “strongly agree” to “strongly disagree.”The alphas for were .73 at T1 and .78 at T2.

We adapted a six-item Independent Functioning scale from Rappaport et al. (1985)to measure independent functioning in areas of daily living such as money management,housekeeping, and meal preparation. Each item was rated on a three-point scale: others’responsibility (1), shared responsibility (2), own responsibility (3). Both residents andstaff, with residents’ consent, completed this measure. The staff and resident versionswere highly correlated at T2 (r 5 .64). The alphas for the resident-rated version were .72at T1 and .75 at T2, while the alphas for the staff-rated version were . 83 at T1 and .82at T2.

Community Integration. Participants were asked which of the following Instrumental Rolesthey were involved in on a part-time or full-time basis: student, volunteer, sheltered work,job training, and/or competitive work. The total number of Instrumental Roles consti-tutes an index of community integration.

We also used Maton’s (1990) four-item measure of Meaningful Activity. Residents rat-ed how often they took part in activities which helped them meet a job, educational, orcareer goal; helped them achieve a personal goal; used the person’s skills or talents; andcontributed to the goals of a group or organization in which they believe. Items were rat-ed on a five-point scale from “not at all” to “very often.” The alphas for this measure were.59 at T1 and .82 at T2.

Quality of Life. We measured Positive Affect and Negative Affect with Diener and Em-mons’ (1985) scales. The five items for each measure were rated on a five-point scale offrequency of occurrence over the past week from “not at all” to “everyday.” The alphasfor Positive Affect were .90 at T1 and .89 at T2, while the alphas for Negative Affect were .77 at T1 and .81 at T2. Using Baker and Intagliata’s (1982) measure of Life Satis-faction, we added five items dealing with housing, resulting in 20 items. Each item wasrated on a seven-point scale from “delighted” to “terrible.” The alphas were .87 at T1 and.89 at T2.

In addition, we asked residents the following open-ended questions at the beginningof the interview: (a) “How have you changed as a person in the past few months? De-scribe both positive and negative changes.” and (b) “If you have changed as a personsince entering the program, do you feel the program contributed to these changes? Ifso, what is it about this program that has influenced these changes?” Like the other out-come indicators, these questions were asked at both T1 and T2. With residents’ permis-sion, we also asked the staff the following open-ended question at both T1 and T2: “Inwhat ways do you see that the person has changed since entering the program?”

RESULTS

Housing and Social Support Processes

Quantitative Analyses. Descriptive information on the housing and social support dimen-sions for the three types of residence is presented in Table 2. Planned comparisons wereused to test the hypotheses regarding differences between groups.

Contrary to our hypothesis, there were no differences between the three groups onthe measure of Housing Concerns. All three groups reported an average of less than oneconcern out of a possible 15, indicating, overall, a very low level of perceived problems.

As hypothesized, SA and GH residents reported much higher levels of Resident Con-


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trol than BCH residents, t(101) 5 8.8, p , .001, and SA residents reported higher levelsof control than GH residents, t(101) 5 2.9, p , .005. However, with one exception, thedifferences we predicted on the Staff Management Style scale were not borne out. GHresidents reported a higher score on the Authoritarian scale than SA residents, t(98) 52.5, p , .05.

With regard to the measure of support, a consistent pattern of differences across set-tings was apparent. As hypothesized, GH and BCH residents reported more Staff Sup-port than SA residents, t(89) 5 2.7, p , .01. Three of the four subscales of the SociallySupportive and Unsupportive Actions measure showed the same pattern. GH and BCHresidents reported higher levels of Positive Emotional Support, t(54) 5 3.0, p , .01, andPositive Problem-solving Support, t(54) 5 1.8, p , .07, and lower levels of EmotionalAbuse, t(51) 5 2.6, p , .05, than SA residents.

