449301

2012
ANP46910.1177/0004867412449301Harvey etal.ANZJP Articles

Research

Australian & New Zealand Journal of Psychiatry

A place to live: Housing needs for 46(9) 840850

DOI: 10.1177/0004867412449301

people with psychotic disorders The Royal Australian and

New Zealand College of Psychiatrists 2012

identified in the second Australian Reprints and permission:

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national survey of psychosis

Carol Harvey1,2, Eoin Killackey3,4, Aaron Groves5 and

Helen Herrman3,4

Abstract
Objective: Access to adequate housing consistent with personal preferences and needs is a human right and supports
recovery from psychosis. This study aimed to: (1) describe people with psychosis living in different housing types, and
their preferences and needs; (2) explore selected demographic and social inclusion correlates in relation to housing; and
(3) compare two subgroups participants living in supported group accommodation and supported housing on key
demographic, functional, clinical and social inclusion variables.
Method: Current housing, preferences, needs and assistance, and housing-related social inclusion variables were
assessed in a two-phase prevalence survey conducted within seven catchment areas across five Australian states. Two
supported housing models were compared: supported group accommodation and supported housing (rental accommo-
dation with in-reach support). Descriptive statistics were used.
Results: Of the total participants (n = 1825), one half were living in public or private rented housing (48.6%) and 22.7%
were waiting for public housing. Despite being the preferred form of housing, only 13.1% were living in their own home.
One in 20 participants (5.2%) was currently homeless; 12.8% had been homeless in the previous 12 months. Residents
of supported group accommodation felt safer in their locality than those in supported housing, but experienced less
privacy and choice.
Conclusions: Although fewer participants were homeless compared with the first Australian survey of psychosis, the
proportion remains high. Housing difficulties are experienced by people with psychoses living in various accommoda-
tion and concern housing adequacy and safety as well as autonomy and choice. Access to public housing is restricted
compared with the identified need. Since residents of supported group accommodation felt safer in their locality than
those in supported housing, but experienced less privacy and choice, each supported housing model may offer different
advantages to people with psychosis, and contribute to services that support and maintain recovery.

Keywords
Community survey, homeless persons, housing, needs, psychotic disorders

Introduction
According to article 11 of the International Covenant on
Economic, Social and Cultural Rights (Office of the United
Nations High Commissioner for Human Rights, 1976),
everyone has the right to an adequate standard of living,
1Department of Psychiatry, University of Melbourne, Melbourne,
Australia
2North Western Mental Health, Melbourne, Australia
3The Centre for Youth Mental Health, University of Melbourne,
Melbourne, Australia
4Orygen Research Centre, Melbourne, Australia
5Queensland Health, Herston, Australia

including decent housing. Various factors are involved

Corresponding author:
in deciding whether housing is adequate, including legal Carol Harvey, Psychosocial Research Centre, 130 Bell Street, Coburg,
security of tenure, affordability, accessibility, habitability, VIC 3058, Australia.
location and cultural adequacy (Australian Human Rights Email: c.harvey@unimelb.edu.au

Australian & New Zealand Journal of Psychiatry, 46(9)

