Gold Award: Supportive Residential Services to Reunite Homeless Mentally Ill Single Parents With Their Children

In May 1994 the Institute for Community Living, Inc., opened the Emerson-Davis Family Development Center—Emerson for short—in a renovated former college dormitory in the Fort Greene section of Brooklyn, making what seemed an impossible dream come true: single parents separated from their families because of their mental illness and homelessness were reunited with their children and provided with a healthy, safe home of their own.

The Institute for Community Living, a nonprofit New York City provider of housing, rehabilitation, and support services for persons with mental disabilities, established the center in response to requests from graduates of its transitional housing and treatment programs for mental illness and co-occurring substance abuse who wanted help in gaining back their children from foster care and other placements. To provide this assistance, the institute developed a continuum of housing and related support services. Emerson's housing now consists of a congregate residence with 38 one- and two-bedroom apartments and several common areas and eight scatter-site family apartments with case-management services for families who no longer need the 24-hour-a-day support of the congregate setting. The congregate residence is structured so that 16 apartments house single-parent families with one or two children each and 22 apartments house recovering single adults, who, whenever possible, are selected as candidates for eventual reunification.

As the most comprehensive program of its type, Emerson is a model for the application of mental health, social service, and educational interventions to the complex, interacting psychiatric and social problems that plague many inner-city neighborhoods. Emerson's approach, with its emphasis on case management and wellness for a very-high-risk group, meshes well with managed care and disease management models of social services that seek improved outcomes at lower costs. The benefits of the Emerson model of services may extend to other high-risk families in which parents are struggling with chronic personal disabilities and associated complex problems of service delivery.

Because Emerson cares for an underserved population that presents multiple interacting needs to the social service community, the Institute for Community Living complemented the center's development with an organized effort to foster general awareness of the service needs of this group and of the potential for a positive response among this group. The institute initiated and has maintained a dialogue among key local and state government agencies, providers, and foundations to generate enthusiasm and optimism about the possibility of favorable outcomes. The promise of the program has attracted visitors from other locales. Officials from Chicago, New York State, and New Jersey as well as professional caregivers from other parts of the country have toured Emerson.

Because of this advocacy, New York City now offers a continuing funding stream allowing the establishment of scatter-site apartments in the community to be used by Emerson's "reunification successes" and families with similar backgrounds to return to mainstream housing. In 1998 Emerson received the Lilly Award in Social Work for its promotion of the community reintegration of its families.

For excellence in providing supportive services for single-parent families challenged by homelessness, mental illness, and substance abuse, Emerson was selected as one of two winners of the Gold Achievement Award for 2000. The award is presented annually by the American Psychiatric Association to outstanding programs for mentally ill and developmentally disabled persons. It includes a $5,000 prize made possible by a grant from Pfizer, Inc., U.S. Pharmaceuticals.

Emerson was selected as the award winner in the category of small community-based programs. The winner of the award for large academically or institutionally sponsored programs is described in a separate article on page 1436. The awards were presented on October 25 during the opening session of the Institute on Psychiatric Services in Philadelphia.

The service model

From the start of the Emerson program, it has been clear that when consumers' mental health needs are considered in conjunction with their other individual and family service needs, only a tightly case-managed consortium of agencies can hold service plans together. To connect its clinical program development and daily social service operations into a seamless whole, Emerson has adopted as its basic case-management principle the creation of individually tailored service plans that encourage parents to build a physically and emotionally safe environment for their family and their personal life.

Findings from the literature on homeless populations with mental illness have guided the formulation of Emerson's service array. Particularly critical have been clinical interventions demonstrating that many parents with mental illness can attain competency in their parenting roles given sufficient support, studies indicating the value of placing adequate housing at the core of social service efforts, and research documenting the individual needs as well as the family needs of single parents.

Staff

The Emerson program was organized under the leadership of Peter Campanelli, Psy.D., who is president and CEO of the institute. Harvey Lieberman, Ph.D., the institute's executive vice-president, was chief project designer and developer; he led a strategic planning task force composed of senior institute and program staff, including Steven Scher, C.S.W., senior vice-president for mental health services, Frantz Lubin, M.D., medical director, Tomas Cruz, C.S.W, vice-president for community support services, Jeffrey Palmer, C.S.W., Emerson program director, and Linda Nagel, Ph.D., learning program coordinator.

Daily program operations depend on the on-site contributions of 15.5 full-time-equivalent staff. Staff composition includes a social worker, who is program manager, a supervisory counselor, a child clinical psychologist who runs Emerson's learning program, a family development specialist, a substance abuse counselor, case managers, and part-time child care workers. Senior agency administrators, including a psychiatrist, psychologists, and social workers, guide project design and dissemination, and outside consultant psychiatrists and other clinicians address family clinical needs. Families participate in program governance through Emerson's formal residence community meetings and through annual consumer satisfaction surveys.

Funding

Since available sources of funding have been too narrow in scope to accommodate the goals of the program, the coordination and advocacy needed for fiscal matters has been similar to that required for clinical matters. Emerson is directly supported by funding from the New York State Office of Mental Health ($414,986 in 1999), the New York City Department of Mental Health ($96,970), Stewart B. McKinney Homeless Assistance Act funds from the Department of Housing and Urban Development ($325,317), fees from client income and Medicaid ($651,331), and private donations and foundations ($17,000). The total budget in 1999 was $1,505,604. The annualized per-person cost for services is $19,333, or about $53 a day.