As expected, proportionately more of SA and GH residents had their own room,compared with BCH residents, x2(2,N 5 106) 5 21.9, p , .001. Other group differencesrelevant to participants’ housing environments were as follows: BCH residents spendmost of their income on room and board, while SA residents spend the least of thegroups on the their rent, x2(6,N 5 97) 5 95.8, p , .001, and proportionately more SA


Table 2. Housing and Social Support Dimensions for the Three Types of Residence at T2

Type of Residence

Housing and Supportive Group Board-and-CareSocial Support Dimensions Apartment Home Home

Housing concerns (M) .69 .74 .83Resident control (M) 22.0 19.2 12.2Staff management style

Democratic (M) 4.1 4.7 5.0Authoritarian (M) 2.1 3.2 2.5Permissive (M) 1.6 .9 1.5

Staff support (M) 1.6 2.8 2.3Positive emotional support (M) 14.6 20.1 18.9Positive problem-solving support (M) 13.4 16.2 16.0Emotional abuse (M) 15.2 11.7 10.4Avoidance-oriented support (M) 12.8 10.9 12.9Own room n (%) n (%) n (%)

Yes 50 (96%) 26 (90%) 14 (56%)No 2 (4%) 3 (10%) 11 (44%)

Proportion of income to rent0–25% 30 (61%) 0 (0%) 1 (6%)25–50% 13 (27%) 7 (23%) 0 (0%)50–75% 5 (10%) 16 (54%) 0 (0%)75–100% 1 (2%) 7 (23%) 17 (94%)

Know neighborsYes 36 (69%) 10 (34%) 10 (40%)No 16 (31%) 19 (66%) 15 (60%)

Type of neighborhoodUrban 12 (23%) 22 (79%) 17 (68%)Suburban 37 (71%) 6 (21%) 7 (28%)Rural 3 (6%) 0 (0%) 1 (4%)

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residents reported knowing their neighbors, x2(2,N 5 106) 5 11.2, p , .01, and livingin suburban neighborhoods, x2(4,N 5 105) 5 27.8, p , .001.

Qualitative Analyses. Responses to the open-ended questions regarding housing, support,and relationships for T2 interviews were transcribed and coded to ascertain the domi-nant categories that emerged. Codes were compared across the different types of hous-ing to see if there were any patterns on this variable. Quotes that illustrated the codeswere then highlighted. The major category that emerged from these questions was Hous-ing Facilitated Personal Growth. More than half the residents in each of the three set-tings stated that their housing had helped to improve their mental or physical healthand/or to promote their independence, growth, social skills, or their ability to cope withstress. The following quotes illustrate this code:

It’s good teaching/training for later on. A lot of us will have to move on but will doso with a lot of experience and training in working with others. . . Being an inde-pendent program, a lot of it is trying to depend on your own initiative. When I wasat the boarding home, I didn’t have anything to do. (A housing support worker) sawthat I wasn’t doing anything and helped moved me here. (SA resident)

(The housing has) helped my health. If I wasn’t here, I would have killed myself along time ago. (GH resident)

I don’t feel so depressed and I don’t feel so down. I feel closer to my family. I solveproblems better and try to get along with people better. (BCH resident)

Participants spoke of several positive aspects of their housing and social relation-ships. One positive factor, which appeared in response to several of the open-ended ques-tions, was Social Support. Across all of the settings, residents indicated the importanceof positive relationships with and support from housing staff, family, friends, and livingcompanions. Social Support included both emotional support and encouragement to be-come more independent and take more responsibility for oneself.

If I have problems, I can talk to the counselor or my roommate; people respect me.(SA resident)

Most of the (relationships with living companions) are pretty good, stable, and sup-portive. We joke around and kid around with each other. (GH resident)

We have lots in common. Everybody here practically has been in the hospital. There-fore, we can talk about our times there. They’re all pretty understanding and givingand funny. (BCH resident)

In response to the question about how their relationships had changed in the pastfew months, proportionately more of the residents of SA, as compared with residents of GH and BCH, indicated that their relationships had deteriorated in some way. Ei-ther there was more friction or conflict or their relationships had become more distant.Relationship problems tended to be with one’s living companions. On the other hand, many of the residents of SA and GH thought their relationships had improved,while most (roughly half) of the BCH residents reported no changes in their relation-ships.

Another positive factor mentioned by participants was Resident Control. While manyof the residents of SA and GH spoke of the control they had over their living environ-


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ment, only one of the residents of BCH spoke of having much control. The followingquotes illustrate this code:

I am free to do the things I want to do when I want to do them without anyone elsegetting in my way. (SA resident)

I have substantial control. You’re treated as an adult. Your opinion is listened to.They’re only a few things you have to do. (GH resident)

You don’t have any control. You got to do what they say to do. You can do what youwant to a certain point. (BCH resident)

Physical Comfort of the residence was another beneficial aspect of housing. A fewparticipants noted that their present residences were much nicer than previous ones.Several people stated that their residence was clean, well maintained, and attractively fur-nished and decorated. Other people thought that the food was good and that they wereeating better than they had in the past. In spite of all these positive features of their hous-ing, however, many residents stated they did not consider their place to be a home andindicated that they wanted to find their own place and live independently.