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Harvey etal. 841
Commission, 2011). In addition, as recovery from psycho-
sis is multidimensional (Herrman and Harvey, 2005), many
individual and environmental factors, including housing,
affect the wellbeing of people living with severe mental ill-
nesses (SMI), including psychoses (State Government of
Victoria, 2011).
Research has increasingly demonstrated the therapeutic
benefits of adequate supported housing to people with SMI
(Sylvestre etal., 2007). Increased choice, control and qual-
ity of housing and the extent to which housing creates
opportunities for people with psychoses to develop mean-
ingful relationships in their dwellings and the community
(community integration) are associated with decreased
symptomatology, enhanced wellbeing and quality of life,
and decreased service use (Nelson etal., 2007; Sylvestre
etal., 2007). Few studies have considered the citizenship
dimension of housing for people with psychosis; that is,
whether housing supports their participation in broader sys-
tems such as programs, mental health systems and society
more generally (Sylvestre etal., 2007). However, assisting
people to live in accordance with their values and prefer-
ences, and promoting their social inclusion and citizenship
is entirely consistent with a recovery-oriented approach
to mental health care (Chopra etal., 2011; Common
wealth Government of Australia, 2009a; Slade, 2009; State
Government of Victoria, 2011).
People with a psychotic illness have always lived in a
range of accommodation, including with their families of
origin in the family home. Although early developments
in community-based mental health services included set-
ting up group homes, hostels, and halfway houses (e.g.
Thornicroft and Bebbington, 1989), housing for people
with psychotic disorders did not become a priority until the
deinstitutionalisation of mental health services occurred in
many countries (Chopra etal., 2011). This led to the devel-
opment of group housing with on-site support staff, often as
part of a residential rehabilitation continuum in the com-
munity (Leff etal., 2009). Permanent, independent housing
is usually positioned at the end point of this continuum
(Henwood etal., 2011). Former long-stay patients experi-
enced increased satisfaction and quality of life when mov-
ing to these forms of housing, although improvements in
symptomatology and functioning were less consistent
(Chopra etal., 2011; Hobbs etal., 2000; Leff and Trieman,
2000; Trauer etal., 2001). However, both here and over-
seas, concern has been expressed about the disruption to
recovery and risk of reinstitutionalisation that may be expe-
rienced by some residents following discharge to alterna-
tive housing (Carling, 1993; Chopra and Herrman, 2011).
A concerning subgroup of people with psychotic disor-
ders is either homeless or living in marginal accommoda-
tion (insecure housing with shared bathroom and kitchen
and living space) (Chamberlain, 1999). Homelessness
amongst people with psychotic disorders has been recog-
nised for some time and is associated with substance use,
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poor physical health, social isolation and exclusion, disabil-
ity, and poor access to effective treatment and rehabilitation
(e.g. Scott, 1993). These problems are largely related to
discontinuity of service provision (Chopra etal., 2011).
Supported housing that is, regular housing (i.e. available
to the general population) coupled with separate in-reach
flexible mental health support has been developed, par-
ticularly for people with mental illness who are homeless or
at risk of becoming homeless (Ridgway and Zipple, 1990;
Tsemberis etal., 2004). Supported housing (commonly
referred to as the Housing First model) can reduce home-
lessness and hospitalisation and enhance residential stabil-
ity (Rog, 2004; Rosenheck etal., 2003; Tsemberis etal.,
2004). Less consistent effects include symptom reduction
and improved functioning, physical health and quality of
life (Ridgway and Rapp, 1997). Not only is this housing
and support model effective for homeless people with men-
tal illness (Nelson etal., 2007), it is also more consistent
with the preferences of most people with psychotic ill-
nesses and with the recovery model, although living in sup-
ported housing may be associated with loneliness (Sylvestre
etal., 2007). Nonetheless, supported housing is increas-
ingly an integral component of mental health services.
Most research on housing models has been carried out in
the USA, but there are similar findings in Australia (Chopra
and Herrman, 2011; Hobbs etal., 2000; Trauer etal., 2001).
Thus, homeless Australians with mental illness suffer from
a high rate of physical and mental health problems and a
shortage of accessible and appropriate housing and support
services (Grigg etal., 2004; Mental Health Council of
Australia, 2005).
The first Australian survey of psychosis, conducted in
19971998, reported high levels of persisting disability and
needs amongst homeless people living with psychotic dis-
orders (Herrman etal., 2004). Further, meaningful activity
and the social needs of people with psychotic disorders liv-
ing in group housing were often overlooked, according to
this first national survey and other Australian research
(Freeman etal., 2004; Harvey etal., 2002). Consequently,
the first national survey concluded that there was a need for
