WK5 SOCW6311 Evidence-based social work practice calls for the use of research data to guide the development of social work interventions on the micro, mez

WK5 SOCW6311 Evidence-based social work practice calls for the use of research data to guide the development of social work interventions on the micro, mez

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Evidence-based social work practice calls for the use of research data to guide the development of social work interventions on the micro, mezzo and/or macro-levels. Kearney (2001) described ways qualitative research findings can inform practice. Qualitative findings can help social workers understand the clients’ experiences and “what it may feel like” (Kearney, 2001). Therefore, social workers can develop clinical interventions that take into account the experiences of their clients. Qualitative findings can also help social workers monitor their clients. For example, if after reading a qualitative study on how domestic violence survivors respond to stress, they can monitor for specific stress behaviors and symptoms (Kearney, 2001). In addition, they can educate their client what stress behaviors to look for and teach them specific interventions to reduce stress (Kearney, 2001)

Given the increasing diversity that characterizes the landscape in the United States, social workers need to take into account culture when formulating interventions. Social workers can utilize qualitative findings to plan interventions in a culturally meaningful manner for the client.

To prepare for this Discussion, read Knight et al.’s (2014) study from this week’s required resources. Carefully review the findings, the photographs, and how the researchers wrote up the findings. Finally, review the specific macro-, meso-, and micro-oriented recommendations.

Then read Marsigilia and Booth’s article about how to adapt interventions so that they are culturally relevant and sensitive to the population the intervention is designed for. Finally, review the chapter written by Lee et al. on conducting research in racial and ethnic minority communities.

Kearney, M. (2001). Levels and applications of qualitative research evidence. Research in Nursing and Health, 24, 145–153.

By Day 3

Post the following:

  1. Using one of the direct quotes and/or photos from Knight et al.’s study, analyze it by drawing up a tentative meaning. Discuss how this would specifically inform one intervention recommendation you would make for social work practice with the homeless. This recommendation can be on the micro, meso, or macro level.
  2. Next, explain how you would adapt the above practice recommendation that you identified so that it is culturally sensitive and relevant for African Americans, Hispanics, or Asian immigrants. (Select only 1 group). Apply one of the cultural adaptations that Marsigilia and Booth reviewed (i.e., content adaption to include surface and/or deep culture, cognitive adaptations, affective-motivational adaptations, etc.)(pp. 424-426). Be as specific as you can, using citations to support your ideas.

Single Room Occupancy (SRO) hotels as mental health risk
environments among impoverished women: the intersection of
policy, drug use, trauma, and urban space

Knight R. Knight1, Andrea M. Lopez2,3, Megan Comfort3, Martha Shumway4, Jennifer
Cohen5, and Elise Riley2

1Department of Anthropology, History and Social Medicine, University of California, San
Francisco

2Positive Health Program, San Francisco General Hospital, University of California, San
Francisco

3Urban Health Program, Research Triangle Institute International

4Department of Psychiatry, Trauma Recovery Center, University of California, San Francisco

5Department of Clinical Pharmacy, University of California, San Francisco

Abstract

Due to the significantly high levels of comorbid substance use and mental health diagnosis among

urban poor populations, examining the intersection of drug policy and place requires a

consideration of the role of housing in drug user mental health. In San Francisco, geographic

boundedness and progressive health and housing polices have coalesced to make single room

occupancy hotels (SROs) a key urban built environment used to house poor populations with co-

occurring drug use and mental health issues. Unstably housed women who use illicit drugs have

high rates of lifetime and current trauma, which manifests in disproportionately high rates of post-

traumatic stress disorder (PTSD), anxiety, and depression when compared to stably housed

women. We report data from a qualitative interview study (n=30) and four years of ethnography

conducted with housing policy makers and unstably housed women who use drugs and live in

SROs. Women in the study lived in a range of SRO built environments, from publicly-funded,

newly built SROs to privately-owned, dilapidated buildings, which presented a rich opportunity

for ethnographic comparison. Applying Rhodes et al.’s framework of socio-structural

vulnerability, we explore how SROs can operate as “mental health risk environments” in which

macro-structural factors (housing policies shaping the built environment) interact with meso-level

factors (social relations within SROs) and micro-level, behavioral coping strategies to impact

© 2013 Elsevier B.V. All rights reserved.

Corresponding Author Information: Kelly Ray Knight, PhD, Assistant Professor, Department of Anthropology, History and Social
Medicine, University of California – San Francisco, 3333 California Street, Suite 485, San Francisco, CA 94143,
kelly.knight@ucsf.edu, 415-867-8405.

