Safe housing for a meaningful everyday life

Type of the Paper: Peer-reviewed Conference Paper / Full Paper

Track title: Topic 1: integration of needs – inclusive, integrated design enabling health, care and well-being.

Safe housing for a meaningful everyday life

Development of housing for people with drug addiction, psychiatric disorders and violence risk

Solvår Wågø ^1,*, Melina Røe and ² Stina Svendsen ²

¹ SINTEF Community; solvar.wago@sintef.no; ORCID: 0000-0002-6574-5316

² NTNU Social Research; melina.roe@samforsk.no; ORCID: 0000-0003-4071-5265

² NTNU Social Research; stina.svendsen@samforsk.no

* Corresponding author.

Abstract:

Objective

(to be completed by the editors) Names of the Topic editors: Names of the reviewers: Journal: The Evolving Scholar DOI:10.24404/6230943244461baae6961522 Submitted: 23 Mar 2022 Accepted: Published: Citation: Wågø, S., Røe, M. & Svendsen, S. (2022). Safe housing for a meaningful everyday life [preprint]. The Evolving Scholar | ARCH22. This work is licensed under a Creative Commons Attribution CCBY license (CC BY). © 2022 [ Wågø, S., Røe, M. & Svendsen, S.] published by TU Delft OPEN on behalf of the authors.

Establishing a safe and worthy place to live is an important step for people struggling with substance abuse and psychiatric disorders. In this project, we have followed Trondheim Municipality in the process of establishing a new housing model that contributes to safety and mastery for people with combined disorders and violent behaviour.

Background

Providing comprehensive services to people with violent behaviour affected by drug use, is challenging. Trondheim Municipality aims to develop a breadth of housing and services for this target group. One of the plans in that context is to establish a home for 6-8 people in close physical connection to the mental health-care department at St. Olav's hospital.

Methods

An action research approach is suitable when the goal is to create change and where the intention is to create new solutions to current problems (Levin, 2017). Qualitative interviews with professionals in the field, user representatives, workshops and participation in the planning process and literature studies, have been conducted.

Results

The need for safety, fixed routines, positive impulses and the opportunity to influence one's own everyday life is pointed out as crucial for people with a behaviour that either scares or is exploited. Several emphasize the importance of activities and food-serving to secure that nutritional status is maintained.

Conclusion

Rethinking housing models for the target group is necessary but difficult in practice. There is a need for innovative solutions, design and services for the individuals that secures the employees and the neighbours.

Keywords: Housing; dignity; architecture; mental health; quality of life

1. Introduction

People with drug-related disorders, substance abuse and the risk of violence have persistent and complex problems and are often experiencing challenges in life as a result of drug addiction and mental disorders. This is a group that is perceived as challenging to help, as they often do not take advantage of the offers that exist or are offered. At the same time, it is also a matter of lacking suitable housing and services (Wågø, Høyland & Bø, 2020). Therefore, it is necessary to see services, activities and housing in context. This requires close cooperation between the mental health service in the municipality and between the municipality and the specialist mental health care.

This paper is based on a collaboration between SINTEF Community and NTNU Social Research where a grant from the Norwegian State Housing Bank made it possible for us to follow and contribute knowledge in the development of a new housing- and mental health care solution for people with drug addiction, psychiatric disorders and violent behaviour in Trondheim Municipality. The municipality was in the process of planning eight co-located rental homes with a service base. The selected plot is located on Østmarka in Trondheim, close to St. Olav Division of Mental Health Care and the newly established security building where patients subject to compulsory mental health care are hospitalized. This was a conscious choice in the municipality’s perspective, since Trondheim Municipality wanted to look at the possibility of giving the residents of the future apartments, better services. Easy access to expertise from St. Olav Division of Mental Health Care, and physical proximity to staff and expertise in the security building was seen as a benefit.

The municipality has also a long-term plan to develop and “normalize” the area with both housing, kindergartens and other functions. Through close collaboration with the municipality, the goal for the research team was to follow the development of new housing and a safe and secure solution for a meaningful everyday life for these people who is the most difficult to settle. Our aim was to contribute knowledge and competence during the first phase of the planning work, to support the establishment of better housing and service solutions, which should be able to work well for both employees, neighbours and users.