better access to public housing, flexible supports linked
to accommodation, and a range of residential disability
support services (Jablensky etal., 2000).
As deinstitutionalisation progressed around Australia,
different programs have been developed that aim to provide
a partnership between housing, disability and mental health
service providers to enable people with psychosis to live
in society with greater access to the full range of opportuni-
ties experienced by all Australians. From the mid-1990s,
Australian state and territory governments have expanded
these programs to keep pace with increasing need as
more people with psychosis live in the community. The
Housing And Support Initiative (HASI) in New South
Wales (New South Wales Health, 2006), Psychiatric
Disability Rehabilitation and Support Services (PDRSS) in
Australian & New Zealand Journal of Psychiatry, 46(9)
842 ANZJP Articles
Victoria (State Government of Victoria , 2003), Project 300
and Housing and Support Program (HASP) in Queensland
(State of Queensland (Queensland Health), 2011),
Independent Living Program (ILP) in Western Australia
(Government of Western Australia, 2004) and Housing and
Accommodation Support Partnership (HASP) program in
South Australia (South Australia Health, 2010), represent
some of these programs. They typically consist of home-
based outreach support for people with severe mental ill-
nesses and significant disability who are living in regular
housing. Access to clinical mental health services is from
Assertive Community Treatment (ACT) teams (Harvey
etal., 2011) or a range of disability and recovery-based
support services may be provided by the non-government
sector. In 2008, the National Mental Health Policy was
updated to reflect the changed service system, with greater
emphasis placed on recovery as a core aim of mental
health services and the stronger partnership needed
for access to support and housing (Commonwealth
Government of Australia, 2009a). Further, the federal gov-
ernments national approach to reducing homelessness
(Commonwealth Government of Australia, 2008) included
an expansion of the Personal Helpers and Mentors (PHaMs)
program to assist people with a mental illness who are
homeless or at risk of homelessness and a no discharge
into homelessness policy. The latter aims to ensure that
appropriate accommodation and support plans are put
in place before a person is discharged from psychiatric
care. The National Affordable Housing Agreement
(Commonwealth Government of Australia, 2009b) is tack-
ling the provision of more affordable housing together with
support for people with mental illness, and new social
housing has been constructed under the current federal
governments National Building and Economic Stimulus
Plan funding. Thus, the expansion of supported housing
is one of the major changes in housing options for
Australians with psychosis in the last decade and, like
elsewhere (Carling, 1993), has led to increasing debate
about the value of the alternative supported group
accommodation model (Chopra etal., 2011).
A second national survey of psychosis was conducted
in 2010. It was designed to cover a wider range of aspects
of life than the aforementioned first survey. Within this
second national survey, this study aimed to: (1) describe
the proportions of people with psychosis living in differ-
ent housing types, including the homeless and those living
in marginal accommodation, together with their housing
preferences and needs; (2) explore selected demographic
and social inclusion correlates in relation to these housing
types; and (3) compare two subgroups participants liv-
ing in supported group accommodation and supported
housing (i.e. public or private rental accommodation with
in-reach support) with respect to key demographic,
functional, clinical and social inclusion variables. This
comparison is important because of recent increased
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availability of both types of housing and support in
Australia. However, their relative advantages in this con-
text have not been examined.
Materials and methods
Survey and participants
All participants took part in the Survey of High Impact
Psychosis (SHIP). This second Australian national survey of
psychosis covered seven catchment areas with a total area of
62,000 square kilometres and a population of 1.5 million
people aged 1864 years, approximately 10% of the
Australian population in this age group. A two-phase design
was used (Pickles etal., 1995). In Phase 1, screening for
psychosis took place in public specialised mental health ser-
vices and in non-government organisations supporting peo-
ple with a mental illness. In Phase 2, people who screened
positive for psychosis in Phase 1 were randomly selected,
stratified by age group (1834 years and 3564 years), for
interview and assessment. The census month was March
2010. Of 7955 people who were screen positive for psycho-
sis and eligible, 1825 were interviewed in Phase 2. Data
were collected on symptomatology, substance use, cognitive
ability, functioning, disability, physical health, mental health
service utilisation, medication use, education, employment
and housing. The study was approved by institutional human
research ethics committees at each of the seven study sites
and all participants provided written, informed consent. Full
details of the survey methodology are given in Morgan etal.
(2011; 2012).