Publisher’s Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our
customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of
the resulting proof before it is published in its final citable form. Please note that during the production process errors may be
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NIH Public Access
Author Manuscript
Int J Drug Policy. Author manuscript; available in PMC 2015 May 01.

Published in final edited form as:
Int J Drug Policy. 2014 May ; 25(3): 556–561. doi:10.1016/j.drugpo.2013.10.011.

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women’s mental health. The degree to which SRO built environments were “trauma-sensitive” at

the macro level significantly influenced women’s mental health at meso- and micro- levels.

Women who were living in SROs which exacerbated fear and anxiety attempted, with limited

success, to deploy strategies on the meso- and micro- level to manage their mental health

symptoms. Study findings underscore the importance of housing polices which consider substance

use in the context of current and cumulative trauma experiences in order to improve quality of life

and mental health for unstably housed women.

Keywords

built environment; SRO hotels; women; trauma; mental health; drug use; ethnography

INTRODUCTION

In the United States, the comorbidity of substance use and mental illness is a widely

recognized phenomenon at a national level (NIDA, 2008; Volkow, 2006; Conway et al.

2004), specifically among the urban poor (Bassuk et al., 1998, Hien et al., 1997).

Epidemiological studies underscore significant gender differences in the presentation of

comorbidity, with women more likely than men to be diagnosed with affective and anxiety-

related mental health disorders (Diflorio & Jones, 2010; NIDA, 2008). Estimates of

depression and Post-Traumatic Stress Disorder (PTSD) are disproportionately higher among

substance-using, unstably housed women than cohorts of housed women (Nyamathi, Leake,

and Gelberg, 2000; El-Bassel et al., 2011; Coughlin, 2011). While research has shown that

access to housing may contribute in a significant way to a number of individual mental

health outcomes (Baker and Douglas, 1990; Hanrahan et al., 2001; Nagy, Fisher and Tessler,

1998; Earls and Nelson, 1988), there is need to understand how housing policies shape

specific built environments, which in turn impact women at risk for poor mental health

outcomes and substance abuse. This paper analyzes the role of place, specifically Single

Room Occupancy (SRO) hotel rooms, in exacerbating and ameliorating negative mental

health outcomes for substance using, urban poor women.

Urban housing environments have received increasing attention as sites that can both

contribute to health and produce harm (Vlahov, et al., 2007; Freudenberg, Galea, and

Vlahov, 2005, Northridge, Sclar & Biswas, 2003), and there is growing evidence linking the

built environment to mental health (Halpern, 1995; Evans, 2003; Parr, 2000; Frumkin,

2003). Contributing factors include neighborhood conditions (Cohen, et al., 2003; Dalgard

& Tambs, 1997; Wandersman & Nation,1998; Leventhal & Brooks-Gunn, 2000; Johnson,

Ladd, & Ludwig, 2002), poor housing quality (Evans, Wells, & Moch, 2003; Freeman,

1984), crowding and lack of privacy (Baum & Paulus 1987; Evans & Lepore, 1993; Wener

& Keys, 1988), and noise (Stansfeld, 1993), which negatively impact depression (Galea, et

al. 2005; Weich et al, 2002), social support (McCarthy & Saegert 1979; Evans & Lepore,

1993) and recovery from cognitive fatigue and stress (Frumkin, 2001; Ulrich, 1991).

Living in an SRO, when compared to living in other housing environments, has been

associated with higher rates of HIV infection, emergency room use, recent incarceration,

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having been physically assaulted, crack cocaine smoking, and cocaine, heroin, and

methamphetamine injection (Evans & Strathdee, 2006; Shannon et al., 2006). Further,

Lazarus et al. (2011) demonstrate that the specific organization and management of SROs

creates a gendered vulnerability to violence and sexual risk taking among women. Political-

economic theories which account for the role place (Popay, 2003; Rabinow, 2003; Bourgois

and Schoenberg, 2009; Fullilove, 2013) have included an analysis of the structural-level

policies responsible for the creation of built environments through the use of public funds.

Drawing from this example, we adapt Rhodes’ (2002, 2009) “risk environment” framework

to argue that SROs can operate as “mental health risk environments” for urban poor women.

Consistent with the risk environment framework (Rhodes et al., 2005; Rhodes et al, 2012),

our analysis examines the interplay between: 1) housing policies addressing comorbid

substance use and mental illness as a macro-level factor shaping the built environments of

SROs, 2) meso-level factors such as the management of social relationships within SROs,

including drug/sex economy involvement, and 3) micro-level individual behaviors related to

drug use and trauma management enacted within SROs.