The most frequently mentioned negative aspect of participant’s housing was Conflictwith Living Companions. While interpersonal conflicts occurred in all three types ofhousing, they were mentioned more often by residents of SA. Participants spoke of theinsensitivity of living companions, personality clashes, and the lack of sharing householdchores, such as cooking and cleaning. Some people also mentioned that they did notlike living with other people who have a history of psychiatric problems. These issues areillustrated by the following quotes:

The negative thing is you don’t always know or have a choice of who your roommatewill be. (SA resident)

. . . I didn’t like when two out of four won’t help with the lawn. Also, some do notclean up garbage, etc., and I sure didn’t like so much cigarette smoke. Also, I wasthe only one to shovel snow. (SA resident)

I don’t agree with putting psychiatric patients together. Some of the residents get medown or criticize me or make me feel lower. (GH resident)

It should be noted that most of the participants did not speak of their relationships withliving companions in entirely negative terms. Rather, most people spoke of their rela-tionships as either a mixture of positive and negative aspects, or they thought their re-lationships with the people they lived with were mostly positive.

Another negative aspect of housing that emerged was Restrictive Rules. While resi-dents in all three types of housing mentioned a variety of rules and restrictions on theirpersonal freedom, such responses were made most often by BCH residents. Participantsspoke about rules related to drinking, smoking, having visitors in one’s room, not hav-ing a key to the front door, and many other ways that staff maintained control. Some GHresidents thought they had a fair bit of control, but that it was usually necessary to ne-gotiate decisions with fellow residents. The following quotes are a sample of this code.

I feel I don’t have enough control over my living environment, and I don’t feel likeit’s my home. I’d like to see the residents be given the power to vote out or expelresidents according to a democratic vote by the residents. I feel that the residents


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should be consulted more as to the making of house rules and policies. (GH res-ident)

You can’t drink here. You can’t bring people to your room. (GH resident)

We can tell them what we believe is wrong, but they always make their own decisionsand we never know what it’s about. . . We have house meetings every five months,but the staff do what they want anyway. (BCH resident)

(I) just have to sit around and keep my mouth shut. (BCH resident)

There were three other codes indicating dissatisfaction with housing, which ap-peared less frequently than the previous two that have been presented: Lack of Privacy,Housing Concerns, and Isolation. Some residents of GH and BCH spoke of not havingenough privacy; a few of the residents of all three types of housing mentioned poor quality food or problems with the physical structure of their housing; and a few of theresidents of SA stated that they felt isolated and wanted more involvement in the com-munity.

Summary. In terms of housing and social support processes, both quantitative and quali-tative data showed that the residents of SA and GH were more likely to have their ownroom and to have more control in decision-making and fewer restrictive rules in the res-idences than people living in BCH, as we hypothesized. However, contrary to our pre-diction, the settings did not differ in terms of the number of housing concerns report-ed. Residents of group facilities (GH and BCH) reported more social support and lessabuse than residents of SA, as we hypothesized. Moreover, the qualitative data showedthat proportionately more of the residents of SA, as compared with GH and BCH, re-ported experiencing interpersonal conflicts and relationship problems with their room-mates.

Adaptational Outcomes

Quantitative Analyses. Mean scores at T1 and T2 on the various outcome measures arepresented in Table 3. After first testing for gender differences on the dependent vari-ables and finding none, we used two-way mixed ANOVAs, with group as the between fac-tor (with three levels) and time as the within factor (with two levels), to analyze the data.Significant group-by-time interactions would indicate that SA and GH residents had im-proved more than BCH residents. There were main effects for group on Mastery, F(2,96)5 3.1, p , .05, and resident-rated Independent Functioning, F(2,101) 5 66.4, p , .001,but there were no significant effects for time or the group-by-time interaction. SA andGH residents scored higher on these measures than BCH residents at both T1 and T2.