Measures and data handling
Within the second national survey of psychosis, data
on current housing, changes of housing in the previous
12 months, housing preferences, needs and assistance,
and housing-related social inclusion variables (e.g. acces-
sibility of shops and public transport) were collected.
Diagnoses were derived from the 10th edition of the
International Classification of Disease (ICD-10) (World
Health Organization, 2010).
Housing was categorised as: public rented house/unit/
apartment (in Australia, public and private rented house/
unit/apartment is typically independent accommodation;
in-reach support may be provided, but this is allocated to
the individual and not the accommodation); private rented
house/unit/apartment (as before); family home; own house/
unit (that is, owned by self or others and no rent paid); sup-
ported group accommodation (that is, group accommoda-
tion with on-site support staff including hostels, group
homes, non-government organisation (NGO)-operated
residences and clinical residential rehabilitation settings
such as community care units; some group accommodation
offers a permanent home those that do not typically offer
Harvey etal. 843
residential rehabilitation on a time-limited basis); homeless
(primary, secondary or tertiary); institution (such as lodges
or nursing homes) or hospital; other (including caravans or
prison). Primary homelessness was defined as living on the
streets, in parks, in deserted buildings; secondary home-
lessness was defined as living in temporary shelters such as
refuges, emergency accommodation or sleeping on a
friends couch; and tertiary homelessness was living in a
boarding room (Chamberlain, 1999).
As people with psychosis are known to move in and out
of homelessness, the survey collected detailed information
on periods of homelessness in the 12 months prior to inter-
view. Participants were asked about their housing over the
previous 12 months as well as separately reporting any epi-
sodes of primary or secondary homelessness or residence in
marginal housing.
In order to compare residents in supported group
accommodation and supported housing, two subgroups
were created. Supported group accommodation was
defined as any group accommodation with on-site staff
support. Supported housing was public or private rental
accommodation combined with in-reach staff support,
either in the form of ACT or home visits by an NGO at
least weekly. We chose to exclude those living in their
family or own home from the supported housing subgroup,
since they were likely to differ with respect to other mate-
rial and personal support available to them. Since the vari-
able concerning housing type referred to current housing,
whereas the support variables concerned support received
in the preceding 12 months, participants were only selected
for their respective subgroups if they had been resident in
the appropriate housing type for the preceding 365 days.
This had the added advantage of selecting only partici-
pants who had been stably accommodated in their respec-
tive housing in order that the comparison between these
subgroups was more likely to reflect real differences
between them. These two subgroups were compared on
selected demographic and clinical variables, together with
key variables (functioning, social inclusion and recovery)
consistent with the literature (Sylvestre etal., 2007).
Descriptive statistics were employed, and subgroup
comparisons were assessed using the chi-squared test or
Students t-tests, as appropriate. All analyses were con-
ducted with SPSS for Windows, version 19 (Chicago, IL:
SPSS Inc., 2009)
Results
Demographic and diagnostic profile of participants
Of the 1825 participants with psychotic disorders, most
were male (59.6 %), not currently partnered (82.9%), born
in Australia (82.2%) and in the older group aged 3564
years (57.6%). All participants met screening criteria for
psychosis. The majority met ICD-10 research diagnostic
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criteria (World Health Organization, 2010) for schizo-
phrenia (46.7%), schizoaffective disorder (16.1%) and
bipolar affective disorder (17.5%). Further details on
demography, diagnosis, course of illness and recent ser-
vice usage of participants are provided in Morgan etal.
(2011; 2012).
Current housing, housing preferences and
satisfaction
Current and preferred housing of Australians living with
psychosis who were interviewed in the second national
survey are presented in Table 1. Comparing participants
current and preferred accommodation types, the main dis-
crepancies were: living in ones own home or unit (which
was the current form of housing for 13.1% compared with
the preferred form of housing for 39.8%), living in a fam-
ily residence (current housing for 19.1% and preferred
housing for 10.4%), and living in supported group accom-
modation (current housing for 11.0% and preferred hous-
ing for 2.8%). Examining the number and proportion of
those not currently living in a particular accommodation
type but preferring to do so (column 3, Table 1), the largest
discrepancy in numerical terms again concerned those par-
ticipants who were not living in their own home or unit but
expressed such a preference (n = 506). This examination
also revealed that amongst the relatively small numbers
preferring to be homeless (whether primary, secondary or
tertiary; 44 participants), three-quarters was not currently
