Critical Ingredients and Mechanisms of Intensive Home Support for People With Severe Mental Illness According to Clients: A Qualitative Study on What Works and How, Using a Realist Evaluation Framework
Abstract
Introduction: Intensive home support (IHS) is a contemporary, innovative outreach approach in the supported housing sector designed to meet the growing need for community living initiatives for people with severe mental illness. Unlike regular outreach, IHS provides 24/7 accessible staff, numerous support hours, and several facilities supporting independent living, including daily activity programs. IHS has not been evaluated before. As the first IHS study, we aimed to identify the critical ingredients for IHS according to clients and unravel how it works.
Methods: We used a longitudinal qualitative design with semistructured interviews after recruiting a purposive sample of IHS clients after 1 year of their recovery journey. Utilizing a realist evaluation approach based on CAIMeR theory and thematic analysis, we explored clients’ perspectives on the impact and key components of IHS.
Results: A total of 42 clients participated in this study, with 32 remaining involved after 1 year. Thematic analysis identified five critical ingredients experienced by IHS clients, including: (1) working alliance; (2) autonomy; (3) relationships; (4) mental and physical health; and (5) housing and living environment factors. The results also highlighted how IHS works and under what conditions, namely, by highlighting trust, continuity, recognition, belonging, and self-confidence. Clients viewed these components as crucial, collectively empowering them toward independent living and recovery. The 24/7 accessibility of trusted support workers increased clients’ self-confidence, although actual use was infrequent.
Conclusions: This study indicated that with IHS, more formerly residential SH clients with severe mental illness can live independently despite experiencing a sense of insecurity and feelings of loneliness. These elements collectively position IHS as an innovative approach to complement existing services, offering valuable support to enhance the independence of individuals with severe mental illness.
1. Introduction
Deinstitutionalization in mental healthcare is the replacement of long-stay psychiatric hospitals with smaller, less isolated community-based alternatives for the care of mentally ill people [1]. It is a practice that has been ongoing for several decades [2]. In the 1980s, the supported housing (SH) sector emerged as an alternative to long-term stays in hospitals [3]. In the following years, more outpatient services emerged [4]. These newer supportive community models are more consistent with personal recovery values [5] and align with the desire of people with severe mental illness to move from residential SH facilities to independent housing within communities [6].
In the last decade, a new wave of healthcare innovation has impacted the SH sector, bringing further specification and forms of SH with different facilities and characteristics [7, 8]. Starting with group facilities, currently, the larger part includes outreach variants in the Netherlands, leading to 75% of clients in the SH sector living independently [4, 9]. Residential SH facilities have been modernized as well, including updating facilities similar to studio living and enhancing autonomy and privacy [4].
In the Netherlands, the deinstitutionalization process was inspired by a national commission report called From supported housing to supported at home in 2015. The commission emphasized housing as a “fundamental right” for everyone and the belief in people’s ability to live independently under the right circumstances. The authors called for renewed beliefs in mental health deinstitutionalization by pleading for more flexible housing options and intensive care facilities that enable individuals to live independently and fully participate as community members [10]. The report urges mental healthcare providers, SH providers, municipalities, and housing corporations to collaborate in innovative approaches, leading to a national movement of shared initiatives among local and regional partners [10]. We refer in this paper to all national initiatives in response to the report’s “intensive home support” (IHS).
Within the SH sector, roughly two different types of supported accommodation can be distinguished: SH and outreach [8, 11]. IHS can be seen as an intermediate form. Ideally, IHS initiatives enable clients to live independently in the community while receiving intensive, outreach support with the same level of care as residential SH. Independent living clients have their private homes in the community with support workers available offsite. Support workers employ new ways of support, including digital accessibility, 24/7 availability, and unplanned support. IHS initiatives also include respite options and an extensive program of daily activities and activation services. As an innovative and complementary approach, IHS aims to contribute to personal and societal recovery, reduce residential SH, and prevent re-institutionalization. Moreover, some SH organizations combine IHS with housing first, an evidence-based housing intervention in the social domain that combats homelessness [12] by providing rapid access to permanent housing and recovery-oriented mental health support [13]. Individuals with severe mental illness are at higher risk of homelessness, and many homeless individuals also have mental health issues [14]. The success of the HF approach is evident; recent Dutch studies found that the vast majority (i.e. 83% and 93%) of people who received immediate housing remain stably housed [15, 16].