On staff-rated Independent Functioning, there was also a main effect for group,F(2,33) 5 9.8, p , .001, but no significant effects for time or group-by-time interaction.Paired t-tests on this measure, comparing T1 and T2, were computed separately for SAand GH residents combined and BCH residents. SA and GH residents improved signifi-cantly from T1 to T2, t(25) 5 2.3, p , .05, while the residents of BCH did not, t(9) 5.3, n.s.

Regarding Instrumental Roles, there were main effects for group, F(2,104) 5 3.9, p , .05, and time, F(1,104) 5 13.8, p , .001, but no group-by-time interaction. Residentsin all three settings improved over time. There were no effects on Meaningful Activity,


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Positive Affect, and Negative Affect. The only significant effect on Life Satisfaction wasthat, surprisingly, BCH residents scored higher than SA and GH residents F(2,40) 5 4.3,p , .05.

Qualitative Analyses. The code Personal growth was the predominant way that participantsexpressed how they had changed. Personal Growth refers to improvements in maturity,responsibility, independence, social skills, goal directedness, and self-esteem. The fol-lowing quotes illustrate this code:

I seem to be mixing more and becoming more like myself. I don’t feel as helpless;I feel more successful. (SA resident)

I’m becoming aware of many things about myself—old patterns. This awareness ofmyself is preventing me from repeating old patterns—negative ones. (SA resident)

I’ve learned to be more open and assertive with people, and, at the same time, I’mlearning how to deal with problems as they arise. (GH resident).

Another code pertaining to outcomes was Improved Health and Emotional Well-Be-ing. This code refers to changes in physical health (e.g., increased energy, weight loss,exercise, smoking reduction, etc.) and mental health and emotional well-being (e.g., lessdepressed, happier, more relaxed, etc.). A few quotes illustrate this code.

I am improving my diet due to high cholesterol problems. I feel spiritually morewhole every month. (SA resident)


Table 3. Mean Scores on Outcome Measures at T1 and T2

Type of Residence

Supportive Group Board-and-CareOutcome Measures Time Apartment Home Home

Personal empowermentMastery T1 20.6 20.7 18.8

T2 21.3 20.4 18.6Independent functioning- T1 16.3 14.8 11.4

resident-rated T2 16.1 14.3 11.0Independent functioning- T1 15.9 14.8 12.1

staff-rated T2 16.6 15.7 12.3Community integration

Number of instrumental T1 .54 .57 .16roles T2 .89 .73 .56

Meaningful activity T1 10.6 13.2 12.2T2 12.2 13.6 12.4

Quality of lifePositive affect T1 15.5 15.1 17.0

T2 15.5 16.8 16.4Negative affect T1 12.3 11.9 10.6

T2 11.6 12.3 9.4Life satisfaction T1 107.7 107.8 117.3

T2 103.5 105.8 118.8

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I’ve changed quite a lot. I’m not nearly as depressed as I was at [a psychiatric hos-pital]. (GH resident)

I feel more active. I feel happier, I don’t feel sad. I don’t let things get me down.(BCH resident)

Increased Community Involvement refers to participation in social, educational, vo-cational, and recreational activities. The following quote speaks to the importance of thisoutcome:

In the past few months, I feel I have improved as a person because I have increasedmy involvement with my community. For example, I have joined a second board ofdirectors, an ad hoc committee, and become involved with the production of (a self-help organization’s) newsletter. I have learned from friends and others that one de-velops an improved outlook with increased input. (SA resident)

A few residents in each of the settings mentioned either a Negative Change or NoChange in their lives in the past few months. Comments to this effect were made mostoften by BCH residents. For example:

The past few months haven’t been good. I’ve become more withdrawn, anxious, orparanoid. It’s not the fault of the program. Now that I’m out of the hospital, my at-titude’s a lot better. . . I have a semi-girlfriend. She keeps calling me. She’s hospital-ized. We kind of keep aggravating each other’s mental health. It’s a bad situation.(GH resident)

The codes Personal Growth, Improved Health and Emotional Well-being, and In-creased Community Involvement were quantified to obtain frequency and percentagedata for each code. This was done so that chi-square tests could be computed to deter-mine if there were associations between type of residence and these codes. Since wequantified these data, it was necessary to obtain inter-rater reliability estimates for thecodes. This was done by having two raters code the data and then dividing the numberof agreements between raters by the number of agreements and disagreements. Relia-bility estimates were as follows: Personal Growth (77%), Improved Health and Emotion-al Well-being (72%), and Increased Community Involvement (67%). The results of theseanalyses are presented in Table 4.