homeless.
Half the sample (52.6%) said they were very satisfied
with their current living situation, with a further three in ten
somewhat satisfied (28.4%); 8.3% were somewhat dissatis-
fied and 4.4% very dissatisfied. Significantly more of the
very dissatisfied group reported that they had no choice
about their current residence (69.6% vs 28.9%, 2 = 58.76,
p < 0.001) and did not have their own room (15.5% vs
5.6%, 2 = 9.62, p = 0.002) as compared with other partici-
pants. They were more often living in publicly rented
accommodation (34.2%) or were homeless (16.5%). The
major reasons cited for dissatisfaction with their current
housing were a preference for living independently (24.1%)
or unsatisfactory practical circumstances such as lack of
safety due to crime or vandalism (15.2%), unsuitability
(12.9%) or substandard conditions (12.5%) of their current
accommodation.
Housing needs and assistance
A total of 414 participants (22.7%) were on a waiting list
for public independent housing (see previous definition).
Compared with the rest of the participants, a higher propor-
tion of those waiting for public housing was either living
in privately rented accommodation (28.3%) or supported
group accommodation (16.4%), or were homeless (11.1%).
Australian & New Zealand Journal of Psychiatry, 46(9)
844 ANZJP Articles
Table 1. Current and preferred housing of Australians living with psychosis.
Housing types Current housing
n (%)
Public rented house/unit 490 (26.8)
Private rented house/unit 397 (21.8)
Family home 349 (19.1)
Own house/unit 239 (13.1)
Supported group accommodation 200 (11.0)
Homeless: primary, secondary or tertiary 94 (5.2)
Institution/hospital 36 (2.0)
Other, including caravan, prison 20 (1.1)
Totala 1825 (100)
aTotals vary owing to missing data.
Just over one in five (21.9%) of participants reported
receiving some assistance with their housing in the con-
text of having moved house, such as acquiring and set-
tling into their housing, in the previous 12 months. Of these,
most (85.9%) reported their housing needs were adequately
met. Only 41 individuals (2.2% of the total) expressed an
unmet need for housing assistance. The majority of those
identifying unmet housing needs were either living in pri-
vately rented accommodation (15 individuals, 36.6%) or
were homeless (10 individuals, 24.4%).
Participants who had a psychiatric inpatient admission
in the year prior to interview were asked if staff had talked
to them about where they were going to stay on discharge.
Over half (58.2%) recollected discussing accommodation
options with staff at the time. Two-thirds (69.4%) reported
not needing further help as they already had somewhere to
live, 23.2% needed and received help finding accommoda-
tion, and 7.5% reported that they had not been given any
help and had nowhere to live on discharge.
Homelessness and housing instability
At the time of interview, 5.2% of participants were home-
less. Further, 12.8% had experienced at least one period of
homelessness in the past year and a quarter (25.2%) had
been fearful of homelessness in the previous year. On aver-
age, those who had been homeless reported 155 days of
homelessness in the past year (SD = 141 days; median = 98
days). Eight individuals (3.4%) had been homeless for
the entire year. The percentage of those experiencing
homelessness was significantly higher for males than for
females (15.4% vs 8.9%, 2 = 16.27, p < 0.001), as was
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Preferred housing
(irrespective of Proportion not living
current housing) in preferred housing
n (%) n (%)
472 (25.9) 187 (39.6)
313 (17.2) 174 (55.6)
190 (10.4) 56 (29.5)
726 (39.8) 506 (69.7)
51 (2.8) 8 (15.7)
44 (2.4) 33 (75.0)
2 (0.1) 0 (0.0)
24 (1.3) 19 (79.2)
1822 (100)
the mean days homeless (170 days vs 117 days, t = 2.66,
df = 231, p = 0.008). Significantly more of those aged
1834 years (16.4%) experienced a period of homelessness
in the past year, compared with the older age group (3564
years; 10.1%, 2 = 16.15, p < 0.001). However, older par-
ticipants were homeless for slightly (but not significantly)
longer than those who were younger (mean of 167 days vs
146 days, respectively). As expected, participants who
were never married were more likely to have experienced
homelessness (15.0% vs 11.1% separated/divorced/wid-
owed and 7.1% married/de facto, 2 = 14.91, p = 0.001).
There were no differences according to whether partici-
pants were born in Australia or not.
Concerning changes of accommodation, over a quarter of
participants (27.4%) had changed accommodation at least
once in the past year, not including admissions in and out of
hospital; 3.7% of all participants moved twice and 6.7%
moved three or more times. A range of reasons was identified
by participants for moving out of stable accommodation in
the past year. The most common main reason identified by
participants was: conflict with parents/partner or housemates
(19.6%); desire for independence or adventure (12.1%); own
mental health problems (excluding anxiety or depression)
(11.7%); non-renewal of lease or rental (10.9%); and finan-
cial troubles (6.3%). Almost 5% (4.6%) moved out of stable
accommodation in the past year as a result of hospitalisation.
Comparison between residents in supported group
accommodation and supported housing
One hundred participants were living in supported group
accommodation and 98 were living in supported housing
Harvey etal. 845