Several internationally recognized community-based models from the mental health sector share similarities with IHS, including the community care unit model [17], intensive home treatment [18], and (flexible) assertive community treatment ((F)ACT) [19]. (F)ACT originated in the mental healthcare sector and provides home-based treatment through a multidisciplinary approach [20], while IHS is focused on housing support provided by an SH organization that mainly employs social workers. Similar community-based housing models in the SH sector include independent SH [21], supportive housing [22], and supported accommodation [6, 23]. Although these support models have common goals for independent living clients, IHS stands out due to its flexibility, intensity, 24/7 accessibility, and strong community integration [10]. Table 1 provides an overview of all important services, models, and programs in this paper.
| Services, models and programs | Characteristics |
|---|---|
| Supported housing sector | The supported housing (SH) sector aims for people who need help maintaining living independence due to mental health issues, disabilities, or other challenges. The SH sector does not provide treatment [24]. |
| Residential supported housing | Supported housing that offers 24/7 building-based support to people in single or shared tenancies with staff inside [25]. Housing and support are not separated. |
| Regular outreach | Outpatient support that offers flexible, visiting support to people in a permanent tenancy with staff offside [25]. Housing and support are separated. |
| Intensive home support | Intensive home support (IHS) offers intensive housing support at the client’s home in the community. IHS differs from regular outreach support by providing 24/7 availability of support workers, daily support possible with the use of digital technology, flexible up- and downscaling of support, and strong integration within the local community [10]. |
| (Flexible) assertive community treatment | (Flexible) assertive community treatment ((F)ACT) is a home-based treatment model provided by the mental healthcare sector through a multidisciplinary approach [20]. (F)ACT is often offered together alongside IHS. |
| Housing first | Housing first is an evidence-based model that provides permanent, immediate, and unconditional housing for formerly homeless people [12]. The model is used within IHS and prioritizes providing clients with stable housing before initiating support. |
- 1.
What are the critical ingredients of IHS according to clients?
- 2.
How does IHS work for these clients, contributing to their recovery goals, and under what circumstances?
2. Methods
2.1. Design
This study was qualitative, and we used a case study design which was guided by the realistic evaluation framework [32], using the context-actors-intervention-mechanism-results (CAIMeR) theory developed by Blom and Morèn [33] for data collection and analyses. The purpose of the RE was to unravel the underlying mechanisms that explain why certain actions lead within their contextual contingencies to the desired outcomes according to the users [34, 35], with the underlying working mechanism called “opening the Black Box.” This was done by looking for “configurations,” which refer to the specific combinations of elements that explain how and why an intervention works (or does not) in particular circumstances [32]. CAIMeR is designed especially to evaluate social work practice [33, 36] rather than evaluating a program theory as in regular RE [32]. Moreover, CAIMeR theory is an expanded version of the original context-mechanism-outcome (CMO) configuration by Pawson and Tilley [32], as it includes two additional components, “actors” and “intervention.” These two components highlight the dynamic interactions between social workers and clients in social work practice [33]. Table 2 shows the different elements of the CAIMeR acronym.
| CAIMeR elements | Description | Examples |
|---|---|---|
| Context | This is the environment where the intervention takes place. There are three different types of contexts: Two relatively narrow that are “close” to clients and social workers (intervention context and the client’s life-world), and one wider in which the two others are embedded (societal and cultural context). | Surrounding world, relationships, neighborhoods, other organizations |
| Actors | Actors are individuals (in)directly involved in the intervention process. | Social worker, therapist, family |
| Interventions | Interventions are (un)conscious actions deployed by actors. The intervention concept contains three types: social workers’ interventions, clients’ interventions, and others’ interventions. | Relational approaches, methods, models, practical help |
| Mechanisms | Mechanisms are processes or underlying causal forces responsible for outcomes. | Response-, challenge-, risk-taking mechanisms |
| Results | The results primarily refer to client effects/outcomes, or changes in the client’s life situation due to the intervention. This is divided into surface, process, and depth aspects. | Stopped abuse, increased social competence, gradually increased responsibility for one’s own change |
2.2. The Context of the Study
The 2015 National Committee report encouraged further deinstitutionalization of housing and daily support in the Netherlands, urging collaboration among mental healthcare and social domain partners [10]. Consequently, IHS approaches emerged, led by the SH sector. HF initiatives already existed, but most IHS initiatives were put into practice after 2015 and are now widely applied nationally, being further studied, and developed. To our knowledge, this was the first comprehensive scientific study of IHS. It involved three major SH organizations across half the Dutch provinces, including the metropolitan area of the capital. These three SH organizations support the clients in their own homes in the community without shared facilities and for which they pay rent. Most clients live in apartments with/without a balcony, some live in a terraced house with a garden. The support workers in the IHS teams are trained as social workers.
SH organization A operates in four provinces in the Netherlands, in the central part of the country. They developed the model “just at home” with newly established teams who support only independent living clients. These teams work alongside the existing residential SH teams and the regular outreach teams. “Just at home” includes five key elements: 24/7 support, respite options, digital support through video calls and WhatsApp messages, strengthening social network and recovery, and meaningful daytime activities. All clients who receive support from these teams currently reside independently without access to SH facilities.
SH organization B operates in the capital of the Netherlands and works with community-based teams, consisting of social workers. The teams support clients living independently in their neighborhoods without sharing facilities with others, often using the HF methodology. In addition, the organization has satellite homes where clients live independently near the SH location. Finally, outreach teams are available to provide necessary support at the individual’s level of need. Many clients can use the facilities of a nearby SH location, such as having coffee in the common room or participating in activities.