Our main task has been to provide input to the process, and also contribute knowledge about key factors in the development of a new and tailored housing and service solution. People with complex disorders and violent behaviour need comprehensive services that include care, activation, security and safety. The findings are useful for Trondheim municipality but will also provide input to similar processes in other municipalities.

2. Theories and Methods

The research design in this research project has been to follow a process and to be close to practice. We as researchers have entered into a research- and learning community with non-researchers who are problem owners or have interests and obligations in the field. This is a working method that is often referred to as follow-up research (Levin, 2017). By being close to the process, researchers gain a deep understanding of the situation (Reason & Bradbury, 2008). At the same time, it will be important to consciously take a critical distance from the process in order to be able to reflect analytically on the phenomenon being investigated (Johansson & Lindhult, 2008).

To shed light on the issues, the project consisted of several parts:

• Participation and observation of the process-work in the municipality (participation in meetings regarding the area and function program and then the scheme design, interviews, site visit and visit to the newly established security building close to the plot, discussions, etc.).

• Collecting knowledge from relevant research and initiatives, mainly Norwegian.

• Obtaining experiences and input through semi structured group interviews in five large cities with key informants from the housing and service area (the Norwegian State Housing Bank's metropolitan network)

• Conducting qualitative interviews with key informants from the field of practice; managers and employees in housing and mental health care in Trondheim municipality

• Knowledge sharing and knowledge development along the way through presentations and dialogue.

An innovative research approach that seeks innovative solutions and development can be illustrated using this figure:

Figure 1. An innovation-driven research approach is based on recognizing a defined challenge and then establishing insight into current solutions, established knowledge in the field, needs and opportunities, and through this create a plan for further development that can create new innovative solutions. Illustration: SINTEF Community.

Participation in the municipal process

The research group had planned to conduct two workshops in the project. As a result of Covid, restrictions and infection control, general meetings were set up digitally. In two of the digital meetings, the research group presented earlier research related to the target group. A physical meeting was later held where Trondheim municipality invited the Division of Mental Health Care at St.Olav hospital. This meeting was led by Trondheim Municipality.

During spring 2021, Trondheim municipality arranged a series of meetings with a working group that worked on the functional brief. This working group had representatives from various municipal units who are responsible for housing for users with substance abuse and mental challenges (both managers and employees), employee representatives, safety representatives and chief safety representatives for health and welfare. Altogether ten employees. From the user side, one representative of a user- and relatives' organization and one representative of Mental Health Trøndelag participated. Three advisors and project managers in the municipal director's professional staff also participated. Two of the researchers in the research group (one from SINTEF Community and one from NTNU Social Research) followed this work with the functional brief for the new housing initiative (meeting series spring 2021) and then the municipality's start of work with the scheme design (meeting series autumn 2021). The work resulted in the functional brief which formed a knowledge base for the work in the scheme design where the architect (two persons) was involved.

Two user representatives participated in the work with the functional brief. Potential residents were not interviewed during this follow-up research project. This was a conscious choice, as a study had recently been done on user experiences in housing for the target group in Jarleveien (Bjørgen et al. 2021). In previous projects, the research team has also interviewed residents about their experiences with existing housing and service solutions (Røe, Woods & Jæger, 2014; Wågø, Høyland & Bø, 2019; Wågø, Bø & Høyland, 2021). These sources are used in this research work.

3. Results

Who are the new residents?

The municipality of Trondheim, like other large cities, experience that there are often major challenges associated with providing housing and services to people with drug addiction, psychiatric disorders and violence risk. What is often defined as one group, "people with combined disorders", is in fact a very complex and heterogeneous group of people. Here you will find people who pose a serious risk of violence, and people who are at great risk of being exploited, abused and exposed to violence.

Most of the employed staff we interviewed state that they experience that the target group needs more help than before, that they intoxicate themselves more and with stronger drugs, and that they are often sicker. They believe this is partly due to premature discharge from psychiatry (SIFER, 2020). It is also pointed out that some in the target group have a developmental disability or developmental disorder, which may or may not be diagnosed. This is a group that is associated with extra great concern.

Women are another group that is described as particularly vulnerable. Several say they could wish for their own women's initiatives. One reason is that it is often perceived as more unstable when there are women and men together. Another reason is that women may be in an extra vulnerable position in the user community.

In addition, there will also be other groups that are extra vulnerable within an already vulnerable group. In other words, there are many different individual needs also within the target group. Changes may also occur over time. One informant pointed out:

People are not static, and the situation and needs can change.