Our application of the risk environment framework to SROs offers potential contributions in

the areas of theory, methodology, and health policy. Theoretically, our analysis foregrounds

how specific constructions of urban space may exacerbate women’s co-occurring mental

health issues and substance use. Methodologically, we employ qualitative methods to

examine the relationship between space, drug use, and mental health to reveal the linkages

between housing policies, the socio-structural organization of urban built environments and

everyday behaviors. In terms of health policy, our analysis highlights the importance of

considering comorbidity in housing policy for active substance users, particularly the role of

trauma-sensitive housing environments for unstably housed women who use illicit drugs.

METHODS

Our participants were recruited from a larger epidemiological study, the “Shelter, Health and

Drug Outcomes among Women” (SHADOW), a cohort study of homeless and unstably

housed women living in San Francisco (Riley et al., 2007). A qualitative sub-sample (n=30)

was selected from the larger SHADOW cohort. Consistent with qualitative study designs,

the sample was not representative of the larger cohort (Silverman and Marvasti, 2008).

Rather, we purposefully sampled (Coyne, 1997; Higginbottom, 1998) women illustrative of

a set of issues (recent physical and/or sexual victimization, unprotected sex, and needle

sharing) previously described in the epidemiological literature to be relevant to unstably

housed women (Coughlin, 2011). Women in the sub-sample underwent a separate consent

process and took part in approximately hour-long taped interviews with trained qualitative

researchers (Knight, Lopez, and Cohen). During the interviews, participants were asked to

describe their current and past living situations, current and past drug use, mental health

(including experiences with diagnosis and psychiatric medications), sexual and friendship

relationships, and experiences with violence and trauma. Participants completed a baseline,

one-year, and 18-month follow up interview and were reimbursed $15 for each interview

completed. All study procedures were approved by the Institutional Review Board at the

University of California, San Francisco. In addition, the first author (Knight) conducted an

independent, four-year (2007–2010) ethnographic study which included interviews with

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housing and health policy-makers in San Francisco and a photo-ethnographic study of a

variety of SRO hotel rooms. Over 500 photographs were taken during this timeframe in 25

different SRO hotels in San Francisco.

Transcribed audio-recorded interviews from each study underwent a similar two-phase

analysis, consistent with methods the authors have employed in several previous qualitative

studies (Comfort et al., 2005; Knight, et al., 2005; Knight, et al., 1996). In phase one, the

team of four analysts (three of whom were the interviewers) used grounded theory

methodologies (Strauss and Corbin, 1990) to construct memo summaries of each interview,

which included basic background information, current circumstances, notable events and

quotations, and analyst impressions and interpretations. Because previous research (Chan,

Dennis, & Funk, 2008; Cohen et al., 2009; Hooper, et al., 1997; Kushel et al., 2003;

Luhrmann, 2008) indicated a potential relationship between lifetime histories of traumatic

exposure, housing instability, current living situations, and sexual and drug use behaviors,

we sought to keep narratives “intact” in the initial data analysis phase. The interview

transcript and summaries were then discussed at a 2-hour meeting devoted to analyzing each

participant’s interview. The team identified each narrative’s micro, meso, and macro factors

for analysis. After the initial group analysis process, the team developed a preliminary

codebook, which was amended throughout data collection. In phase two of analysis,

interview transcripts were coded and entered into a qualitative data management software

program (www.Transana.org), to produce aggregate data for the entire qualitative sample.

For the purposes of this analysis, memoed summaries and multiple aggregate sections of

coded data (e.g., codes for housing, trauma, mental health, neighborhood) were analyzed.

Photo-ethnographic data were coded by location, type of hotel, and date.

RESULTS

Macro-level factors: housing policies shape SRO built environments in San Francisco

The widespread implementation of mental health deinstitutionalization policies which took

place in the 1970’s and 80’s in California was not accompanied by structured housing plans

for the uptake of mentally ill persons now residing in the community (Lamb, 1984). Thus,

community reintegration of adults with disabling mental illnesses created a housing need,

which was largely unmet. One policy maker outlined the statistics on co-morbidity among

the population in San Francisco, underscoring the relationship between drug use, place, and

social policy in this setting:

Of the people in supportive housing in San Francisco, 93% have a major mental

illness that we can name. That is very, very high. 80% use cocaine, speed, or heroin

every thirty days, or get drunk to the point of unconsciousness. There are no more

disabled people in this country.