SH organization C operates in the province of North Holland and works with the concept of “living circles,” including a satellite approach. The team operates in a central hub, mostly in residential SH accommodation. The same team provides IHS to independent living clients and supports residential SH clients. All IHS clients live independently in their own home in the community up to 10 min by bicycle from the central hub and can use the SH facilities to meet other clients or their support workers. Moreover, certain teams help young adults transitioning out of residential facilities by offering IHS support from the organization’s training center. Finally, several outpatient teams support clients in more rural areas. These teams do not have a central hub accessible to clients.
2.3. Recruitment Process and Sampling Strategy
This study included adults (> 18 years old) meeting the severe mental illness criteria: people with persistent mental illness (more than 2 years), people with a need of care and support for a longer period, and people who experience a large impact on their general functioning, social contact, and community participation [37, 38]. They received IHS for up to 3 years of the three participating SH organizations. All clients lived in individual accommodations in the community without shared facilities (e.g., kitchen, bathroom) with other clients for which they pay rent. Table 3 provides an overview of the inclusion criteria of this study. Clients who were unable to give consent or did not speak Dutch were excluded from the study following discussion between the support worker and the researcher. The exclusion of non-Dutch speaking IHS clients may introduce selection bias. The recruitment process took place between November 2021 and October 2022. The sample frame included three large-scale SH organizations, spread over four provinces geographically. The clients were selected by purposive sampling [39], with a minimum of 40 clients. This also ensured a proportional distribution across the three organizations, regions, and municipalities. Before starting recruitment, we identified the IHS teams supporting eligible clients in all three organizations. Subsequently, the first author visited these teams and discussed their potential participation with the team members. Because of privacy rules, recruitment was done through the support staff. The support staff informed clients by an information letter. Clients contacted the researcher independently if they wanted to participate, or the researcher contacted the client after the client’s consent. We also distributed the information letter as a flyer so that clients could contact the researchers directly. During the first contact between the client and the researcher and before the first interview, it was confirmed that the client fully understood the study and had no remaining questions. The study received ethics approval from the Ethics Review Board Tilburg School of Social and Behavioral Sciences (RP561) and was performed following the ethical recommendations of the Helsinki Declaration. Respondents signed an informed consent form before participating in the study.
| Criteria | Eligibility criteria |
|---|---|
| Population |
|
| Setting |
|
2.4. Data Collection Method
The first author conducted semistructured in-depth interviews with IHS clients who met the inclusion criteria mentioned above. The first round of interviews was conducted from January 2022 until November 2022, and the second round took place from January 2023 until October 2023. We conducted two waves of interviews with the same respondents over 1 year to map their recovery progress. The interviews lasted 45 min, on average. The interviews were conducted in Dutch and were face-to-face, with four exceptions held online due to COVID-19. The remaining interviews occurred at clients’ homes or the organization’s offices/locations. Thirteen clients preferred to have a support worker present during the interview. Saturation was reached after 30 interviews. We adapted the RE methodology to fit our respondents. Realist interviewing [40], for example, was not appropriate because of clients’ limited reflective ability and many respondents having mild intellectual disabilities. Therefore, the topic list was created with the support of an expert by experience and relied on our previous studies [41, 42] and assumed outcomes of IHS, such as recovery, social inclusion, and participation. The topic list was graphically designed as a “topic clock” to support transparency and repeatability. This one-page document includes the main topic and sensitizing concepts and is attached as a supplement (see Supporting Information 1). The design helped the first author structure interviews while maintaining conversational authenticity and provided transparency and predictability for the respondents. The first interview protocol included questions on the living environment; sources of support; support structure; and effective/ineffective support aspects. One year later, a second interview addressed additional topics: work/daytime activities; stigma/discrimination; neighborhood contacts; the client’s support priorities; and what they missed in the past year. Before the second interview, we conducted simplified CAIMeR configurations in keywords based on the first interview results, reviewed them with clients afterward as a member check, and refined them based on their feedback.
2.5. Analysis Methods
After verbal transcription, we conducted an inductive analysis for both research questions. The transcripts of the first interviews were used as foundation for both research questions. The second interview transcripts were used especially to check the changes after 1 year in the client’s life and why and how they occurred. For the first research question, we searched through the transcripts for the overarching themes that described the different aspects according to clients by open, axial, and selective coding [43]. Afterward, we scanned transcripts for text fragments highlighting context (C), actors (A), interventions (I), mechanisms (M), and results (R). Together, these text fragments formed the CAIMeR configurations [33]. With this analysis, we addressed the second research question. The first author coded all transcripts. Two researchers (RM and MvE) coded 5% of the transcripts for verification. Braun and Clarke recommend using co-coding for about 10% of the data [43]. However, in this study, we opted for 5% due to the large volume of data, which includes 74 interviews. This decision was made to manage the analysis process effectively while still ensuring a degree of reliability in our findings. The software programs Atlas.ti and Microsoft Excel were used in both analysis methods.