Table 2. Demographic and clinical characteristics of residents in supported group accommodation and supported housing.

Supported group accommodation Supported housing

(n = 100) (n = 98)
n (%) n (%)

Male 77 (77.0) 45 (45.9)

Aged 1834 years 30 (30.0) 31 (31.6)

Never married 78 (78.0) 53 (54.1)

Australian born 88 (88.0) 82 (83.7)

ICD-10 diagnosis
Schizophrenia 57 (57.0) 42 (42.9)
Schizoaffective disorder 11 (11.0) 20 (20.4)
Bipolar, mania 10 (10.0) 15 (15.3)
Othera 22 (22.0) 21 (21.4)

Course of illness
Single episode 7 (7.0) 5 (5.1)
Multiple episodes good recovery 17 (17.0) 28 (28.6)
Multiple episodes partial recovery 29 (29.0) 32 (32.7)
Continuous chronic illness 26 (26.0) 23 (23.5)
Continuous chronic illness with deterioration 21 (21.0) 10 (10.2)

Inpatient admissions for mental health in previous year 15 (15.0) 28 (28.6)

aIncludes depressive psychosis, delusional and other non-organic psychoses, severe depression, screened positive for psychosis but did not meet full

criteria for an ICD-10 non-organic psychotic disorder.

(regular housing with in-reach support) for the entire year
prior to interview. In the latter subgroup, 53 participants
received ACT and 54 were visited by an NGO case man-
ager and saw their case manager at least weekly. Thus, nine
participants in the supported housing group received both
types of outreach support service.
Participants living in supported group accommodation
and those living in supported housing were similar con-
cerning proportions of Australian-born individuals (88.0%
vs 83.7%, 2 = 0.76, p = 0.38) and the younger group (aged
1834 years) (30.0% vs 31.6%, 2 = 0.06, p = 0.80).
However, residents in supported group accommodation
were more likely to be male (77.0% vs 45.9%, 2 = 20.22,
p < 0.001) and to have never married (78.0% vs 54.1%,
2 = 17.94, p < 0.001) (Table 2).
Overall, participants in these two housing types did not
vary significantly by diagnostic category (2 = 5.89, p =
0.12), duration (t = 1.92, p = 0.06) or course (2 = 7.24,
p = 0.12) of illness (see Table 2). Nonetheless, more partici-
pants living in supported group accommodation were diag-
nosed with schizophrenia (57.0% vs 42.9%) and fewer with
schizoaffective disorder (11.0% vs 20.4%) and bipolar
affective disorder (10.0% vs 15.3%). On average, this sub-
group also had longer illness duration (19.7 vs 16.9 years)
and more participants with continuous chronic illness
with deterioration (21.0% vs 10.2%) rather than multiple
episodes with good inter-episode recovery (17.0% vs
28.6%). Fewer residents in supported group accommoda-
tion, however, had inpatient admissions for mental health in
the previous year (15.0% vs 28.6%, 2 = 5.36, p = 0.02).
Selected social functioning indicators were examined
across the two subgroups. Those in supported group accom-
modation were significantly more disabled according to the
Personal and Social Performance (PSP) scale (Morosini
etal., 2000) (Table 3). There were 22.0% classified as hav-
ing poor functioning sufficient to require intensive support
and supervision, compared with only 6.1% in supported
housing (Fishers exact test, 2 = 13.23, p = 0.001).
Residents of supported housing reported significantly
greater frequency of face-to-face contact with family and
other relatives (daily/almost daily: 41.2% vs 8.0%, 2 =
31.67, p < 0.001), yet were rather more isolated and lonely
(43.6% vs 34.3%, 2 = 1.75, p = 0.186).
The two subgroups were compared on key social
inclusion and recovery indicators related to their housing
(Table 3). Whether in supported group accommodation or
supported housing, most individuals had easy access to a
supermarket (87.9% and 88.7%, respectively) and public
transport (88.0% and 92.8%, respectively). However, more
supported housing residents felt unsafe in their locality
(23.5% vs 1.0%, 2 = 22.74, p < 0.001). In contrast, fewer
residents of supported group accommodation were likely to

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846 ANZJP Articles

Table 3. Comparison of residents in supported group accommodation and supported housing: social functioning, social inclusion
and recovery indicators.

Supported group accommodation Supported housing

(n = 100) (n = 98)
n (%) n (%)

PSP Scale (last 12 months)

Poor functioning requiring intensive support/supervision 22 (22.0) 6 (6.1)
Varying degrees of disability 76 (76.0) 84 (84.5)
Absence of disability or only mild difficulties 2 (2.0) 8 (8.2)

Face-to-face contact with family (last 12 months)

Not at all 15 (15.0) 9 (9.3)
Less than once per month 30 (30.0) 18 (18.6)
At least monthly 27 (27.0) 12 (12.4)
At least weekly 20 (20.0) 18 (18.6)
Daily/almost daily 8 (8.0) 40 (41.2)

Isolated and lonely 34 (34.3) 41 (43.6)

Has access to supermarket 87 (87.9) 86 (88.7)

Has access to public transport 88 (88.0) 90 (92.8)

Unsafe in locality 1 (1.0) 23 (23.5)

Have own room (if living with others) 72 (80.0) 33 (94.3)

Have choice about housing 53 (53.5) 74 (77.1)

have their own room if living with others (80.0% vs 94.3%,
2 = 3.83, p = 0.05) or reported having a choice about where
they currently lived (53.5% vs 77.1%, 2 = 11.90, p =
0.001). Finally, the majority in both supported housing and
supported group accommodation preferred to live in rental
accommodation (61.2% and 43.4%, respectively) or their
own home (31.6% and 21.2%, respectively); however, one
in four (25.3%) of those in supported group accommoda-
tion preferred to live there.
Discussion
Our key findings are that many Australians living with psy-
chosis continue to experience homelessness, a mismatch
between their actual and preferred form of housing and
unaddressed housing needs. However, comparisons of
those receiving services through state-run specialised men-
tal health services in a given month have revealed impor-
tant improvements in their housing circumstances since the
first survey in 19971998 (see Jablensky etal., 1999, 2000;
Morgan etal., 2011 for further details). These include an
increased proportion of people living in rented accommo-
dation (from 34.2% to 49.2%) and supported group housing
(from 5.2% to 10.9%) and a drop in homelessness (from
13.0% to 5.0%) (Morgan etal., 2011; 2012). These
welcome improvements are likely to be linked with mental
health service delivery changes such as deinstitutionalisa-
tion, and the further development of community-based
mental health services including treatment and support pro-
vided through ACT (Harvey etal., 2011) and disability and
recovery-based support services provided by NGOs within
peoples homes. They are also likely to have resulted from
broader policy developments that have targeted homeless-
ness and the increased provision of affordable housing and
support services for people with severe mental illnesses,
such as psychoses, so that they may gain and maintain
housing (Commonwealth Government of Australia, 2008,
2009b).
Need is complex and difficult to adequately define and
elicit. A particular strength of this second national survey
was that various enquiries were made of participants con-
cerning their housing needs. Notwithstanding the above
positive findings, these revealed unaddressed housing
issues. Further, our findings suggest that housing difficul-
ties are experienced by people with psychoses living in a
variety of accommodation types. As expected, the subgroup
of participants who were very dissatisfied with their current
living situation contained a higher proportion of the home-
less, although those in publicly rented accommodation
were also over-represented. In line with existing literature
about beneficial housing features as well as consumer