Because of San Francisco’s small size and geographic boundedness, it was expedient to use

existing SROs as sites to house the burgeoning urban poor. To date, there are more than 500

SROs in San Francisco, providing homes for approximately 30,000 low income individuals

(CCSRO website). These built environments include both larger and smaller building stock,

with some SRO hotels housing up to 200 persons and others with only 25–30 rooms. The

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necessity of using existing SRO housing as sites to accommodate the expanding population

of impoverished individuals created a trifurcated system. This system has led some women

to find housing in older, privately run and managed SROs, some in previously privately-

owned buildings whose master lease had been purchased by the City of San Francisco, and

other to be housed in new buildings built on the demolished cites of older SROs or in other

urban spaces1. These three types of built environments presented different challenges to

women in the management of their mental health.

The department of Housing and Urban Health (HUH), the first in the country to formally

integrate housing management with public health, was created within the San Francisco

Department of Public Health to develop and manage the publically funded older and newer

SRO buildings. The HUH discovered through the course of this progressive housing

initiative that building new, publically-funded SROs is more cost effective and produces

better housing and health outcomes for the tenants, than converting exiting privately owned

SROs. Even if rental payments could be deferred through welfare or subsidy payment

mechanism, simply placing adults indoors in older SRO building was not efficacious if the

indoor environment was still chaotic, dangerous, and poorly managed. At the macro-level,

the built environment needed to be responsive to “trauma.”2 For a population of tenants with

such high rates of co-morbid substance use and mental health issues, the built environment –

the organization of the physical and social space – was construed as critical to ensuring

housing success. One health and housing policy maker compared the different levels of

housing stability for tenants in new SRO built environments to those in older SROs, to

emphasize the interactive relation between the built environment and trauma:

When we look at our success in keeping people housed in our buildings, what we

see is that places like the Marque3, which has small, dirty rooms, case

management, but shared bathrooms. The rate of people staying housed there for

two years consecutively is 30%. That is horrible. The Zenith, a new building, has

case management, same as the Marque. But it is beautiful; every room has its own

bathroom. 70% of the tenants stay at least two years.” The point is the good stuff is

the better investment when it comes to supportive housing. The environment

matters. I think it is about trauma. People, who have had so much trauma cannot

stabilize, cannot stay housed if they still living in a dump.

The following pictures draw a comparison between the physical environment deemed to be

“trauma-sensitive” and a standard situation from a privately-owned SRO. The physical

layout of a typical SRO is a single, 8×10″ room with shared toilets and showers down the

hallway. Newly built SROs were often clean, less chaotic, well-managed, and safer. Newer

SROs included individual bathrooms and sometimes small kitchens to prepare food. In

contrast, older and privately-owned SROs often consisted of a double or single bed, a sink, a

1The payment structure for rent in these three types of SROs is complex and varies for tenants depending on whether they pay for
SRO rooms out of pocket, or through welfare program linked subsidies, of which there are several. Discussion of the complex
payment structures is beyond the scope of this paper, but is discussed at length in a forthcoming publication. See Knight, KR Limited
Addiction: Pregnancy and Madness in the Daily-rent Hotels, forthcoming with Duke University Press.
2“Trauma” here is a colloquial (as opposed to clinical) term deployed to refer to the complex array of affective symptoms many
chronically-homeless persons, especially women, demonstrate in daily life as a result of historic experiences of abuse and current
vulnerabilities.
3The names of SRO hotels are pseudonyms.

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small chest of drawers, and a desk. The physical conditions which routinely affected

women’s mental health in our study included the presence of rats, mice, and bed bugs;

graffitied walls and broken furniture; and, non-operating sinks, electricity, door locks, and

TV sets. As demonstrated in the photos, the condition and functionality of the physical

aspects of the built environment varied a great deal and this variation contributed in positive

and negative ways to women’s mental health outcomes.

Meso and micro-level factors: social relations and behavioral strategies intersect with the
built environment to influence mental health

The women in our sample had high rates of co-occurring mental health and substance use

issues and extensive histories of childhood and adult sexual and physical victimization,

making the management of trauma symptoms an everyday life challenge. One woman

described the impact her new calm, controlled environment had on her risk for poor mental

health:

I discovered that my environment had a lot to do with my mental state. So, when I

had my own place, I was in control of the environment. You know, there was no

drama, everything was nice and mellow, and so I was able to function. Everything

was on an even keel; that was fine. It was when other people and situations were

introduced into my environment that I couldn’t get away from, that would send me

over the edge.

The physical and social organization of specific SRO housing environments made such a

significant impact on the women in our studies that many reported choosing street

homelessness or homeless shelter stays if they could not secure a room in a monthly rate,

clean, and safe SRO. Reinforcing the data provided from the housing policy-maker, one

woman described “shopping” for an SRO which meet her mental health needs, rather than

accepting the first publically subsidized built environment offered to her.