3. Results
We first report the demographic details of the respondents at both measurements (Table 4). Second, we present the thematic analysis results on the critical ingredients, followed by the RE results displaying the perceived impact and mechanisms experienced by the clients.
| Characteristics | Respondents N = 42 (%) |
|---|---|
| Gender | |
| Male | 27 (64.3%) |
| Female | 15 (35.7%) |
| Age | |
| 20–29 | 14 (33.3%) |
| 30–39 | 10 (23.8%) |
| 40–49 | 6 (14.3%) |
| 50–59 | 9 (21.4%) |
| 60+ | 3 (7.1%) |
| Employment | |
| Full-time (paid) | 2 (4.8%) |
| Part-time (paid) | 4 (9.5%) |
| Education | 3 (7.1%) |
| Voluntary work | 8 (19%) |
| Unpaid sheltered work | 12 (28.6%) |
| Currently no work | 7 (16.7%) |
| Declared unfit for work | 6 (14.3%) |
| Support before IHS | |
| Supported housing | 17 (40.5%) |
| Regular outreach | 17 (40.5) |
| No support | 2 (4.8%) |
| Other (e.g., psychiatric hospitals, homeless shelters) | 6 (14.3%) |
| Marital status | |
| Married | 0 (0%) |
| Living together | 2 (4.8%) |
| In a relationship | 5 (11.9%) |
| Divorced | 4 (9.5%) |
| Widow/widower | 1 (2.4%) |
| Single | 30 (71.4%) |
| SH organization | |
| A | 15 (35.7%) |
| B | 14 (33.3%) |
| C | 13 (31%) |
| Years in IHS at study’s start | |
| Up to 1 year | 20 (47.6%) |
| From 1 to 2 years | 10 (23.8%) |
| From 2 to 3 years | 12 (28.6%) |
3.1. Demographic Details of Respondents
In total, 42 respondents took part in the first round. After a year, 32 respondents (76.2%) stayed involved, and 28 of them (87.5%) still received IHS. There were several reasons for study dropout, including difficulties in reconnecting (N = 5), re-admission due to addiction relapse or psychiatric symptoms (N = 4), and suicide (N = 1). Respondents were for a few weeks to 3 years in IHS when completing the first interview. During the second interview, four clients no longer received IHS and three were close to finishing it. Among the 42 respondents, most were male (N = 27), between 20 and 67 years old, but the majority were between 20 and 30 years old (N = 14). Most respondents had multiple mental health diagnoses from a psychologist/psychiatrist, including addiction problems and mild intellectual disabilities as comorbidity, based on diagnoses established recently. Most clients were diagnosed (self-report) with personality disorders (N = 14), including borderline and antisocial personality disorders. Other common diagnoses were autism spectrum disorder (N = 12), mood disorder (N = 8), several addictions (N = 7), posttraumatic stress disorder (N = 6), and psychosis sensibility (N = 5). Respondents included people with mild intellectual disabilities (N = 7) (self-report). More than half of the clients (57%) have a treatment provider alongside IHS, which includes a FACT team or psychologist. Some respondents were previously homeless (N = 4). Finally, some respondents were born abroad (N = 8), while three of these respondents were adopted.
3.2. The Critical Ingredients of IHS
We identified the following five critical ingredients for IHS based on interviews with clients: (1) working alliance; (2) autonomy; (3) relationships; (4) mental and physical health; and (5) housing and living environment factors. These ingredients were felt important according to the participating clients to achieve their recovery. Below, the content of these ingredients is explained, based on our interview findings.
3.2.1. Working Alliance
3.2.1.1. Mutual Trust
The clients saw mutual trust as essential in support: The support worker must have and show trust in the client, and the client must be able to trust the support worker. This involved having hope and showing it to the client. Working on the client’s self-confidence was important, too.
3.2.1.2. Continuous Open Communication
That option is there, although I don’t use it often (…). Yes, so that the option is there and that it can be [used] if needed. That’s enough. (C21)
I think you also limit yourself that way. I think if you become too dependent on those one or two people, you just don’t manage to ask for help at all in general anymore. (C40)
I benefit very much from my support worker because he can read me, he understands me, he knows me, he can put himself in my place. He doesn’t ask the standard questions. I can say a lot to him, but he also hears on the phone when there’s something wrong. (C19)
Listening is very important to me. I always say for me being able to share is already often 80% of the tension, emotion, or stress. (C2)
3.2.1.3. Supportive Engagement
Clients highlighted the effectiveness of a support worker standing beside them, offering a constant fallback. Tackling new tasks step-by-step together motivated clients to handle the tasks independently in the future. Moreover, clients with limited social networks valued support workers who accompanied them to crucial appointments, such as at government offices or the hospital. However, not all organizations permitted clients to ride along, leading to frustration for some.
