Recovery processes

Table 4 outlines the synthesis of data. Although most findings corresponded to the existing five first-order processes in the CHIME framework, ^{Reference Leamy, Bird, Le Boutillier, Williams and Slade7} two additional processes were identified: first, ‘security and stability’, which related to obtaining safe and stable housing, having a home versus a shelter, security in services and financial and food security. The second new first-order process, ‘dual recovery’, related to dual recovery from mental health issues and substance use. As with the original CHIME model, processes interacted and influenced one another. However, importantly, the data highlighted that ‘security and stability’ was foundational to the other recovery processes. Accordingly, SECURED was deemed a more fitting framework acronym. CHIME was transformed into SECURED through the addition of security and stability and dual recovery, as well as by the alteration of CHIME headings and their order: ‘connectedness’ was changed to ‘relationships and connectedness’; ‘hope’ to ‘encouragement and hope’; ‘identity’ to ‘constructing identity’; ‘meaning’ to ‘understanding and meaning’; and ‘empowerment’ remained the same.

Table 4 SECURED: mental health recovery processes for people with experience of homelessness

SECURED, security and stability; encouragement and hope; constructing identity; understanding and meaning; relationships and connectedness; and empowerment and dual recovery. CHIME, connectedness, hope, identity, meaning and empowerment. Themes shown in bold are additions or alterations to the CHIME framework. Total numbers for themes are also in bold.

The findings related to each of the seven key recovery processes that define the SECURED framework are outlined below.

Security and stability. A prevalent finding across many papers was security and stability in housing, services and basic needs as a necessary foundation for other recovery processes to take place. Stable and safe accommodation meant that people did not have to focus on survival and hypervigilance, which provided the opportunity to focus on recovery: ‘this is my home. I have a roof over my head and I can do the things I have to do and I can concentrate on my recovery’. ^{Reference Smith, Padgett, Choy-Brown and Henwood53} Participants differentiated between a home and shelter. A home was described as a place with a sense of security, stability, privacy, ownership and control over their environment, in contrast to transitional housing or shelters, in which these things were often absent: ‘recovery was going from either living on the streets or transitioning from house to house to house or staying in unsafe environments, to having an apartment of my own … secure’. ^{Reference Watson and Rollins23} Having secure and safe housing, as well as food and financial security, offered opportunities for participants to look after their physical health, which contributed to improved overall well-being: ‘I sleep better, eat better, I feel secure.’ ^{Reference Rhenter, Moreau, Laval, Mantovani, Albisson and Suderie52}

Encouragement and hope. Optimism from the original CHIME ‘hope and optimism’ theme was removed because the a priori subthemes of ‘positive thinking and valuing success’ and ‘motivation to change’ from the original CHIME model were not found to be substantially endorsed in studies. Instead, encouragement from others was identified as being important in facilitating hope for this population, given the accumulated adversity many had faced over their lives. Relationships with peer workers inspired hope in some participants: ‘knowing that they’ve achieved what they achieved is like a light at the end of a tunnel’ . ^{Reference Reid, Khan, Soklaridis, Kozloff, Brown and Stergiopoulos51} As with other processes, security and stability were often a prerequisite for hope, particularly housing. Security and reliability in services was important in fostering hope for some: ‘when I see everything happening according to the way they said it would, I was like this is the start of a new life for me’. ^{Reference Kirst, Zerger, Harris, Plenert and Stergiopoulos47} Narratives of hope were often related to gaining a ‘normal life’: ‘I just wanted to have a normal life like everybody else.’ ^{Reference Karadzhov43} In many studies hope also related to regaining control over one’s life, growing self-esteem and rebuilding and developing new relationships. Many participants also spoke about dreams and aspirations related to gaining employment and developing skills and relationships: ‘I am going to get my Grade 12 and I am going to take my nursing course.’ ^{Reference Kirst, Zerger, Harris, Plenert and Stergiopoulos47}