Australian & New Zealand Journal of Psychiatry, 46(9)

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Harvey etal. 847
preferences (e.g. Sylvestre etal., 2007), underlying reasons
concerned practical issues of housing adequacy and safety
as well as preferences for greater choice, privacy and inde-
pendence. Whilst access to regular housing such as pub-
licly rented property is broadly consistent with citizenship
rights and a recovery-oriented approach to mental health
(Chopra etal., 2011; Commonwealth Government of
Australia, 2009a; Slade, 2009), our findings suggest that
not all such accommodation can be defined as being of
adequate quality. Further, although few of the participants
(2.2%) expressed unmet needs for housing assistance, per-
haps because housing needs may not be readily identified
or expressed by this group, those who did express needs
were predominantly homeless or living in privately rented
housing. In addition, underscoring the complexity of
expressed preferences and needs with regard to housing,
only 10 (of 94) homeless participants expressed an unmet
need for housing assistance and an additional 33 individu-
als were not homeless (however defined) but expressed
such a preference. These data challenge the common
assumption that no one wants to be homeless and suggest
that some people with psychosis may prefer to live on the
streets, in temporary shelters or in a boarding room rather
than in some other types of accommodation. This finding
warrants closer examination in future analyses. A plausible
explanation may be perceived advantages with respect to
greater independence compared with institutional and sup-
ported group accommodation, as identified within the first
national survey (Harvey etal., 2002).
Almost one-quarter of all survey participants was on the
public housing waiting list. This suggests that, whilst sub-
stantial progress has been made in improving the access of
people living with psychoses to adequate housing, there is
still more that could be done. In particular, considerably
more investment is needed to meet unmet preferences for
own housing as well as alternatives to institutional living
and living in the family home. Availability of housing stock
is a general issue (Grigg etal., 2004; Herrman etal., 2004).
However, wider availability of, and access to, services
offering housing assistance could be helpful (New South
Wales Health, 2006). Only one in five survey participants
were asked if they received these services if they had
moved house in the previous 12 months, but most of these
reported that their needs were adequately met. A particu-
larly important gap is identified by the participants (7.5%)
who reported that they had not been offered any help with
accommodation when inpatients and yet had nowhere to
live on discharge. This finding is concerning given the
agreement by all states and territories to adopt a policy of
no discharge into homelessness as part of the National
Affordable Housing Agreement (Commonwealth
Government of Australia, 2008). With continuing pressure
on inpatient beds and emergency departments and clear
evidence that lack of appropriate and affordable supported
accommodation is a significant contributor to length of stay
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(Zhang etal., 2011), it is imperative that the housing needs
of inpatients are better addressed.
Although fewer participants were homeless compared
with the first survey of Australians with psychosis, the pro-
portion remains high and is a matter of public concern.
Homelessness affects the lives of a substantial minority of
people with psychoses, with one in eight having experi-
enced homelessness and one in four fearful of this pos-
sibility. Our data also highlight the linked phenomenon of
housing instability, which is more prevalent than in a com-
parable group of the general population (18.6% of those
aged 1564 years) (Australian Bureau of Statistics, 2007).
Further, although homelessness is often considered an older
persons problem, our data underscore the importance of
the growing recognition of youth homelessness (16.4% of
participants aged 1834 years in this survey) (e.g. Victorian
Homelessness Strategy Ministerial Advisory Committee,
2001) and the corresponding need for youth-specific inter-
ventions (National Youth Commission, 2008). As a more
general response to homelessness, the ACT model, and par-
ticularly the supported housing model (which similarly
incorporates home-based support), have been shown to be
effective (Rog, 2004; Rosenheck etal., 2003; Tsemberis
etal., 2004) and could be made more widely available for
people with psychoses who are homeless or at risk of home-
lessness. In addition, it may be useful for mental health ser-
vices to identify and target frequent movers for outreach
interventions where available. Further, since moving out of
stable accommodation was commonly precipitated by
interpersonal conflict at home, wider availability of effec-
tive interventions to improve relationships with significant
others, such as family interventions, is warranted (Pharaoh
etal., 2006).
Our findings highlight that many people with psychosis
experience a mismatch between their housing preference
and their current living situation. From a rights perspective,
this suggests that the development of a full range of
services is needed to adequately address this disparity.
This would also be consistent with existing evidence
concerning the therapeutic value of attending to housing
choice (e.g. Sylvestre etal., 2007) as part of the recovery
