The Emergence of the Linear Continuum Paradigm

Many of the residential treatment programs were established to provide housing for persons being deinstitutionalized. Many of these individuals had spent considerable time in psychiatric hospitals and some had developed an "institutionalization syndrome" characterized by extreme dependence. Partly in response to the needs of this emerging population and to create an effective transition from the hospital to the community, many of these early programs devised a continuum of residential settings. This continuum was conceptualized as a series of residential steps to accomplish the transition between the hospital and independent living (Carling, 1994). In essence, the first step consisted of a living arrangement very similar to an inpatient setting: high amounts of structure and rules, 24-hour staff supervision, and few privileges. Subsequent steps, which usually meant moves to other residential settings, brought increasingly less structure, staff supervision, and rule restrictions. At the last step the individual was "transitioned" into the community at large. This approach to residential treatment has been called the linear continuum paradigm (Ridgway & Zipple, 1990).

Thus, the halfway house approach became augmented by the addition of different housing situations, each offering varying amounts of staff support, structure, and supervision. These steps might consist of quarter-way houses, typically located on the grounds of state psychiatric institutions (Carling, 1994); three-quarter-way houses, in which staff were no longer present around the clock (Campbell, 1981); and supervised apartments, semi-supervised apartments, and other residential options that represented steps toward the eventual goal of fully independent living. Some residential continua also include crisis alternative residences, also called respite care, designed to help acutely symptomatic consumers avoid a hospitalization (Carling, 1994).

Throughout the 1980s, and into the 1990s, in some places, the linear continuum paradigm dominated the field of residential services (Ridgway & Zipple, 1990). Although this conceptual framework is less favored today, the idea of transitional housing is still in evidence. It is important to examine how a linear continuum approach affects the consumers' adjustment to community living.

Exactly what is offered along a particular residential continuum varies, as do the names given to the different types of programming. It is therefore difficult to compare these residential approaches, and a clear idea of the ideal continuum has never emerged (Ridgway & Zipple, 1990). However, some basic assumptions characterize programs that adhere to this linear residential service continuum approach (Ridgway & Zipple, 1990):

1. Several residential settings are available that offer different levels of service provision, staff supervision, and restrictiveness.

2. Program participants are expected to move, in an orderly fashion, from the more restrictive level to a less restrictive level.

3. Participants in each setting are similar in terms of clinical stability and functional ability. They are expected to make progress before graduating to another level on the continuum.

4. If a program participant decompensates and returns to the hospital, he or she often reenters the continuum at the most restrictive level (i.e., he or she has to start over again at the bottom).

5. The ultimate goal is to move on to independent living and no longer require services from the program.

Research conducted on the efficacy of the residential continuum model is scant and inconclusive. As indicated earlier, it is hard to study an approach in which the nomenclature varies and clearly defined, consistent intervention strategies do not exist. In addition, most of the studies that have been done did not use rigorous experimental methods and thus are not very useful. The literature that is available on transitional residential treatment suggests that the approach is not particularly successful in helping people to achieve the PsyR goal of community integration (Carling, 1994).

It is also important to keep in mind that residential programs of this type only serve a small percentage of the people in need. In the early 1990s, the housing resources available in local mental health systems (such as money earmarked to buy houses, rent apartments, and staff residential continuum programs) provided services for fewer than 5% of the people with psychiatric disabilities (Carling, 1994). Identifying these governmental resources is somewhat difficult, however, because in many places the bulk of resources to support housing is not found in the mental health budgets.

While the linear continuum approach may seem to be a coherent strategy for helping consumers become gradually reintegrated into the community, we should question the use of this approach when 30 or more years later there are no strong research findings to back it up. At the same time, the monetary resources are not available to provide the service to the vast majority of consumers. In addition, consider some of the issues raised by Joanna's story.

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