quality of life in boarding houses and hostels: a residents' perspective

Community Mental Health Journal, Vol. 37, No. 4, August 2001

Quality of Life in Boarding Housesand Hostels: A Residents’ Perspective

Matthew E. Horan, D.PsychJuanita J. Muller, Ph.D.Sharon Winocur, Ph.D.Norman Barling, Ph.D.

ABSTRACT: In the last forty years deinstitutionalization has transferred the care ofpeople with a serious mental illness from the psychiatric hospitals to community basedfacilities. More recently it has been questioned whether these new facilities offer theanticipated benefits of quality of life. This study examines the Quality of Life (QOL)of people diagnosed with schizophrenia living in two different accommodation facilities,hostels and boarding houses. QOL is examined from the resident’s perspective. Lehman’s(1988b) QOL Interview was used to measure objective, subjective, and global QOL of60 participants in three hostels and two boarding house clusters. Hostel and boardinghouse data were compared and results showed that residents preferred boarding houseaccommodation. Overall, residents of both accommodation facilities reported satisfac-tion with QOL, and indicated that they regard them as asylum or sanctuary from theoutside world.

KEY WORDS: Quality of Life; hostels; boarding houses; schizophrenia; Lehman.

It has now been over forty years since the process of deinstitutionaliza-tion moved the locus of care of people with severe and persistent mentalillness from the psychiatric hospitals to more community-based net-works of services (Mercier, 1994). With this move new concerns emerged

Matthew E. Horan is affiliated with the School of Humanities & Social Sciences, Bond University.Juanita J. Muller is affiliated with the School of Applied Psychology, Griffith University. NormanBarling is affiliated with the School of Humanities & Social Sciences, Bond University.

Address correspondence to Juanita J. Muller, School of Applied Psychology, Griffith University,PMB 50 Gold Coast Mail Centre, Queensland 9726, Australia; e-mail: [email protected].

323 2001 Human Sciences Press, Inc.

Community Mental Health Journal324

with respect to the quality of life (QOL) afforded by community living(Davidson, Hoge, Merrill, Rakfeldt & Griffith, 1995).

With the exception of some well-planned and well-resourced initia-tives in the United Kingdom (see Leff, Dayson, Gooch, Thornicroft &Wills, 1996), the consensus from research (Kiesler, 1982; Lamb, 1979)suggests that few positive changes occurred for most seriously mentallyill patients. Most individuals remained poor, isolated from mainstreamsocial life and unhappy (Shadish, Lurigio & Lewis, 1989).

Reviews (Burdekin, 1993; Reich, 1973; Talbott, 1979) have describedmost community accommodation available to the mentally ill as expen-sive, substandard or inappropriate. Furthermore, a number of unin-tended consequences such as homelessness (Bassuk, Rubin & Lauriat,1984), social isolation (Mechanic, 1986), lack of independent living skills(Mowbray, 1990), inability to deal with life’s pressures (Duffey & Wong,1996) and the side effects and non-compliance with medication (Casey,1997) have not been adequately addressed.

Providing accommodation and some level of support became the ‘newissue’ of concern as research has shown that chronically mentally illpatients in the community require asylum and sanctuary in the formof indefinite residential support (Hall & Brockington, 1991; Kavanagh,Opit, Knapp & Beecham, 1995; Lamb & Peele, 1984; Wasow, 1993;Wing, 1990). Findings from the National Inquiry into Human Rightsof People with Mental Illness in Australia (Burdekin, 1993) indicatedthat supported accommodation is “the single greatest need for peoplewith psychiatric disability” (p. 352).

In Australia, hostels and boarding houses emerged to satisfy thisdemand. In America, board and care and nursing homes have beendescribed by Lamb (1979) as the ‘new asylums’ in the community. Whilstthey offer asylum from life pressures, a degree of structure, and sometreatment, especially medication and supervision, they are also charac-terized by substandard and impoverished living conditions. In Australiathere appears little difference with Burdekin (1993) describing hostelsand boarding houses as the ‘new institutions.’

Several models of community care have been trialled in the UnitedKingdom, with the ‘ward-in-a-house’ (Shepherd, 1995), the staffed com-munity houses (Leff et al., 1996) and hospital hostel/haven (Wing, 1990)showing some degree of success. These facilities, however, are not typicalin Australia, where community care more closely resembles the situationin the United States. A review of the literature (Burdekin, 1993; Shad-ish, 1989) shows that Australia and America both share similar prob-

Matthew E. Horan, D.Psych, et al. 325

lems in the provision of adequate community accommodation in a looselyregulated industry.