Moreover, clients mentioned that support can be quickly increased when needed to prevent their situation from worsening and ensure proper monitoring. Likewise, it can be gradually reduced when less support is required, ensuring the client receives the right level of support and engagement.
3.2.1.4. Equivalence
They should … instead of standing above me, stand right next to me, put an arm around me: “Hey, shall we do it together?” That’s much better than standing right opposite someone or up there because in my case, you will repel me otherwise. (C11)
She’s a nice girl; we connected immediately. She has a completely different background in terms of care and what she’s been through than I do, but you feel that recognition that you’ve both just been through a lot of bad things. You both feel understood. (C2)
3.2.2. Autonomy
3.2.2.1. Empowerment and Self-Direction
The clients in independent living situations assumed greater responsibilities, with support workers playing a crucial role in fostering self-reliance. This required other communication and support techniques compared to regular SH. It included maintaining a strong belief in their clients’ abilities and ensuring 24/7 availability. Moreover, clients expressed the need for empowerment in decision-making. They appreciated support workers who respected their pace and wishes. Some clients mentioned they gained confidence and control when support workers expressed belief in them.
3.2.2.2. Work
Yes, unpaid sheltered work has always helped me. I think that was clear in our previous conversation. I enjoy it there, and it’s very beneficial for me. The daily structure is very important for me. It’s also when there’s a holiday and I don’t go for a week, I immediately notice that my sleep rhythm shifts. (C12)
I did a training 4 months ago for the [welfare organization] as a buddy, so … a kind of social volunteer to work with people in the community to give them a listening ear. And I specifically asked for “people with addiction backgrounds because I understand them best.” (C26)
3.2.2.3. (Barriers to) Participation
Clients often felt societal pressure to participate, viewing paid work as the ultimate goal. However, this may not be feasible or desirable for everyone. Moreover, many clients expressed uncertainty about the future. However, they all agreed on not wanting to return to their former lives in psychiatry or SH accommodations. They emphasized the ongoing need for support to sustain stability and emphasized the importance of the present without concerns about the future.
I could have done that [going out] much earlier, but there was no monetary possibility for that due to my benefits. That felt unfair! Am I not human? Why are they giving me less than a minimum wage? (C1)
3.2.3. Relationships
3.2.3.1. Friends and Family
[They did help me with] social contacts and so on, and there is also a support center. They said: “There you can meet other people and then you will see that it all goes a bit easier.” I’m very glad that they told me to go there because I have some nice contacts now. (C9)
3.2.3.2. Changing Family Ties
I think already the very first time they [my parents] came to visit me here […]. They were not at all prepared that I became independent in the meantime and made decisions independently. I don’t close myself off to advice, but I decide by myself. I don’t self-efface for them anymore. And because I don’t have to do that anymore, I can assess my priorities better. (C26)
3.2.3.3. Fellow Clients
I think if [SH locations] go away, I’d fall into a gap. I have a second place to go, where I can have coffee, where I can meet people. (C18)
3.2.3.4. Maintaining Friendships With Nonclients
It is often a bit more difficult for us to make contact, to trust people, and to maintain contacts. [Support worker] would arrange something for me through a community center. That’s very cool, but then I still have to maintain it. (C2)
3.2.4. Mental and Physical Health
3.2.4.1. Mental Health Problems
The F-ACT team is more for my psychiatric treatment. [SH organization] is more the support of my home and a bit about social things. They can also help with finances. (C14)
3.2.4.2. Physical Health Problems
You do notice that people with mental problems do have a lot of physical symptoms, but there is also a lot of stress involved. (C5)
3.2.4.3. Stigma in Healthcare
I suffered from my stomach for a long time. Because I had psychiatric diagnoses, they [doctors] said: “Yes, that’s tension. You should drink more water.” Last year, it was the opposite. I finally had a doctor, it was a woman, and she did take it seriously. I had much inflammation in my intestines. (C10)
3.2.4.4. Collaboration between IHS and Treatment
They may call each other with my permission. I don’t know if that happens. I have no idea. (C3)
So, for me, I made a separation between the 12-step part and everything about addiction, and the social part, social workers. [SH organization] is part of that. (C26).
3.2.5. Housing and Living Environment Factors
3.2.5.1. Independent Living
You do just have a starting point with less stress compared to SH accommodations. There you put a lot of different people together with all their baggage and problems. They will negatively affect each other, like catalysts. (C28)
Yes, that [the freedom of living alone] is sometimes tricky, especially when you live independently, then you have the whole realm and freedom to yourself alone. If there is no support worker or whatever … that is the thing, but yes, I must learn that. (C5)
3.2.5.2. Suitable Housing
I’ve seen enough institutions that make me say: “Okay, I don’t want to go back into such an institution. Outside of it, I don’t mind, but never back to an institution.” I do need [care organization] in there. (C15)
Some clients were dissatisfied with their noisy accommodation. They mentioned that a shortage of affordable housing had forced them to stay in SH longer than necessary. They emphasized the importance of considering specific housing needs and were willing to wait for a suitable property.
