People can live in their own home, even if they are mentally unwell and need support. But studying residential coaching is challenging. | Photo: Getty Images

People with severe depression or personality disorders usually prefer to live within their own four walls, not in any supervised setting. But it remains relatively rare for people to get the professional coaching they need to be able to live independently. Dirk Richter works with the University Psychiatric Services Bern (UPD), and Matthias Jäger is the director of the Clinic for Adult Psychiatry at Psychiatrie Baselland, and together they’ve been investigating why this model has yet to enter into wider use.

Ethics force the abandonment of a study

Psychiatric rehabilitation usually works according to the so-called ‘stepladder principle’. Those who are affected are first expected to go through various supervised settings before being offered the prospect of their own apartment. But staying in residential homes and in residential groups is linked to strict conditions, ranging from sobriety to compulsory adherence to an official schedule. People are expected to learn to cope with the demands of autonomous everyday life, one step at a time. “At least that’s the idea”, says Richter. “The problem is, it doesn’t usually work”.

Independent living, with the help of professional coaching, is the complete antithesis of the above approach. Those affected are first helped to find an apartment – or to keep the one they already have – and are then given individual support, whether at meetings with their landlord or with household management. But there are still very few studies on the effect of these different forms of living. Anyone wanting to compare them faces methodological challenges. Randomised controlled trials (RCTs) are considered the gold standard, but allocating professional coaching to help someone with their living situation, or assigning someone to a control group, are not things you can determine on a random basis. Very few test subjects are willing to give up the freedom of choice over where they are going to live. Observational studies have the advantage of being conducted within a setting that is more in line with the wishes of the person who is affected. But this type of study only offers up limited evidence.

The team of Jäger and Richter actually wanted to conduct the first-ever RCT on ‘non-homeless’ people who are being given professional coaching to help with independent living; then they wanted to compare their results with those of an observational study. “But we had to break off the trial prematurely”, says Jäger. “Most of the participants only took part in the study because it put them on the waiting list for residential coaching. If a place on that programme happened to come free, it could have meant withholding it artificially for purposes of the study, which wouldn’t have been ethically justifiable”.

An observational study is undoubtedly an alternative for the research team, as long as it fulfils the statistically high requirements. After all, “it would make little sense if we offered residential coaching only after getting the highest level of empirical proof”, says Jäger. Especially since this model has so far performed no worse than others and is likely to be significantly more cost-effective. “If the preferences of those affected are also very clear, then that should actually be argument enough in its favour”.

Data alone are not enough

Marius Knorr is a senior physician at the University Hospital of Psychiatry Zurich (PUK), and he is convinced that even the best data are of little use if the authorities responsible aren’t willing to provide residential coaching. Funding bodies, such as the cantonal departments of health, often don’t know where to situate this particular model because it’s not obviously a medical service. “It’s difficult to provide empirical proof that an improvement in someone’s health can also be linked to their living situation”.

Charles Bonsack is the head of the Community Psychiatry Service at Lausanne University Hospital, and he believes that there are both cultural and financial reasons for the hesitance in establishing residential coaching. He has noted that a shift to outpatient care is more pronounced in French-speaking Switzerland than in the German-speaking part of the country.

And he is convinced that research findings in social psychiatry are also often overshadowed by the promises of neuroscience. “In recent years, however, it’s primarily been evidence-based interventions by social psychiatry that have revolutionised the everyday lives of people with severe mental illness”, he says. “Most of the medication available has been known to us since the 1950s”.