[The homeless shelter administrator] told me I would find a place [through a

subsidized program] if I work with them. And they did find me a lot of places, but I

didn’t want to go, because [those] SROs they have now are really nasty. Really tore

up, tore down. Syringes in the bathroom. Blood on the toilet. Because you use the

same toilet that everybody else uses. So it wasn’t sanitized. So I didn’t want to go.

And I found the Martin Hotel and I went in and it was a really clean, nice place. So

I went back to [the shelter] and I asked them ‘Can you please get me a place inside

that hotel?’ They said that would be cool, they would work on it. And within two,

three weeks I had a place at the Martin.

SRO environments where women felt unsafe exacerbated several physical and emotional

symptoms associated with poor mental health. The physical organization of SROs, which

consisted of crowding people with addiction and mental health issues into a single space.

This, in combination with, chaos related to drug/sex economy interactions (drug dealers,

runners, pimps and sex workers), and rapid cycling of new tenants contributed to stress-

related sleeping problems, hyper-vigilance, and drug and alcohol use. Many women

described needing prescription sleep medication to rest in chaotic hotel settings and avoid

conflicts with neighbors:

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When I go in [to the SRO hotel] and shut my door, I just try to shut my eyes and

block it out. Sometimes they [neighbors] have their TVs on and I want to say

something. I’m thinking, ‘You know, [says her own name], just be quiet! Just go to

sleep.’ Once I take my [sleeping] pills, I’m good.

Women commonly adopted a strategy of deliberate social isolation to shield themselves

from risk for victimization within unsafe SRO environments. For some women, isolation in

the hotel room was an emotionally self-protective response to living daily in a traumatized

state. One woman provided an example of isolation linked to on-going fears of being

attacked:

So I started using back in 2009, which I have been using drugs for a year now. I got

raped last year. I got raped, I got kidnapped. I was tortured for days. My best friend

died, as I told you. It’s just everything fell apart and I have been tore up since

then…Since I moved to [my SRO], I basically stay in my room all day.

For others, isolation served as a strategy to avoid being “caught up” in unpredictable

violence and social disorder associated with the drug-sex economy:

So, now I’m here, you know, just trying to deal with a lot of different things, you

know. Adjustment of being back [in my SRO room] which I’m getting more

adjusted to it, but I don’t like the space that I’m in because it’s small. Of course, I

don’t mingle with my neighbors either…I just tend to stay to myself because I see

trouble there and I avoid that because I don’t need that in my life, you know. So,

that’s another thing I deal with on a day-to-day basis you know.

In contrast to the women above who described deliberate social isolation as a mental health

survival strategy, another woman positively described increased safety and independence in

built environments which were perceived as safe and non-chaotic. For example, one

positively described her highly structured SRO housing environment, a place specifically

designed to reduce her fear and anxiety over repeated victimization and to enhance her

ability to manage her mental health symptoms despite years of trauma and housing

instability:

Oh, it’s [my room’s] beautiful, it’s comfortable and it’s quiet and it’s clean! I mean

the manager there is up on it. He’s got security cameras now. It’s secure, I’m high

up. The only way you can get into my window is if you try to do it. And if you try

to do it and you fall, you’re going to die. It’s out of the way [out of the

neighborhood], yeah. And so the [public] bus takes me to school. Takes me straight

to school, straight home. Boom, no chaos. Walgreen’s right there. Boom, psych

meds, boom right there, boom. Bus pass, Walgreen’s right there, boom.

Everything’s right there. You know [the bank] is right on the corner, boom. I’m just

— McDonald’s everything, grocery store, laundromat, everything is just right there

in my commute. I don’t have to go a block to go to the laundromat. I don’t have to

go through a block to go to grocery shopping. So, everything is just perfect for me.

In terms of localized drug policy and housing, the adjudication of in-building drug use was

not prioritized by the women in our study to the same extent as other measures taken to

ensure the built environment was spatially and socially organized to reduce fear, anxiety,

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and conflict. While women acknowledged the risks that the drug-sex economy posed to their

mental health, many also actively participated in those economies as drug users and

(intermittently) as sex workers. Even women who were seeking to reduce or eliminate their

own drug use, or who were abstinent, did not suggest that drug use or sex work should be

outlawed within their hotels to promote safety. Opinions veered towards a “closed-door”

policy, particularly about drug use. Women expressed that, ideally, open-air drug markets

and the street-level chaos and violence often associated with the drug-sex economy should

be mitigated by the hotel management, thereby promoting safety and control within the

housing environments. In one example, several women in our study positively described an

active campaign by SRO management, which evicted drug-dealing tenants from the

building. Drug-using tenants were not targeted; however, those participating in the economy

that brought associated violence and socia

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