HOSTELS AND BOARDING HOUSES

Hostels were established in Australia in the 1960’s and 1970’s specifi-cally intended to cater for the mentally ill (Burdekin, 1993). Boardinghouses have evolved from their original purpose of being a respectableform of housing for people visiting the city for work or on holiday, tobecome convenient repositories for the chronically mentally ill (Burde-kin, 1993). They quickly met the need for an ever-increasing demandfor low-income housing created by deinstitutionalization (Cleary, Wool-ford, & Meehan, 1998).

Hostels and boarding houses share many of the same problems forresidents, such as lack of privacy, treatment, activity and finances.Burdekin (1993) reported, however, that hostels have become institu-tionalized, arguably due to their original purpose of establishment. Theyare usually larger complexes, typically with a large kitchen, shareddining, lounge and bathroom facilities. Meals are provided, medicationdispensed and spending money is generally allocated by staff. The onlyofficial specification is adherence to local council fire safety regulations.

Boarding houses appear to blend into the community better thanhostels as they tend to be smaller in structure than hostels, resemblingmore a large house. They offer more personal space with regard toprivacy in bedrooms, displaying of personal items, having decorationson walls, and community living areas. Boarding house residents aregenerally more involved in meal preparation, and have to share withless people. There are generally no differences in the level of supportoffered or required, the diagnoses and levels of functioning of peoplereferred for placement, the agencies from which referrals are made,the socio-economic status of the location; and the personal financialresources of the individual.

Boarding houses, however, appear to foster a more normalized ap-proach to community living with more personal freedom in the senseof privacy and less stigmatisation due to more normalized living condi-tions. As they are less institutionalized than hostels, it is argued thattheir residents will have higher QOL. It is also expected that boardinghouse residents also will express more satisfaction with their livingsituation than hostel residents.

Recently, there has been an enormous amount of negative media


coverage of accommodation facilities for the mentally ill in Australia(60 Minutes, Channel 9, 11/6/00) with a push for government regulationof the industry. Although, objectively, conditions appear substandard,no investigation has taken into account the expressed views of thementally ill. A common dilemma encountered in the assessment of qual-ity of life among persons with a severe mental illness (Lehman, 1988b)is that their perceived QOL often differs from what social norms wouldexpect (Davidson et al., 1995). A person with a severe mental illnessmay be living in what appears to be sub-standard housing but mayexpress satisfaction with this living arrangement. Surely, then, theviews of the consumer or resident should be considered.

Identifying consumer needs is paramount in improving services andacknowledging the rights of the mentally ill. Current research indicatesthat consumers should be included as genuine contributors and partnersin the treatment process. As argued by the National Mental HealthStrategy Evaluation Steering Committee (1997), “improving the rightsof individuals with a mental illness provides a stark contrast to theneglect and gross human rights abuses over the past century” (p. 11).

Australian research has shown that between 80% to 90% of peoplediagnosed with a mental illness would prefer to live in the communitythan in an institution (Burdekin, 1993). This is consistent with findingsof 86% in the United Kingdom (Leff et al., 1996) and is supported bystudies from other western countries (Davidson et al., 1995; Herman &Smith, 1989; Solomon, 1992).

Based on a review of the literature (Horan, 1998) on the treatmentand care of people with schizophrenia in the community, it is evidentthat further research needs to be conducted in this area. There is alsoa particular need for Australian based research, using a quantitativemethodology since, to date, there appears to be only a small number ofqualitative investigations.

AIM AND RESEARCH HYPOTHESES

The aim of this study is to examine QOL from the residents’ perspectiveand to compare QOL in boarding houses and hostels. The main hypothe-sis is that individuals diagnosed with schizophrenia will have highersubjective and objective QOL measures if their accommodation is board-ing houses rather than hostels. This is based on the notion that boardinghouses offer more freedom, consistent with the philosophy of deinstitu-tionalization.


METHOD

The independent variable is accommodation type (i.e. boarding house or hostel) andthe dependent variable is Quality of Life. The definition of Quality of Life used in thisstudy is by Lehman (1983a)—“the sense of well-being and satisfaction experienced bypeople under their current life conditions” (p. 143). It is measured using Lehman’sQuality of Life Interview (1988b) that examines both subjective and objective qualityof life.

The Lehman Quality of Life Interview

The Lehman Quality of Life Interview (Lehman QOL Interview) is both objective (whatpeople actually do and experience) and subjective QOL (peoples’ feelings about theseexperiences). It provides a broad based assessment of the recent and current life experi-ences in a variety of life areas of potential interest, including living situation, familyrelations, social relations, leisure activities, finances, safety and legal problems, workand school, and health.

The QOL Interview attempts to address the multi-dimensionality of QOL by viewingthe experience of general well-being as a product of personal characteristics, objectivelife conditions in various life domains, and satisfaction with life conditions in thesedomains (Lehman, 1988b). It has been shown to have satisfactory parallel form reliabil-ity, internal consistency, and difference score reliability (Lehman, 1983b, 1988b). Subjec-tive quality of life has also been shown to correlate with objective quality of life onthree independent samples of subjects (Lehman, 1988b). A review of the QOL literaturesupports the use of Lehman’s QOL Interview (1988a) in working with the severelymentally ill.