Constructing identity. Building a positive sense of identity was an important recovery process, and was often related to building a sense of worth and personhood, in contrast to experiences of feeling dehumanised and devalued while homeless: ‘I see myself as a person of value now versus another nobody.’ ^{Reference Reid, Khan, Soklaridis, Kozloff, Brown and Stergiopoulos51} Being rehoused was again often a prerequisite for the reconstruction of a sense of self and identity, facilitated further by building connection with others, gaining self-acceptance and a sense of contribution or achievement. Deconstructing stigma as an original CHIME subtheme was expanded to incorporate stigma related to both homelessness and mental health, and often comprised deconstructing stigma on societal and internalised levels: ‘I’m in the healing process from a lot of stigma that society has put on me, a lot of self-stigma that I placed upon myself … I’m putting that stigma to rest.’ ^{Reference Cabassa, Nicasio and Whitley44} Some participants spoke of a drive to assume or reclaim a more powerful identity, after feeling powerless while homeless: ‘I wanna live above what they [society] think I am.’ ^{Reference Smith, Padgett, Choy-Brown and Henwood53} Another new subtheme that was identified related to rebuilding a citizenship identity, having previously felt on the margins of, or excluded from, society: ‘What’s important to me is being a part of society. So, if I can’t work then I will volunteer.’ ^{Reference Kerman and Sylvestre19}

Understanding and meaning. Understanding and meaning was the only first-order theme represented in all reviewed studies, and incorporated broad processes of finding understanding and meaning in the present, future and past. Participants discussed leaving ‘survival mode’ ^{Reference Karadzhov43} by being housed and building food and financial security, enabling quality of life, and being able to ‘enjoy some nice things’. ^{Reference Macnaughton, Townley, Nelson, Caplan, Macleod and Polvere48} From this base, participants were then able to build a meaningful life through setting goals and finding direction: ‘[recovery] means that you always have a goal to try to do better for yourself’. ^{Reference Watson and Rollins23} Engaging in meaningful activity improved confidence, helped to regulate emotions, provided structure and a sense of progress and served as a distraction: ‘If you focus on something, it takes your depression mode away. It feels good because you’ve done/you’ve achieved something. It was a therapy.’ ^{Reference Karadzhov43} Religion and spirituality also imparted meaning and facilitated a sense of security and hope during difficult times for some people: ‘God makes me stronger … that’s how I get my peace of mind by praying.’ ^{Reference Cabassa, Nicasio and Whitley44}

Understanding their mental health difficulties and the context in which they may have formed was described as a necessary next step following housing by some participants: ‘I first had to understand why I was feeling the way I was feeling.’ ^{Reference Karadzhov43} Finding this understanding helped foster self-acceptance and compassion in others: ‘learn to at least like myself or not hate myself … trying to understand the different emotions about what happened in the past … and being able to see some worth in life’. ^{Reference Kirst, Zerger, Harris, Plenert and Stergiopoulos47} This understanding and self-acceptance could be built upon by helping others, which facilitated finding meaning in their past, present and future: ‘your lived experience, which might have seemed like just a bad time or a mess, can be something productive for yourself and other people’, ^{Reference Reid, Khan, Soklaridis, Kozloff, Brown and Stergiopoulos51} and seemed helpful for some participants in shifting their identity and social roles, from that of helped to helper: ‘I am an employee of the shelter that I used to stay in … that means something to me.’ ^{Reference Kerman and Sylvestre19}

Relationships and connectedness. Social relationships were highlighted as being important across many studies. Opportunities to build positive new and helpful peer relationships in services and third-party organisations were beneficial: ‘my social group is much broader than it used to be … And that’s really what helped, [the feeling that] I’m not alone.’ ^{Reference Reid, Khan, Soklaridis, Kozloff, Brown and Stergiopoulos51} Sense of mutuality within this was useful: ‘a lot of trust because you’re with other people who have been in similar lived experience situations … you learn and grow together in that vital stage of starting out’. ^{Reference Reid, Khan, Soklaridis, Kozloff, Brown and Stergiopoulos51} These new relationships were often a move away from unhelpful social relationships and environments experienced on the streets, in shelters and sometimes in their families. Participants discussed being able to ’set boundaries’ with those who did not have their best interests at heart: ‘I cut off a lot of people because … I am actually in the process of getting things together, but definitely these people were slowing me down.’ ^{Reference Macnaughton, Townley, Nelson, Caplan, Macleod and Polvere48} Crucially, having secure, stable housing enabled participants to have more control in managing their social environment and relationships: ‘anybody wants to come through that door, it’s up to me to decide whether they get in or they don’t get in’. ^{Reference Kirkpatrick and Byrne46} Being housed also offered the possibility of building or rebuilding relationships. For example, one participant discussed being able to invite his brother over to rebuild their relationship: ‘I have a place where I can receive him. That’s an important thing. So I can have a family again.’ ^{Reference Kirst, Zerger, Harris, Plenert and Stergiopoulos47}