3.2.5.3. Formerly Homeless Clients
If you just give someone [who is homeless] a place to live, then several processes in terms of stress fall away. Having your own home and being able to do your own thing gives you privacy. (C28)
3.2.5.4. Mixed Living
I just have a lot of sleepless nights now because my neighbor has music on at night. I also now have an opposite neighbor who games up until 3 in the morning. And those are all not people [of a care organization]. We live mixed with other residents who don’t receive help. But I don’t know, I notice that I don’t sleep much because of that. (C10)
3.3. How and Under Which Circumstances Does IHS Work?
We identified 15 CAIMeR configurations addressing how and under which circumstances IHS appeared to work. We present a comprehensive overview of them below based on the mechanisms found. Each alinea shows how the interventions lead to results by these mechanisms. The complete detailed version of the CAIMeR configurations is available in Supporting Information 2.
3.3.1. Promoting and Maintaining Trust
Trust was the main topic and must be seen as the key mechanism in IHS. Mutual trust (M) allowed support workers and clients (A) to work actively toward recovery goals (R). Support workers and care organizations (A) could do many things to ensure the growth of trust, like having the same support workers for longer periods, being easily accessible, and matching clients and support workers with mutual connections (I).
Despite having many contact moments per week, clients still experienced moments of urgent help (C). Many clients appreciated the 24/7 accessibility (I) because it provided a sense of trust and security that someone was always available (M); it was more about the idea than the actual use. The low threshold to be in contact with support workers enabled clients to ask for help before it was “too late” (R). This aspect contributed to more clients being able to continue living independently.
3.3.2. Ensuring Continuity in Support
Many clients shared long histories with clinic settings and care institutions, having seen many support workers come and go. Frequent changes led to distrust, as clients repeatedly told their stories, experienced misunderstanding, and struggled to establish social relationships (C). The continuity of the same support worker (I) contributed to being able to work together toward recovery goals (R) because they had time to get used to the (method of the) support worker and build trust (M).
3.3.3. Feeling Understood and Recognized
The clients indicated that they did not always feel understood by support workers because they did not know what they had gone through. A long history in institutions where they experienced stigma and discrimination also contributed to feeling misunderstood (C). Experts by experience could play an important role in this (A + I). With them, clients felt more equality, and they recognized themselves in each other’s stories (M). This brought “peace of mind” and a renewed perspective on their life situations (R). Also, fellow clients were important in this (A) since they went through a similar process and understood fears and thresholds in society (M). By actively seeking collaboration with nearby SH locations (A + I), clients could meet each other in such low-threshold places and reduce loneliness (R). Moreover, despite living alone, they still experienced a sense of belonging (M).
3.3.4. Feeling Equal
Support workers (A) could take “concrete action” within the working relationship to foster a sense of equality (M) among clients, like showing details of themselves, showing confidence in the client, and approaching the client as an equal by standing beside them (I). This led to trust (M), allowing recovery goals to be worked on (R).
Many clients reported an “unhealthy relationship” with family members because the relationship was affected by continuous caring. This put pressure on the often vulnerable and limited network (C). The support workers took care tasks off the hands of the family (I), which contributed to a healthier relationship with family members (R) because the family members felt more equal with each other (M).
3.4. Feeling Peaceful and Secure at Home
Many clients had spent extended periods in institutions and were now living independently for the first time (C). For them, a home contributed to their sense of belonging in society (M). However, they had to satisfy specific needs, including a “quiet neighborhood” and well-insulated housing. With the current housing shortage, it was difficult to meet these wishes (C). Also, some clients lived in housing about to be demolished; this caused stress which prevented clients from working on their recovery. Poor insulation and noise also negatively affected well-being (C). The housing association and support worker played crucial roles (A) in finding suitable housing (I) because clients indicated that a “pleasant home” in a quiet neighborhood contributed to recovery (R) due to peace of mind, reduced stimuli, and minimized stress (M). The privacy of one’s own home (C) also contributed to symptom reduction (R), according to many clients. It helped clients organize their lives and living spaces freely (M).
3.4.1. Feeling Useful
A structured daytime activity (C) also contributed to a sense of belonging (M). A support worker, job coach, or IPS worker could have a significant impact in this (A) to help find a suitable workplace (I). According to many clients, they did not need a paid job as long as they felt useful (M). They could thus still expand their social network and participate in society (R).
3.4.2. Growing Self-Confidence in Independent Living
The clients needed to feel capable of taking care of themselves. This was often lacking at the beginning of the support process, partly due to self-stigma and hospitalization in institutions (C). Support workers played an important role (A). They could teach clients essential household management skills step-by-step (I) and show confidence in the client’s ability to learn (I). The clients wanted to experience increasing success, which boosted self-confidence and motivated them to complete tasks independently (M). Ultimately, they could perform tasks independently and rely less on support workers (R).