All such factors are important to take into account when discussing who should be included in the new housing.

What should the new housing offer?

The aim of the new housing solution is to provide a safe home that contributes to coping and improvement for people with serious combined disorders and with a risk of violent behaviour. The project aims to:

• Provide housing suitable for people with combined disorders in need of a specially reinforced and adapted round-the-clock service offer

• Ensure the safety of employees and the environment

• Contribute to users receiving comprehensive services from the municipal and specialist health service

The municipality outlines that there should be a staff base associated with the housing, in addition to the residents being able to receive services from ambulant teams.

It is further pointed out that in general in society there is a desire for the greatest possible degree of normalization. This means that as many people as possible should live in ordinary homes in ordinary neighbourhoods and have the opportunity to live independent and active lives. It is therefore limited to what degree the municipality should facilitate to support the residents. Some informants state that the support may also take place through ambulant teams.

At the same time, many of those we interviewed who work in various housing measures are sceptical about cutting the 24-hour staffing. One says that:

Full-time staffing is the alpha and omega for the housing solution to work.

On the one hand, they want to avoid "wrapping up" the residents and contribute to helplessness. On the other hand, informants warn against having unrealistic expectations to the residents.

Resident composition is important for the residents' experience of security

The advice from the employees to ensure safety, stability, well-being and quality of life for both employees and residents can be summarized in the following points:

• Do not put women and men together.

• Be careful not to put bitter enemies together; the drug environment is harsh.

• Avoid putting people who go on different drugs together. For example, amphetamine-addicted people may be perceived as too hectic for the calmer opiate addicts.

• Think about the age composition; if young people are put together with older drug addicts, it can lead to becoming heavy drug addicts themselves.

Location

It has been argued that the new homes will be located at Østmarka to take advantage of the proximity to the expertise from St. Olav Division of Mental Health Care. The municipality points out that the location provides proximity to quick health care. The goal, as described by the municipality, is that there should be close follow-up, with a methodical, professional approach based on everyone being different and needing different solutions.

Several employees in the specialist health service and the municipality highlight what they consider to be clear disadvantages of the location as the homes will represent easy access to drugs and cause noise for patients at Østmarka who need security. It is also pointed out as well-known that many of the possible residents express that they have bad experiences with Mental Health Care services and may find it stigmatizing to live next door to the Mental Health Care hospital.

Homely, safe, robust

Physical design can affect people's activity, choices, and not least security and well-being (Thaler & Sunstein, 2008; Ulrich et. al 2018).

Figure 2. The scheme design dated 20^th October 2021. Drawings: Eggen Architects as.

Most of the informants point out that the homes should look like ordinary homes, and not have too much of an institutional character. The target group wants to avoid visual access, and it was argued that a high ground floor or a second floor can provide an increased experience of security for the residents. Another point when it comes to transparency, is that many people in the target group do not want windows that go all the way down to the ground, but rather that windows are placed high up on the wall.

Several point out that the apartments should have their own direct exit, and not exit via a corridor. In terms of safety (both for residents and staff), it may be appropriate for apartments to be on a high ground floor with exits at both the front and the back, as this can also constitute escape routes. There should be clear lines of sight to the entire apartment, including the escape route, from the front door, and one should avoid kitchen drawers with access to knives right at the entrance.

There is a balance between reinforcement and homemaking for a target group that can periodically be violent. Examples of reinforcement of homes can be replacing plaster walls with harder boards, removing mouldings, laying floor coverings that go up the walls, removing cabinet doors and installing steel sinks and steel toilets. At the same time, it is pointed out by a manager that one must think about the living experience, that it will also affect how the home is experienced. Steel furnishings can be stigmatizing and are more expensive to replace than toilets and sinks in porcelain. Materials used and fixtures installed should be affordable, not easy to injure themselves or others, and easy to replace. Visible vandalism generates more vandalism and triggers aggression, dissatisfaction and mistrust.

When it comes to the size of the housing units, there are many who point out that 50 square meters appears to be too large for some residents, and that 35 square meters will be large enough for most. Several can be collectors, filling up the apartments with things that others would describe as rubbish. At the same time, there were some informants who emphasized that the apartments must be large enough to handle if a person needs help.