There was a relationship between type of residence and Personal Growth at T1,x2(2,N 5 94) 5 10.2, p , .01, but not at T2. The highest proportion of residents re-porting Personal Growth occurred in GH, followed by SA, with the lowest proportion oc-curring in BCH. There was no association between type of residence and ImprovedHealth and Emotional Well-Being at either T1 or T2. While there was no association be-tween type of residence and Increased Community Involvement at T1, these two vari-ables were related at T2, x2(2,N 5 101) 5 6.8, p , .05. Proportionately more of the res-idents of SA and GH reported involvement in the community than BCH residents.Finally, analyses were performed to see if type of residence was associated with at leastone of the three types of positive personal changes. Significant relationships were foundat both T1, x2(2,N 5 94) 5 7.0, p , .05, and T2, x2(2,N 5 101) 5 8.3, p , .02. At bothtime periods, the highest proportion of residents reporting at least one positive changeoccurred in GH, followed by SA, with the lowest proportion occurring in BCH.

Staff perceptions of how residents had changed were very similar to those of resi-dents. The one additional code that emerged from the staff data was Improved House-


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hold Management Staff regarded residents as better able to maintain their residencethrough improved cooking and cleaning skills.

Summary. The hypotheses that SA and GH residents would improve more than BCH res-idents on quantitative indicators of personal empowerment, community integration, andquality of life were not supported. SA and GH residents showed more improvement thanBCH residents only on staff-rated Independent Functioning. However, the qualitativedata showed that proportionately more residents of SA and GH than BCH reported atleast one positive change at both T1 and T2, lending some support to the hypothesis thatthere would be differential improvement favoring the residents of SA and GH.

DISCUSSION

Housing and Social Support Processes

Contrary to our expectation, the three types of residence did not differ on a measure ofhousing concerns. In contrast, Nelson and Earls (1986) found that consumer/survivorsliving in their own home, a GH, or with their parents reported significantly more prob-lems than people residing in private apartments or BCH. It is our impression that mostof the BCH that we sampled in this study were clean and well maintained. Also, we didnot find that the settings differed on a measure of staff management style, as we had hy-pothesized. We observed positive relationships between BCH staff and residents, and weonly heard about one setting in which staff behaved in a punitive or authoritarian man-ner. Perhaps, there was a selection bias in our BCH sample such that operators of morerun-down or autocratically operated BCH (see Capponi, 1992) did not want the residentsof these settings to participate in a study in which residents would voice their opinionsabout their housing. Thus, the lack of differences between the types of residence on thehousing concerns and staff management style measures could be a reflection of havingselected residents from the more physically and socially desirable BCH.


Table 4. Personal Changes Reported at T1 and T2

Type of Residence

Supportive Group Board-and-CareApartment Home Home

Time n (%) n (%) n (%)

At least one positive change T1 30 (65%) 21 (84%) 11 (47%)T2 31 (62%) 22 (75%) 8 (36%)

Personal growth T1 24 (52%) 18 (72%) 6 (26%)T2 23 (46%) 13 (44%) 5 (22%)

Health and emotional well-being T1 11 (23%) 10 (40%) 4 (17%)T2 8 (16%) 7 (24%) 4 (18%)

Increased community involvement T1 2 (4%) 2 (8%) 2 (8%)T2 10 (20%) 8 (27%) 0 (0%)