4. Discussion
In this study, we found promoting and maintaining trust as key mechanisms in clients’ recovery, ensuring continuity in support. Also, feeling understood and recognized, feeling equal, feeling useful, and growing self-confidence all contributed to clients’ abilities to live independently. The support worker was crucial in providing continuity, building trusting relationships, and giving clients practical skills and emotional support. Moreover, we identified five critical components for IHS which relate to the client’s immediate environment, including the working alliance, relationships, autonomy, and mental and physical health factors. The component “housing and living environment” was broader than just the client’s immediate environment. As a result, this study identified more micro-level components than our scoping review [41].
The main findings were that most clients felt satisfied with their new lives and valued living independently. The clients who no longer received IHS during the second interview indicated that they have developed enough self-confidence, and they can manage on their own or with regular outreach once every (few) week(s). Additionally, a few clients mentioned having recently contact with an expert by experience, whom they found to be “very helpful.” According to some clients during the interviews, societal pressures drove their desire for paid employment, yet their primary goal was to contribute meaningfully to society. Volunteering could sometimes fulfill this desire just as effectively. There were wide variations between clients in their wishes regarding collaboration between support and treatment and what this collaboration looked like in practice. The main challenge was maintaining new friendships rather than meeting new people. Finally, family ties improved as care tasks shifted to IHS and loved ones who were not often involved in the recovery process. However, promising models like the active recovery triad model [44], peer-supported open dialogue [45], and resource group method [46] involve people from clients’ networks actively. Further steps should be taken to involve significant others.
Moreover, in this study, participating clients emphasized the support worker’s important role. The support worker often focused on teaching practical skills and other tasks, which was appreciated, but more effort was needed to reduce the loneliness many clients felt. Clients mentioned nearby SH locations as valuable for meeting peers. Peer groups were seen as successful interventions to improve social networks [47]. Support workers could also guide clients to other options in the community that were not mentioned in the interviews, such as recovery colleges and community centers. Recovery colleges provided a space where clients found recognition and acknowledgment through peer support and recovery activities, fostering the exploration of diverse recovery possibilities together [48]. This required that support workers have good knowledge of neighborhood facilities. Besides the support workers, experts by experience, family, and fellow clients are important actors according to clients. Their role may be more significant than indicated by this study. Further research from their perspective is needed to fully explore the role of these actors in IHS.
This study emphasizes the added value of IHS besides other housing models to achieve recovery. First, independently living, with or without outreach support or IHS, enhances social participation compared to residential SH [3], and clients experience enhanced autonomy and normalization [49, 50]. Almost all clients emphasize this, especially those who moved out of residential SH. In addition, our study highlighted the added value of IHS toward regular outreach housing support. The opportunity for multiple times support a day along with 24/7 availability enables IHS to provide what regular outpatient services cannot offer. According to the clients, this level of support allows them to live independently who would otherwise require residential SH, and they don’t have to move when they make progress or relapse in recovery [25, 51]. Finally, (F)ACT and IHS both serve clients in independent living with a shared goal of promoting recovery but with different focuses: (F)ACT emphasizes treatment [20], while IHS prioritizes supporting more social inclusion and participation. This makes the two approaches complementary, highlighting the importance of collaboration between them and allowing SH organizations to offer broader care to their own clients.
Furthermore, physical health was a recurring theme in the interviews. Clients mentioned numerous physical issues alongside mental challenges, attributing life’s dominance by mental health to a lack of energy for physical well-being. Research has indicated gains through attention to eating healthier, quitting smoking, and exercising more to improve mental well-being [52]. Support workers can support and inspire, for example, by advocating for a healthier diet and increased physical activity. There also seemed to be significant potential for improvement in these areas. Although physical health was also important in residential SH, recognizing health problems of IHS clients is even more crucial because these clients are seen less frequently, which means problems can go undetected.
The working alliance was critical in IHS according to the clients, but this was also in clinical settings and residential SH [53]. Our RE showed that 24/7 accessibility was a key intervention in IHS. This distinguished IHS from other settings because no support worker was present in the building [8], yet it provided peace of mind knowing that support was always available and close by phone. Digital contact with support workers facilitated timely support, yet some clients were hesitant to call if they anticipated an unfamiliar worker answering. However, some clients experienced 24/7 accessibility as fostering “dependency” because they also sought help when they could solve a problem independently. The mentioned connection between support worker and client was noteworthy; in urgent situations, familiarity should not matter if support is available. The high pressure on healthcare due to staff shortages challenges SH organizations to provide 24/7 support. Is not the guarantee of 24/7 availability of a well-trained support worker more important than having your own support worker picking up the phone in case of emergency? Distrust played an important role in this.