Service area and common area

When planning service areas and any common areas, it should be clear what the needs on the service side will be, residents’ needs, and staff needed. The staff plan, which functions that are to be covered in these areas, whether common meals or activities or the like are planned, must be clarified before outlining the measure's physical design.

The need for common areas was also discussed. Some believed that there should not be many activities "on the House", and that the residents to a greater extent should use existing activities in the city. Others thought that activities related to the common areas of the home are important for low-threshold activities and contact between the residents and employees. Such meeting points around, for example, meals or hobby activities, can help to create good moments.

Staff visual overview

In interviews, several express that it is important that the employees have a good overview of the area and can see who is coming and going. Some residents need help with protection from visitors or other residents and may have difficulties setting boundaries for their own and others' behaviour. Other residents may feel monitored. The safety of both staff and users may mean that technological solutions (doors, locks, monitoring) must be used. These solutions must be assessed in relation to the residents' freedom and wishes. There can be a lot to gain from a design that can provide an overview instead of control.

Activities

A consistent and clear message in the interview material is a desire for more activities related to housing solutions for the target group. This was emphasized by both employees, experience consultants and user representatives. It is pointed out that many in the target group are creative and artistic. Many of them have large amounts of energy they are not able to use constructively. The importance of getting to know the residents and what they like to do, what can be brought out of interests they may have forgotten, is extremely important. This is an unused field, the informants believe.

Relationship building is important. Activities can then function as an important "interaction pretext" - you get a reason to interact with each other. Activities and trips create relationships between staff and residents (and between the residents) and it gives variation in the residents' everyday life - an everyday life that is otherwise largely about hunting for drugs (Hope & Anthun, 2021). Activities also provide good observation opportunities and the opportunity to create shared memories. Experiences from housing and services for the target group in Oslo (Oslo municipality, 2020) show that talking about an activity rather than talking about "you and your problems" lowers the threshold for building a relationship.

4. Discussion

A recurring question in our follow-up research has been:

• Does the planned housing solution and service offer represent something new?

• Is the location on Østmarka appropriate?

Several of those we interviewed want a greater degree of innovative thinking about the collaboration between mental health care and the municipality, as well as a discussion on how to utilize the location on Østmarka.

In the interviews, we asked employees if they could briefly say what they want the new housing to include and what is most important in establishing new housing for the target group. One of the leaders we interviewed gave the following answer, which actually summarizes many of the points we have looked at in this report:

I hope that it will be a home with the physical prerequisites to provide good services, at the same time as I want there to be activities employees can bring people with them, both at the house and in the city. At the same time, the composition of the residents must be well thought out. And of course, there must be good cooperation with the specialist health service and with the ambulatory teams.

In order to create a new housing, there is a need for innovative solutions, both in terms of the home's design, surroundings, activities and service models, but also of the planning process itself.

In contrast to more traditional meetings, which due to the pandemic, have been held digitally here, working methods such as workshops and dialogue conferences, which allow for interdisciplinary discussions, and where different perspectives and input are heard and assessed, are a suitable form of work. The purpose of such working methods is not to inform the participants, but to work together to create new knowledge, new solutions and innovative service solutions. A wide range of actors may have better conditions for creating something that can represent something innovative and new.

Trondheim Municipality points out that the proximity to Østmarka could provide opportunities for closer collaboration on service models with the specialist health service. The housing that are planned will affect the area in different ways. It will therefore be crucial that the location is utilized to create new and strengthened forms of collaboration between the municipality and the specialist health service, and gains that outweigh any disadvantages the housing measure may entail.

5. Conclusions and lessons learned

In the interviews, it is pointed out that relationship work must be facilitated. This requires time, a secure framework, stability and predictability. Many informants point out the access to activities, positive impulses and the opportunity to influence own everyday lives as key elements. Several emphasize the importance of food serving to maintain a certain nutritional status, and that medication is well taken care of.

At the same time as the housing must be a good place to live for the residents, it must also be a safe and attractive workplace for employees. The safety of employees and neighbours must be taken seriously. A close collaboration between the municipality and the specialist health service is absolutely crucial.

Activity is an untapped field for this target group, and a greater degree of innovation around this topic is welcomed. Based on completed interviews, we recommend new thinking related to recruiting employees. In addition to health and social work staff, there are good experiences with hiring, for example, craftsmen and musicians to get more perspectives on how to work environmentally therapeutically and actively. There are also several examples of good experiences by hiring experienced consultants and a further development of the role of environmental caretakers. The goal in a longer perspective will be for the residents to be able to make greater use of the general services that are for everyone in the municipality.

