Does bringing mental health services into women’s shelters reduce rates of hospitalization?

A local health integration network in Ontario reached out to EENet to review the evidence on mental health interventions for women in homeless or domestic violence shelters (referred to as “shelters” from this point on), and to assess any impact of those interventions on hospitalization rates. The research has clearly shown a need for increased support for mental health services for homeless populations.1 However, little is known about the effectiveness of mental health interventions for women in shelters.

This rapid review presents the results of our research on this topic. Read the rapid review below or download the PDF.

What you need to know

  • There’s a link between violence against women, homelessness, and mental health.
  • The social and health impacts of specific mental health interventions for women in shelters (not including rates of hospitalizations) have been discussed in four studies.
  • There are several women’s shelter programs in Canada that specifically include mental health services and programs.
  • No formal program evaluations could be found specific to agencies or organizations that may be providing this type of service.
  • Mental health and social services need to collaborate to support women in shelters.

What’s the problem?

A local health integration network in Ontario reached out to EENet to review the evidence on mental health interventions for women in homeless or domestic violence shelters (referred to as “shelters” from this point on), and to assess any impact of those interventions on hospitalization rates. The research has clearly shown a need for increased support for mental health services for homeless populations.1 However, little is known about the effectiveness of mental health interventions for women in shelters.

What did we do?

In December 2017, two members of the EENet team—a knowledge broker and a research analyst—conducted a search of the literature, using the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, In Process Medline, PsycINFO, and the Cochrane Database of Systematic Reviews.

A total of 384 articles were found related to the search terms: shelter(s), hostel(s), transitional housing, crisis centre, safe house, homeless, underhoused, women, mother, violence, battered, mental* or psychiatr* or nurse* or social work* or counsel* or case manag*, outreach* or collaborat*, or partnered or partnership*. Articles published before 1996 were excluded.

The two team members independently reviewed the abstracts and came together to discuss and identify which articles to include in this review. Five were selected and the full-text articles were requested from the CAMH library.

They also looked at grey literature to access any relevant unpublished program data and to identify existing programs that provide mental health services to women in shelters.

Finally, they contacted two prominent researchers in the field of mental health and homelessness to see if there was recent or current research that may be unpublished at the time of this review, but that could provide insight.  The researchers confirmed that there was no research on this topic at the time that this review was written.  

What did we find?

There are no published studies about mental health services for women in shelters and about rates of hospitalizations (either emergency or mental health department). And while there is significant published evidence that shows the positive impacts of mental health services and interventions for homeless people, generally, there’s limited evidence specific to women in shelters.

A comprehensive review of the health costs of homelessness is outside the scope of this review. However, health costs add important context to a discussion of mental health interventions that may keep homeless women out of the hospital and improve their overall health and social wellness (possibly preventing future homelessness and hospitalizations). This review did confirm that the hospitalization of homeless people with mental illness comes with significant costs, and mental health care interventions should be included in any plan to address homelessness.2

Mental health interventions for women in shelters

While limited, this review showed positive outcomes from the following four mental health interventions for women in shelters: motivational interviewing; short-term counselling; telehealth psychological services for women in rural or remote communities; and an adapted collaborative care intervention for homeless mothers.3-7 None of these findings refers to rates of hospitalization as an outcome measure, but they all show improvements in indicators of women’s overall health and social functioning.

Motivational interviewing

Motivational interviewing for women in a domestic violence shelter was assessed in one study. Two articles were published and discuss the qualitative results of the intervention from the client perspective,3 as well as the effect of training shelter staff in motivational interviewing.4 Both articles discuss the impact of motivational interviewing by trained shelter counsellors on the resident’s “readiness for change.” One study found these counselors “were more effective in maintaining and increasing high levels of readiness for change in women seeking services from a [domestic violence] shelter.”3

While the intervention is not specifically intended to treat women experiencing a mental health crisis, it resulted in significant improvements in overall mental wellness and women’s desire to keep making improvements in their lives.3 There are implications for healthcare costs, though hospitalization rates were not specifically measured in these studies. The authors conclude that motivational interviewing is a client-centred, cost-effective, and empowering approach that can be easily implemented in a shelter through in-house training and follow-up consultation and coaching.4

Short-term counselling

The impact of short-term counselling for women in a domestic violence shelter was analyzed in one study, in which three master’s-level social workers delivered three-to-five sessions of counselling to 119 women who came through a domestic violence shelter.5 The intervention had a “feminist orientation” and consisted of counselling with “eclectic elements of cognitive–behavioural, existential, solution-focused, and family or systems concepts” that focused on the specific needs of women seeking shelter from domestic violence.