Overall, trust was found to be the most important mechanism in IHS. This manifested in different ways: The support worker trusted the client, the client trusted the support worker, and the client trusted themselves (e.g., self-esteem). Reciprocity played a significant role in this. Establishing trust required a strong bond between the client and the support worker, alongside easy access to them. This long-term interaction should align with the client’s pace and preferences, ultimately fostering their self-reliance, facilitating recovery, and promoting participation in society. In addition, support workers ideally serve as hope-givers for clients [54]. These findings align with the four elements of empowerment: strengthen, connect, trust, and resist [55]. Support workers can significantly contribute to clients’ empowerment as bridge builders, educators of several skills, and facilitators of tailored participation [55, 56]. This underscores empowerment as a relational concept just like the working alliance—an important relational variable in the treatment outcomes of patients with different diseases [57] and serving to help mediate change [58]. Finally, as the last element of empowerment, “resistance” was mentioned in our study within the theme of autonomy; the clients were making their own choices and learning to advocate for themselves.
We knew that support workers were crucial in signaling, motivating, and supporting clients. However, support workers cannot influence everything, such as the availability of quality low-rent housing. Clients emphasized that having a house that felt “like home” was crucial for initiating the recovery process, boosting self-esteem, and improving quality of life. SH organizations typically search for suitable houses for their clients which they can accept or reject. However, due to a shortage of low-rent housing, many clients struggled to find suitable housing, like many other Dutch people. This also influenced the outflow from SH accommodations, underscoring the complexity of the implementation of IHS and the need for intensive collaboration due to people’s dependency on housing associations that rely on government decisions. While the rise and success of HF are steps in the right direction [12, 16], more government action may be necessary because housing is a human right [59]. Contrary to literature that suggests clients live more often in disadvantaged neighborhoods, our study found that many clients lived in newer properties, up to 10 years old, in mixed neighborhoods alongside owner-occupied houses [60]. More “social housing” was becoming available through mixed-living projects, enhancing social inclusion. However, despite the increase in successful projects, scientific evidence for mixed living is scarce [15, 61, 62]. Despite positive trends, the clients often lacked contact with neighbors, prioritizing other aspects. Future research might explore how neighborhoods can foster social connectedness and reduce loneliness among IHS clients.
4.1. Study Strengths and Limitations
This study had several strengths. The first was the empowering effect of participation for the interviewed clients. Respondents said they felt “honored” to have their experiences heard. The topic clock and discussion of the first interview results during the second interview further contributed to this. Also, two interviews separated by 1 year ensured that results were not a snapshot in time. In addition, our research methodology was a strength of our study. With an RE, we qualitatively assessed the effectiveness and mechanisms of IHS. Our thematic analysis contextualized the important elements not revealed by the CAIMeR configurations. Another strength is the first author’s practical experience as a support worker in SH and the extensive rehabilitation research background of the other authors, specifically regarding people with severe mental illness. These experiences enhance the study’s trustworthiness by informing data collection and analysis with in-depth, field-specific insights. Finally, our large number of respondents for a qualitative study was another plus. The many stories provided valuable insights into the experiences of this group.
Still, this study had limitations. Ideally, we would have interviewed new clients for a baseline measurement. Unfortunately, only a small number of new clients participated. This is understandable, though, as they were in a transitional period with new living arrangements and support workers. Another possible limitation was the presence of the support worker, which might have affected the openness and honesty of the respondents but allowed more clients to participate and better reflect on their recovery process.
5. Conclusions
Our main findings were that most clients in this study were satisfied with living independently. Moreover, despite diverse mental health conditions, the clients shared common support needs including mutual trust, continuity, and flexibility. The working alliance was emphasized as “crucial,” alongside 24/7 support accessibility. Unfortunately, some clients mentioned that living independently often brought a sense of insecurity and feelings of loneliness. Nonetheless, all these elements together make IHS a new approach that complements the existing national and international services and could help many people with severe mental illness live as independently as possible. This suggests that our study supports the national commission’s hypothesis that a part of the most care-intensive group within the SH sector can also live independently with IHS. Further research is needed to evaluate IHS on a larger scale.
Nomenclature
-
- SH
-
- Supported housing
-
- IHS
-
- Intensive home support
-
- CAIMeR
-
- Context-actors-interventions-mechanisms-results
Conflicts of Interest
The authors declare no conflicts of interest.
Author Contributions
C.M.H.v.G. contributed to the development of the research questions and strategies, data collection, analysis, and writing the main part of the manuscript. D.P.K.R and M.D.v.V. participated in the development of the research question and strategies and in writing the manuscript. J.v.W. and T.V.R. participated in the development of the research questions and strategies and supervised the advancement of the project. M.v.E. contributed to coding the transcripts and co-writing the manuscript. All authors contributed to the article and approved the submitted version.
Funding
This study was funded by three organizations for sheltered and supportive housing (Kwintes, Leviaan, and HVO Querido) in the Netherlands.
Acknowledgments
We thank Rishana Matai for her support with coding the transcripts.
Supporting Information
Additional supporting information can be found online in the Supporting Information section.
Open Research
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