Another important part of connectedness was feeling as though there was ’someone in your corner’ in services – namely a professional who would provide respect, consistency, advocacy and support: ‘The one thing through all of that – my friends bailed, everybody bailed – I had that case worker … I knew that I had at least one person in my corner … I don’t think I would have been able to go to treatment the last time, the one that helped me stay clean, without them.’ ^{Reference Kerman and Sylvestre19} A sense of community belonging was also helpful and contributed to citizenship identity work: ‘I wasn’t a member of the community. I was what the community despised. The guy who hated … is now standing beside me to help save a tree.’ ^{Reference Macnaughton, Townley, Nelson, Caplan, Macleod and Polvere48}

Empowerment. Empowerment represents a crucial component of personal recovery in this population, given prevalent experiences of powerlessness while homeless. As with the original CHIME model, personal responsibility and having control over one’s life were endorsed subthemes. Having control was important for many people who had experienced a lack of control while homeless and in shelters. Control was interlinked with taking responsibility for decisions: ‘[I am now] able to make decisions, to take action on things … to build that support system so that when I feel as though I lose control, [I can] get back in control.’ ^{Reference Reid, Khan, Soklaridis, Kozloff, Brown and Stergiopoulos51} Two additional subthemes that supported the processes of responsibility and control were self-efficacy in skills and having a sense of ownership. Building skills in symptom management, aspects of daily living and beyond facilitated a sense of control and self-efficacy, which prompted personal responsibility: ‘To be the one who had the skills and executed them … I found that really, really empowering because I didn’t have to rely on anyone else to do it once I learned the skills.’ ^{Reference Kerman and Sylvestre19} A sense of ownership also represented control and autonomy for people who had long experienced deprivation: ‘I have my own appliances. That, to me, symbolises the autonomy [needed] to succeed.’ ^{Reference Piat, Seida, Sabetti and Padgett50} For one participant, a sense of ownership also facilitated a greater sense of meaning in activity: ‘At [previous home], we had one, but it was a garden for them; it wasn’t a garden for me. Whereas this one, it’s really mine. I grow stuff for me.’ ^{Reference Piat, Seida, Sabetti and Padgett50}

Dual recovery. For many participants, recovery comprised dual recovery from substance use and mental health difficulties: ‘In my case, I think it’s all together.’ ^{Reference Karadzhov43} Substance use issues had often developed prior to or while on the streets as a means of coping, survival and to ‘self-medicate’. ^{Reference Patterson, Currie, Rezansoff and Somers40} Support for substance use issues was therefore an important part of mental health recovery for many participants. Secure and stable housing was again a prerequisite for supporting with substance use, with abstinence-based requirements for housing being unhelpful: ‘[you] don’t have to be sober … Getting me into that environment [permanent housing] became the number one thing to do first, and then out of that we were able to identify what the cause of the [substance use] problem was, treat the cause, and then go onto to stability in the other areas [of his life]’. ^{Reference Watson and Rollins23} Other participants emphasised the importance of control in this process: ‘they gave me the opportunity to make the decision [to quit using] at my own pace and my own time.’ ^{Reference Watson and Rollins23}

Challenges

Several challenges and barriers for personal recovery were identified from the data (see Table 5).

Table 5 Specific challenges and barriers in recovery for people with experience of homelessness

Total numbers for themes are in bold.

These challenges aligned with the SECURED themes but opposed the main recovery processes. It is important to recognise the challenges to personal recovery. ^{Reference van Weeghel, van Zelst, Boertien and Hasson-Ohayon14} However, because the current study aims are concerned with exploring processes supporting recovery, studies focusing solely on barriers were excluded, and this is therefore not a comprehensive list of challenges. Further description and illustrative quotes for the challenges identified in the included studies are detailed below.