As with the motivational interviewing studies, the intervention did not target women with mental illness, specifically, but rather measured how well the clients were coping with the following five discrete life components: finances/money; work/employment; family/partner/spouse; housing/living arrangements, and overall life functioning. The results showed that women who received services for partner abuse at a domestic violence shelter significantly improved in terms of life functioning and coping ability, and expressed the feeling that they benefited from the counselling.

Telehealth psychology outreach

A telehealth psychology outreach service to rural survivors of sexual and domestic assault receiving care at crisis centres showed significant improvements specific to both post-traumatic stress disorder (PTSD) and depression symptoms.6 The counselling services were provided using secure, encrypted video conferencing technology, by master’s-level therapists working toward a doctoral degree in Clinical Psychology who have extensive training in trauma intervention theory and techniques. All services were also supervised by licensed doctoral-level psychologists. The women receiving care had positive clinical outcomes and indicated a high degree of satisfaction with the service. The trainees and crisis centre staff participating in the outreach program also expressed high satisfaction with the intervention.

Integrated care model for homeless mothers

One study evaluated the integrated care model for homeless mothers, a collaborative approach to care for mothers in homeless shelters showing symptoms of depression.7 The intervention takes a comprehensive approach by engaging organizational leaders in redesigning the system (e.g., involving executive directors and clinical leaders to commit to providing universal depression screening, using clinical decision tools, and collaborating with primary care). It also includes enhanced training for case managers on depression, psychoeducation, and the facilitation of patient goal-setting and self-management. 

Over one-third of the women in the study screened positive for depression, and many also had other mental and physical health challenges. Almost all of the women had multiple traumatic experiences. The study’s results show that 30% of women in the intervention group achieved at least a 50% improvement in depression symptoms at six months compared to 5.9% of those who received the usual care. Women in the intervention group also had significantly more engagement with treatment overall compared to those who received usual care.

Limitations of published studies

The four studies in this review had similar limitations in terms of small sample sizes, as well as the challenges of measuring impact over the medium and long term with an often transient population. The findings cannot be applied to other settings.

Grey literature review

Our review of the grey literature revealed three programs in Canada that provide mental health services in shelters for women who are homeless or fleeing domestic violence. They are: the Vivian Transitional Housing Program for Women (Vancouver, BC), Discovery House Family Violence Prevention Society (Calgary, AB), and the London Homes for Women (London, ON).

Vivian Transitional Housing Program for Women

This program was designed for women living with concurrent mental illness, addiction, and other challenges. It uses a harm-reduction philosophy, which focuses on meeting the needs of people who are at significant risk of negative life outcomes as a result of their mental health, substance use, or other challenges, and may face barriers to obtaining housing, mental health, and addiction services.

Discovery House Family Violence Prevention Society

The Society provides integrated shelter and community services to abused women and children, including services from a mental health specialist.

The London Homes for Women

This shelter uses gender-specific as well as trauma-informed principles to ensure that women who experience violence or with a history of trauma have access to housing and avoid homelessness.

Themes in the grey literature

This review of the grey literature identified the following themes specific to women, violence, homelessness, and mental health:

  • There is recognition of the link between violence against women and homelessness. Violence against women is one of the main causes of homelessness among Canadian families.
  • Supportive housing improves overall quality of life and neuropsychological functioning.
  • Supportive housing reduces admissions to hospital, psychiatric hospital admissions, psychiatric symptoms, and substance use.
  • Supportive housing significantly reduces reliance on hospitals, emergency services, jails, and shelters.
  • Individuals who are living with disabling mental health conditions tend to experience worsening psychiatric symptoms when they are homeless.
  • The majority of homeless families are headed by single mothers.
  • The mental health problems (i.e., PTSD, depression, anxiety) of women who are survivors of domestic violence are often exacerbated by housing instability, which increases their risk for homelessness. 