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Compared with SA and GH, fewer BCH residents have their own rooms; there aremore residents living in BCH; and BCH residents have less control over decision-makingrelated to their housing. These characteristics of BCH suggest a more institutional envi-ronment than SA and GH. In large settings in which residents must share rooms, thereis a loss of privacy, which was apparent in our qualitative data. One study of con-sumer/survivors in an institution found that the number of people sharing a room waspositively correlated with withdrawal (Ittelson et al., 1970). Such a response might reflectpeople’s need for privacy. Moreover, Barker and Gump’s (1964) behavior settings theo-ry posits that in large settings, as compared with small settings, people experience lesspressure to become involved and take care of the setting. Applied to community resi-dences for psychiatric consumer/survivors, staff in large settings would tend to takemore control and focus on maintaining regimented routines and schedules, rather thaninvolving residents in the day-to-day work of the residence. Our qualitative data supportthis notion in that BCH residents tended to speak of the support they received from staffin terms of “being taken care of,” whereas SA and GH residents talked about their rela-tionships with staff and living companions more in terms of the supports and hassles ofliving with other people. Similarly, both the quantitative and qualitative data clearlyshowed that BCH residents have less control in decision-making and are subject to morerestrictive rules than SA and GH residents. One final liability of BCH is that, as profit-making enterprises, they take most of the little income that residents have. Residents ofBCH and some GH spoke of how they had only about $100 per month for all expensesother than room and board, and some talked about how staff controlled the little mon-ey they did have. Not having an adequate income poses significant barriers to becomingindependent and participating in the community.

As we expected, residents of the group settings (GH and BCH) reported more staffsupport than SA residents. Also, GH and BCH residents reported more social supportand less emotional abuse than SA residents. Similarly, Pomeroy, Cook, and Benjafield(1992) found that psychiatric consumer/survivors living independently (in apartmentsor rooming houses) reported less social support than those living in group homes orwith their families of origin. Furthermore, our qualitative data showed that more SA res-idents than GH and BCH felt isolated and thought that their relationships with othershad deteriorated in some way over the year in which they participated in the study. Thesefindings suggest that in SA the cost of having the increased freedom and control of anapartment is a loss of support, while in GH freedom is sacrificed for support. Thus, achallenge for new approaches to housing for psychiatric consumer/survivors is how toprovide people with the support they want and choice and control over their housing(Hogan & Carling, 1992).

Another problem noted by residents of all three types of housing was conflict withliving companions. While most participants noted that these relationships were both sup-portive and conflictual, some people thought that such friction was harmful to theirhealth and emotional well-being. Similarly, several participants stated either that they didnot like living with other people with mental health problems or that they had no choiceover with whom they lived, which sometimes resulted in a poor match of a housemate.Thus, lack of choice over living companions is another liability of the supportive hous-ing approach (Hogan & Carling, 1992). Finally, while most people spoke positively abouttheir housing, many did not consider the place they lived to be their “home” and want-ed their own place.


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Adaptational Outcomes

Analyses of the quantitative outcome indicators showed improvements over time on staff-rated independent functioning and instrumental role involvement. Our findings repli-cate previous research, which showed improvement on these two indices for both SA(Nelson et al., 1995) and GH residents (McCarthy & Nelson, 1991). However, with theaddition of a BCH comparison group in this study, we found that BCH residents im-proved as much as SA and GH residents on instrumental role involvement, but not staff-rated independent functioning. The fact that BCH residents improved as much as resi-dents of SA and GH in instrumental role involvement may reflect a bias in our BCHsample. As was suggested previously, perhaps we sampled people in the most desirableBCH. In more than one BCH, we heard from staff and residents about how residentswere encouraged to become more active in instrumental roles in the community. In con-trast, our qualitative data revealed more community involvement for residents of SA andGH than for residents of BCH.

Furthermore, there was no improvement over time for any of the groups on thethree subjective quality of life indicators, meaningful activity, resident-rated independentfunctioning, and perceived control. Similarly, the qualitative data showed no differencesbetween the groups in terms of improved health and emotional well-being. Previous lon-gitudinal evaluations of SA (Boydell & Everett, 1992; Depp et al., 1983; Hodgins et al.,1990; Nelson et al., 1995) and GH (Dickey et al., 1986; Fairweather et al., 1969; Lamb &Goertzel, 1971, 1972; Lipton et al., 1988; Okin et al., 1983; Okin & Pearsall, 1993) haveseldom reported improvement over time for residents of such settings on indicators ofperceived control or quality of life. It may be that supportive housing with a rehabilita-tion emphasis is more likely to have an impact on indicators that tap tangible lifechanges, like independence, involvement in instrumental roles in the community, andsocial skills, than more subjective indicators, which tap perceptions and feelings. Changein subjective indicators of adaptation may be more related to one’s expectations and thequalities of housing and support than to the type of housing in which one lives.