Program innovations

Population served

Most applicants for admission come from homeless shelters, psychiatric inpatient units, or transitional housing programs. Since its opening, Emerson has reunited 45 families with 63 children. At any given time, Emerson has 85 to 95 people in residence. In addition to their psychiatric illnesses, all adult residents were previously homeless, and 46 percent are recovered substance abusers. Forty-two percent have a diagnosis of schizophrenia, 40 percent have a diagnosis of a mood disorder, and 19 percent have other diagnoses. Twenty-nine percent were referred by shelters, 22 percent by psychiatric hospitals, and 18 percent by transitional housing programs.

Typically parents and children have been separated for more than two years before their admission to Emerson, although some of the children have been infants and toddlers. Children's ages have ranged from one week to 15 years, and 63 percent have been under age six at the time of admission; they have been nearly evenly divided between the sexes. In many cases, they are not their parents' only children. Most of the parents have been women (93 percent) from minority racial or ethnic backgrounds; 62 percent have been black; 20 percent, Hispanic; 15 percent, white; and 3 percent, Asian. Parents' ages have ranged from 22 to 56 years, with a mean±SD of 33.9±6.9 years. Nearly two-thirds have never been married. Only 36 percent completed high school.

Service delivery

Case management

To support Emerson families, the Institute for Community Living has developed a comprehensive array of on-site and community resources for parents and children. In instances where a needed service was not accessible in the community, the institute has either developed the capacity to provide the service itself or attracted a community provider to develop it. Case managed services integrated within Emerson service plans include mental health services, on-site counseling and rehabilitation, on-site crisis intervention, medication monitoring, adult and child health care, legal services, special needs assistance, on-site educational services for children and adults, psychoeducational assessments, on-site parenting skills training, and others.

The learning program

Emerson's learning program, which is located on-site and serves only Emerson families and graduates, establishes personal learning goals for all families and their members. Parents' learning goals typically focus on adherence to a comprehensive mental health regimen, activities of daily living, health maintenance, the adoption of sound parenting practices, family planning, and social, educational, vocational, and citizenship skills. For children, learning goals address activities of daily living, socialization, and educational skills.

On coming home from school or day care, children at Emerson are encouraged to spend their time in the building's learning program with child care workers, tutors, and therapists. This gives their parents a chance to unwind when they come home from work, school, or training programs and to prepare dinner. Parents also can ask on-site staff for assistance with the demands of parenting and daily living.

The social problem solving program

Many Emerson parents have underprivileged backgrounds and were abused or traumatized in some fashion during childhood. To create a constructive atmosphere for socialization at Emerson, a residence-wide approach to the teaching of socialization skills is sponsored by the learning program and has been integrated into almost all Emerson activities. These social-cognitive skills modules were adapted from the skills training approach formulated at Rutgers University for high-risk urban children. They were modified in consultation with the original author for implementation with both parents and children at Emerson. The modules teach the ground rules for social interaction in a plain, direct manner that can be easily maintained when families graduate from Emerson.

Community involvement

To win community support, the Institute for Community Living undertook an extended community relations process that guided neighbors from an initial attitude of hostility or indifference to one of active advocacy for Emerson.

Emerson opened its doors amid controversy. The local Brooklyn community was so displeased with the center's location that numerous heated public debates took place and legal action was initiated against it. Throughout this period, however, the institute continually reached out to the community to encourage constructive dialogue and problem resolution. A community advisory board was formed consisting of local citizens, merchants, local elected officials, and others. As a result of these efforts and of Emerson's successful—and quiet—operation, community attitudes changed dramatically.

In recent years the Emerson facility was dedicated to the deceased daughter of a community advisory board member, and community members who had initiated legal action now participate in Emerson holiday celebrations and an annual Family Day celebration by contributing funds and toys for Emerson children. A junior community advisory board, formed by the son of a local elected official, integrates Emerson's children into community activities with neighborhood children.

Evaluation

The program has evolved constantly as service delivery approaches have been refined. Because of the backgrounds of its clients and the presence of children, service plan adherence data have been closely monitored as an indicator of success. The adherence rates for both Emerson's adult and children service plans have run between 87 percent and 100 percent. According to the clinical judgment of the staff, 86 percent of Emerson adults and 90 percent of their children have shown a positive response to services since admission.

Over the past three years, the annual psychiatric hospitalization rate among parents was 12.5 percent, and the substance abuse relapse rate was 3.6 percent. After their hospital stays, all parents have returned to live with their children.

Consumer survey data collected anonymously from parents reflect general satisfaction with services; 60 percent were very satisfied, and 33 percent were satisfied. Parents feel that Emerson helps them achieve their goals (88 percent) and that they are learning to manage their disabilities (94 percent).

As noted, Emerson has reunited 45 families with 63 children, and 23 of 30 families who moved out of the congregate residence have departed with the family intact. For discharged parents, level-of-functioning scales indicated a significant improvement on parental skills scales and parental activity of daily living skills (χ²=4.26, df=1, p≤.05).

Lengths of stay in the congregate residence have ranged from two days to 65 months. As the Emerson-supported scatter-site apartment program has developed, median lengths of stay of persons successfully discharged from the congregate residence have dropped from periods of two to four years to periods less than one and a half years.

Overall, the clinical data suggest that the family reunification process leads to gains for most participants, especially the children, even when reunification is not successful. Emerson services cost only 71 percent of traditional New York City shelter and foster care programs, and Emerson offers substantially more therapeutic and rehabilitative alternatives.

To better understand how Emerson assists its consumers and the depth of these effects, an evaluability study was completed in June 2000 as a dissertation project by a doctoral student at the Graduate School of Applied and Professional Psychology at Rutgers University.

The Institute for Community Living invites the interest of other professionals and agencies in the Emerson Center and would welcome collaborative projects in this area. For more information about Emerson, contact Harvey J. Lieberman, Ph.D., 40 Rector Street, New York, New York 10006; phone, 212-385-3030, ext. 112; fax, 212-385-2849; e-mail, [email protected].