What are the limitations of this review?

This review has a number of limitations. First, it does not include interventions for women experiencing intimate partner violence (IPV) who are not homeless or living in a shelter. There is a significant body of research that identifies mental health interventions for these women, but these studies were outside the scope of this review. However, the interventions could be applicable to shelter-based women.

Additionally, this review does not include mental health interventions for the larger homeless population (e.g., Housing First, Critical Time Intervention, Assertive Community Treatment, etc.). These interventions also may be applicable to women in shelters.

Finally, the grey literature review did not include provincial or municipal plans to end homelessness, which may provide information about programs and services at the local and regional level. It also did not have an international scope.

What are the conclusions?

Women in shelters face many barriers to good mental health. They often experience a multitude of complex comorbidities and traumas.  Additionally, shelter staff are often unprepared to provide acute mental health care support. In many cases, there are also barriers to accessing adequate referrals to other community organizations, agencies, and primary healthcare services.

The published evidence on mental health services for women in shelters is limited, but the value of these interventions is significant. There is no published study that definitively links such an intervention to decreased hospitalizations in this population, but the overall positive impact on health and wellbeing is clear.

Acknowledgements

The authors of this rapid review are Julie Kivinen, Regional Knowledge Exchange Lead, and Tanya Abate, Research Analyst. The authors would like to acknowledge Emma Firsten-Kaufman, Knowledge Broker, as well as Terri Rodak, CAMH Librarian, for assistance with the database search, and, for editorial support, Jason Guriel, EENet Supervisor, and Rossana Coriandoli, EENet Supervisor/Communications Coordinator.

References

  1. Stergiopoulos V, Shuler A, Nisenbaum R, deRuiter W, Guimond T, Wasylenki D,  et al. The effectiveness of an integrated collaborative care model vs. a shifted outpatient collaborative care model on community functioning, residential stability, and health service use among homeless adults with mental illness: a quasi-experimental study. BMC Health Services Research. 2015; 15:348.
  2. Latimer E, Raboiun D, Cao Z, Ly A, Powell G, Aubry T, et al. Costs of services for homeless people with mental illness in 5 Canadian cities: a large prospective follow-up study. CMAJ. 2017 Jul-Sept; 5(3): E576–E585.
  3. Rasmussen L & Hughes M. The Utility of Motivational Interviewing in Domestic Violence Shelters: A Qualitative Exploration. Journal of Aggression, Maltreatment & Trauma. 2010 19:3, 300-322.
  4. Rasmussen L, Hughes M, Murray C. Applying Motivational Interviewing in a Domestic Violence Shelter: A Pilot Study Evaluating the Training of Shelter Staff. Journal of Aggression, Maltreatment & Trauma. 2008; 17:3, 296-317.
  5. McNamara J, Tamanini K, Pelletier-Walker S. The Impact of Short-Term Counseling at a Domestic Violence Shelter. Research on Social Work Practice. 2008 March; 18(2), 132-136.
  6. Gray M, Hassija C.  Provision of Evidence-Based Therapies to Rural Survivors of Domestic Violence and Sexual Assault via Telehealth: Treatment Outcomes and Clinical Training Benefits. Training and Education in Professional Psychology. 2015; 9(3), 235–241.
  7. Weinreb L, Upshur C, Frisard C. Managing Depression Among Homeless Mothers: Pilot Testing an Adapted Collaborative Care Intervention. The Primary Care Companion for CNS Disorders. 2016; 18(2). 

Acknowledgements

 

The authors of this rapid review are Julie Kivinen, Regional Knowledge Exchange Lead, and Tanya Abate, Research Analyst. The authors would like to acknowledge Emma Firsten-Kaufman, Knowledge Broker, and Terri Rodak, CAMH Librarian, for assistance with the database search and, for editorial support, Jason Guriel, EENet Supervisor, and Rossana Coriandoli, Communications Coordinator.

 

Disclaimer

Rapid reviews are time-limited ventures carried out with the aim of responding to a particular question with policy or program implications. The information in this rapid review is a summary of available evidence based on a limited literature search. EENet cannot ensure the currency, accuracy or completeness of this rapid review, nor can we ensure the efficacy, appropriateness or suitability of any intervention or treatment discussed in it.

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