While the findings on the quantitative measures provide little support for the rela-tive efficacy of SA and GH in the rehabilitation of psychiatric consumer/survivors, thequalitative analyses painted a different picture. The majority of residents of SA (rough-ly two-thirds) and GH (three-quarters or more) reported at least one positive way inwhich they had changed as a person over the one-year period of the study, comparedwith less than half of the residents of BCH. The types of changes varied from person toperson but the primary changes indicated personal growth (e.g., improved social skills,responsibility, self-esteem) and/or increased community involvement (e.g., greater par-ticipation in social, recreational, or vocational activities in the community). These find-ings speak to the value of using qualitative methods in research with consumer/survivors(Lord et al., 1987). Overall, the residents of SA and GH appeared to more growth ori-ented, whereas the residents of BCH appeared to less concerned with change and morecomfortable and satisfied with their lives. This may reflect, in part, their stage in life, asthe residents of SA and GH were younger than the residents of BCH.

Also, proportionately more residents of GH reported positive changes than residentsof SA or BCH. The GH have a more structured rehabilitation emphasis than either theSA or BCH. Many residents of SA have lived in GH and have moved on to more stableand private housing after they have gone through a rehabilitation process. These find-ings suggest that GH tend to be used to assist people early in their recovery, while SA


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tend to be used at a later stage after people have made significant growth. However, thisresidential continuum approach may not be necessary to help people meet their goals.As Hogan and Carling (1992) have suggested, support and housing can be “de-linked”so that people can get both the type of support they want and the type of housing theywant. Support should be available according to people’s needs, and not dependent ontype of housing.

Limitations and Future Research Directions

One limitation of this research was that the participants in the comparison group (BCH)were older, had less education, were less independent in their functioning, and had livedin their residences longer than those in the intervention groups (SA and GH). Thus, dif-ferences in outcome between the two groups could be due to these differences (i.e., se-lection factors) rather than to the settings. Furthermore, it is possible that the residentsof BCH showed the most growth when they first moved into these settings, just as wefound for the GH residents. However, since the residents of BCH had lived in these set-tings for an average of three years, we could not determine if this was the case.

Another limitation of our study was that the outcome measures did not tap some ofthe dimensions that emerged from the qualitative data and thus may not have been sen-sitive to the types of changes that the residents reported. However, the codes thatemerged from the qualitative data appeared to be more consistent with the quantitativeoutcome indicators used by Velasquez and McCubbin (1980), who found a clear impacton several outcome measures (e.g., social skills, social functioning, and social participa-tion) for GH residents relative to people in a comparison group. Other methodologicalfactors might have accounted for their findings, such as their young sample and relianceprimarily on staff rather than residents’ ratings (Velasquez & McCubbin, 1980).

For future research we recommend using the measures employed by Velasquez andMcCubbin (1980) or developing measures that tap the dimensions uncovered by thequalitative analyses in this study. Such measures could be more sensitive to the types ofchanges residents reported than our measures. Second, we urge researchers to use qual-itative methods, given their value in this and other studies. Third, although the resultsof small-scale, single-group studies of SA and GH without comparison groups can pro-vide useful leads on outcomes expected from supportive housing, comparison groupscan help to rule out some threats to internal validity. Because it is virtually impossibleand ethically questionable to randomly assign participants to various housing settings,non-equivalent comparison groups, such as our BCH group, can serve a useful purpose.While recruiting participants for BCH comparison groups is very difficult, researchersshould strive to find ways of finding participants in intervention and comparison settingswho are comparable in terms of personal characteristics. This is necessary to help ruleout the possibility of the selection bias noted earlier. Fourth, given the high drop-outrate in our study and the need for statistical power to test hypotheses, large sample sizesare necessary.

Finally, a valuable alternative to the type of outcome research we conducted is par-ticipatory action research (Rappaport, 1990; Serrano-Garcia, 1990). In this approach, re-searchers, staff, and consumer/survivors collaboratively plan, implement, interpret, andtake action. In this way, the research agenda is owned by the stakeholders in the setting,not by the researchers, and there is a strong commitment to using the data to createchange. The role of the researcher is one of facilitator, consultant, and resource person,


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who helps the setting to develop its own research capacity. Everett and Steven (1989)have demonstrated the utility of this approach for studying supportive housing for psy-chiatric consumer/survivors.

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