This instrument was chosen for use in the current study as the eight life domainsreflect many of the areas of concern described by Burdekin (1993), and the issues raisedby overseas research on the chronically mentally ill (Lamb, 1979; Lamb & Goertzel,1971; Segal & Aviram, 1978; Talbott, 1979).

Participants

The participants of the study were 60 people who had been diagnosed professionallyas suffering from schizophrenia, and were living currently and had lived for two yearsor more in either hostel or boarding house accommodation in south-east Queensland,Australia. The hostel sample consisted of 25 males and five females, ranging in agefrom 25 to 78 years, with a mean age of 45.9 years. The boarding house sample consistedof 20 males and 10 females, ranging in age from 21 to 80 years, with a mean age of46.7 years. These sample characteristics were comparable in age and sex to the studyby Lehman, Reid and Possidente (1982). As discussed above, there are no actual criteriafor referral to either of these facilities. Placement is generally made on availability ofspace at the time of referral. Both types of facility are within the same sociol-economicand demographic region.

Procedure

The QOL Interview was conducted individually with participants in their respectiveaccommodation facilities. Participants’ psychiatric symptomatology was assessed by asenior psychiatrist within two days prior to the interviews being conducted for thisstudy to ensure they did not have positive symptoms. The diagnosis of schizophreniawas confirmed using DSMIV criteria.


This assessment incorporated a clinical review and interview by the psychiatrist, whoalso reviewed their medical/clinical notes, hospital discharge summaries and medicationregimes in accordance with Lehman (1983a). It was considered that this would ensure,as much as possible, that a consistent diagnosis was made for the entire group andthat they had similar levels of functioning. Within the two categories of accommodation,there were three hostels and two clusters of boarding houses. The three hostels arelabeled Hostel 1 (H1), Hostel 2 (H2) and Hostel 3 (H3). The two clusters of boardinghouses are labeled Boarding House 1 (BH1) and Boarding House 2 (BH2).

TESTS OF THE HYPOTHESIS

Presented here are the results of the hypothesis tests in which scalesand indicators of quality of life were compared for the two living contexts:boarding houses and hostels. The hypothesis tests were conducted oneight subjective scales and eight objective scales/indicators (five scales,three indicators) recommended by Lehman (1988a, pp. 128–129). Heargued that the pairing of subjective and objective measures was “essen-tial to the quality of life assessment model” (p. 39). Additional subjectivescales (school and work satisfaction) were omitted, however, becausethey were not relevant in the sample used in this study. These indepen-dent group t-tests were divided into the two groups of dependent vari-ables: subjective scales and objective scales or indicators. Consistentwith the hypothesis that residents in boarding houses will report ahigher quality of life, one-tail tests were conducted.

Subjective Scales

Differences emerged between residents of boarding houses and hostelswith the mean satisfaction score always higher (but not often signifi-cantly) for those from the former and lower for the latter. The differencewas most precisely different when the satisfaction with living situationscale was tested. The mean scores and test statistics for each scale byresidence type can be found in Table 1.

General Life Satisfaction. Satisfaction with life in general differedby living context. Participants from boarding houses reported highersatisfaction with life than those from hostels, as hypothesised (t =1.75(58), p ≤ .05).

Satisfaction with Living Situation. While both hostel and boardinghouse participants scored above the mid-point on the 1 to 7 range onthe Satisfaction with Living Situation Scale, boarding house residents


TABLE 1

Mean QOL Subjective Scores by Residence Type

Measures and Residence Type M t df p (1-tail)

General life satisfactionBoarding house 5.50 1.75 58 .05Hostel 4.90

Satisfaction with living situationBoarding house 5.31 2.21 58 .02Hostel 4.66

Daily activitiesBoarding house 5.07 1.61 58 NsHostel 4.66

Family relationsBoarding house 4.58 0.38 57 NsHostel 4.43

Social relationsBoarding house 5.09 1.06 58 NsHostel 4.90

Financial satisfactionBoarding house 4.55 0.78 58 NsHostel 4.25

SafetyBoarding house 5.45 1.23 58 NsHostel 5.10

HealthBoarding house 5.50 1.10 58 NsHostel 4.89

Note: Higher score indicates greater satisfaction.

reported higher satisfaction (t = 2.21(58), p ≤ .02). This finding was con-sistent with the hypothesis.

Objective Scales

A difference emerged between residents of boarding houses and hostelson only one of the objective scales: victimisation. The mean scores andtest statistics for each scale by residence type can be found in Table 2.