Last – but not least: Physical environment influences behaviour. Physical design of the homes can prevent stigma, unwanted incidents and contribute to security and well-being for both residents, employees, relatives and neighbours. The design can help to shield and protect both from visual impressions that can trigger, or give positive visual, sensory and tactile impressions (green surroundings, access to a garden, materials, airiness).

By following the process of this project an important lesson is learned: A better point of departure for municipalities and other initiators would have been to start with what kind of housing this should be, and what should the housing and services connected, contribute to for the residents. When being too busy with the building, construction projects often become out of step with what e.g. the housing should be and lead to for the residents. This is potentially transferable also to other building projects and contexts in other parts of society.

Acknowledgments

This research is financed by the Norwegian State Housing Bank. We would also like to thank our partners in Trondheim municipality for a good collaboration and interesting discussions. We thank everyone who volunteered for the interviews and shared experiences and input with us.

References

1. Bjørgen, D., Småvik, G., Klevstuen, L. & Johansen, K.J. (2021): Jarleveien 10 –Beboernes erfaringer med boligløsning for rusavhengige. Kompetansesenter for brukererfaring og tjenesteutvikling (KBT).

2. Hope, S. & Anthun, K. S. (2021): Et godt Dagsverk? En kvalitativ evalueringsstudie av dagsverkets virksomhet, med vekt på deltakernes opplevelse av tilbudet. Trondheim: NTNU og Stavne KF.

3. Johansson, A.W. & Lindhult, E. (2008): Emancipation or workability? Critical versus pragmatic scientific orientation in action research. Action Research, 6(1), p.95-115.

4. Levin, M. (2017): Aksjonsforskning som forskning – epistemologiske og metodiske utfordringer. I: Grøtterud et al (2017) Aksjonsforskning i Norge: Teoretisk og empirisk mangfold, Oslo: Cappelen Damm Akademisk.

5. Oslo kommune, Velferdsetaten (2020): Bosetting av personer med sikkerhetsproblematikk i egne boliger. "Sammen om bolig"; et innovasjonsprosjekt utarbeidet av seks bydeler i Oslo.

6. Reason, P., & Bradbury. H. (2008): The SAGE Handbook of Action Research, Participative Inquiry and Practice. Second Edition. London: SAGE.

7. Røe, M., Woods, R. & Jæger, I. (2014): Stolt beboer- Folk og hus i Tollåsenga. Trondheim: NTNU Samfunnsforskning.

8. SIFER (2020): Utskrivningsklare pasienter i sikkerhetspsykiatrien – en kartlegging av utskrivningsprosessen fra sikkerhetsavdeling til kommune. https://sifer.no/wp-content/uploads/2020/11/Utskrivningsklare-pasienter-i-sikkerhetspsykiatrien-en-kartlegging-av-utskrivelsesprosessen-fra-sikkerhetsavdeling-til-kommune.pdf

9. Thaler, R. H. & Sunstein, C. R. (2008): Nudge. Improving decisions about health, wealth and happiness. Penguin books.

10. Ulrich, R. S., Bogren, L., Gardiner, S. K. & Lundin, S. (2018): Psychiatric ward design can reduce aggressive behaviour. Journal of Environmental Psychology, 57 (2018) p.53-66. https://www.sciencedirect.com/science/article/pii/S0272494418303955

11. Wågø, S., Bø, L. A. & Høyland, K. (2021): Småhus – hjem og verdig botilbud? Kommunenes erfaringer og beboernes stemmer i 14 norske kommuner. Trondheim: SINTEF Community.

    https://www.sintefbok.no/book/index/1279/smaahus_hjem_og_verdig_botilbud_for_personer_med_ruslidelser_og_psykiske_lidelser_kommunenes_erfaringer_og_beboernes_stemmer

12. Wågø, S., Høyland, K. & Bø, L. A. (2019): Bokvalitet og verdighet -en evaluering av boliger for mennesker med rus- og psykiske lidelser. Trondheim: SINTEF Community.

    https://www.sintefbok.no/book/index/1210/bokvalitet_og_verdighet_en_evaluering_av_boliger_for_mennesker_med_rus_og_psykiske_lidelser