paradigm (Commonwealth Government of Australia,
2009a). However, as suggested by Sylvestre etal., further
work is required to understand how programs and policies
can be re-modelled to adequately address choice, take
appropriate account of factors such as diminished expecta-
tions and adaptation among people with psychosis (Herrman
etal., 2002), titrate support to changing needs, and balance
the best interests of the individual and community.
Supported housing is not only an effective interven-
tion for homelessness, but also has wider benefits for people
with psychoses (Nelson etal., 2007; Sylvestre etal., 2007).
These have led to growing adoption of this model both in
Australia and overseas. This study compared two participant
subgroups within the national survey with different types of
Australian & New Zealand Journal of Psychiatry, 46(9)
848 ANZJP Articles
housing and support: supported group accommodation and
supported housing (regular housing with in-reach support).
The subgroups resembled each other with respect to diagno-
sis and course of illness, although there was a tendency for
greater disability among those in supported group accommo-
dation that was also reflected in their social functioning rat-
ings. This may be a selection effect due to residential
assignments being matched with applicants characteristics
(Wong and Solomon, 2002) and cannot be used to draw con-
clusions about the relative effectiveness of the models. Key
differences emerged between the two subgroups with respect
to social inclusion and recovery indicators that are consistent
with the literature (Leff etal., 2009; Sylvestre etal., 2007).
Whilst supported housing appears more consistent with
recovery-oriented practice, it may exact a cost in the
increased likelihood that participants feel unsafe in their
locality as well as more isolated and lonely, despite greater
contact with relatives. Conversely, the opportunity to live in
housing of choice is still an unmet need for a greater propor-
tion of those in supported group accommodation. Given that
recovery is a complex and individualised process (Slade,
2009), it may be better to view these two models as comple-
mentary, rather than one leading to or replacing the other.
Whilst not as overtly consistent with recovery values, there is
evidence that supported group accommodation can support
peoples recovery and may be required to maintain this
recovery (Chopra and Herrman, 2011). Without sufficient
diversity of housing types available to support and maintain
recovery, and sufficient flexibility of policy and practice,
some of the most disadvantaged groups among those living
with psychosis will become or remain socially isolated, and
more rather than less disabled, over time.
Limitations
The survey method was likely to underestimate the home-
less with psychosis. This is because they are less often in
contact with services and were not specifically targeted for
this survey (Harvey etal., 2002; Herrman etal., 2004). The
survey was cross-sectional and so cannot be used to draw
conclusions about effectiveness of housing models. There
was relatively little data collected on neighbourhood char-
acteristics in this survey despite growing recognition of
the importance of neighbourhood characteristics in relation
to housing outcomes and satisfaction. The limitations of
satisfaction data in this population are also noted given the
possibility of diminished expectations or adaptive prefer-
ences. Some of the variables used to inform the subgroup
comparison may have been imprecisely rated: for example,
ACT is a complex service model which is difficult to define
briefly in the context of a lengthy survey interview and may
have been poorly understood by participants. In addition,
this survey did not collect data on model fidelity of ACT
and other outreach support and the extent and content
of NGO outreach support provided to participants was
Australian & New Zealand Journal of Psychiatry, 46(9)
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unknown. Finally, although the subgroups were restricted
to participants residing for the previous year in the relevant
housing in order to select well-defined and stable sub-
groups, participants could have spent brief unaccounted-for
periods of time elsewhere, such as in transitional accom-
modation or respite. Further, this approach may have intro-
duced selection bias due to differential rates of housing
tenure in these two housing models.
Acknowledgements
This publication is based on data collected in the framework of the
2010 Australian National Survey of High Impact Psychosis. The
members of the Survey of High Impact Psychosis Study Group
are: V. Morgan (National Project Director), A. Jablensky (Chief
Scientific Advisor), A. Waterreus (National Project Coordinator),
R. Bush, V. Carr, D. Castle, M. Cohen, C. Galletly, C. Harvey, B.
Hocking, A. Mackinnon, P. McGorry, J. McGrath, A. Neil, S. Saw
and H. Stain. Ethics approvals for the study were obtained from
the relevant institutional human research ethics committees.
This report acknowledges, with thanks, the hundreds of men-
tal health professionals who participated in the preparation and
conduct of the survey and the many Australians with psychotic
disorders who gave their time and whose responses form the basis
of this publication..
Funding
The study was funded by the Australian Government Department
of Health and Ageing.
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
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