TABLE 2

Mean QOL Objective Scores by Residence Type

Residence Type M t df p (1-tail)

Daily activitiesBoarding House 0.39 1.13 58 nsHostel 0.35

Family contactBoarding House 1.75 −0.58 58 nsHostel 1.88

Social contactBoarding House 1.56 0.66 58 nsHostel 1.46

Financial adequacyBoarding House 0.81 0.79 58 nsHostel 0.76

VictimisationBoarding House 0.23 −2.84 58 .005Hostel 0.77

Note: Higher score indicates greater frequency.

Victimisation. The data showed that victimisation was lower amongboarding house residents and higher among those who lived in hostels.(t = −2.84(58), p ≤ .005). Indeed, on this scale, which can take on a valuebetween zero and two to reflect whether the participant had ever beena victim of either of two classes of crime, boarding house residents wereclose to zero and hostel residents were closer to a score of one. Thehypothesis was confirmed.

Objective Indicators

Table 3 presents the results of tests for significant differences on objec-tive indicators. These are single-item indicators used to assess spending,employment and arrest. While boarding house residents had moremoney to spend, the two groups were otherwise undifferentiated onwork and arrest variables.


TABLE 3

Mean QOL Objective Indicators by Residence Type

Residence Type M t df p (1-tail)

Amount of money spent on selfBoarding House 185.67 1.75 57 .05Hostel 143.31

Employment levelBoarding House 0.07 1.44 58 nsHostel 0.00

Number of arrestBoarding House 0.07 −1.34 58 nsHostel 0.20

Note: Higher score indicates greater amount.

Amount of Money Spent on Self. Boarding house residents had moremoney to spend on themselves than did hostels residents (t = 1.75(58),p ≤ .05). On average, boarding house residents spent $186 per monthon themselves compared with $143 for those in hostels. The hypothesiswas confirmed.

DISCUSSION

Significant differences were found, with boarding house residents re-porting higher general life satisfaction and satisfaction with their livingsituation, having more money to spend on themselves per month afterrent had been paid, and less victimization. Overall, these results sup-ported the general hypothesis that people with schizophrenia living inboarding houses have a higher quality of life than people with schizo-phrenia living in hostels. This study has taken deinstitutionalizationfurther than just community living to examine different types of commu-nity living facilities—boarding houses and hostels.

An examination of the results of the total group (boarding house andhostel residents), however, offered an even greater insight into thisgroup of seriously mentally ill individuals in relation to quality of life.It was found that both groups reported general life satisfaction, satisfac-tion with their living situation, daily activities, family and social rela-


tions, finances, safety and health. The residents of both boarding housesand hostels generally appeared to be satisfied with their quality of life,despite objective measures showing that they had almost negligibleparticipation in daily activities, had few family contacts and social out-ings, and had limited finances. These results support the findings ofother studies that subjective indicators were better predictors of globalwell-being than objective indicators (Davidson et al., 1995; Lehman,1988b; Lehman et al., 1982).

Residents views, however, represent only one facet of the concept ofQOL. Obviously, objective living conditions are important and someindividuals need more restrictive care than others. This research doesnot negate the need to improve services in these areas or suggest thatother perspectives of care are not important. Rather it presents theresident’s perspective which has generally been ignored (Davidson etal., 1995).

The daily lives of the residents in the current study were consistentwith the findings of Davidson et al. (1995). They found that individualswith a mental illness living in the community described their lives asconsisting primarily of sleeping, drinking soft drink and coffee, andwatching television or listening to the radio. Although these deficitsalso closely resembled descriptions of their lives in hospital settings, asignificant majority of residents preferred to live in the community(Davidson et al., 1995). This is supported by the findings of other studies(Davidson, Hoge, Godleski, Rakfeldt & Griffith, 1996; Herman & Smith,1989; Solomon, 1992).

Overall the findings of this study suggest that irrespective of objectiveindicators, both groups of residents perceived that they had QOL. Eventhough in comparison to hostel residents, boarding house residents re-ported more satisfaction. One reason for this could be that boardinghouse residents had more money to spend on themselves, which couldbe viewed as ‘freedom.’ This issue should be addressed in future studies.

It appears, then, that irrespective of objective conditions, boardinghouses and hostels offer something to residents’ that research and publicopinion tend to overlook. This is the sense of freedom, the notion on whichdeinstitutionalization was initially based. As one resident expressed—

This place is my home, where I have my friends. The supervisors, they look afterme. You know, I’ve lived in hospital from when I was 15 . . . for the next 20 years.I’d rather live here than there! You’ve got a room and friends, but your not lockedin a cell. You’ve got your freedom.


As argued by Davidson et al. (1996) findings should allow policy tomove beyond the question of hospital or community setting. We mustnow ask residents what else can be done to improve their quality oflife.

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quality of life in boarding houses and hostels: a residents' perspective

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