Control over Where and How One Lives: Barriers and Facilitators of Subjective Housing Stability Among Individuals with Co-Occurring Disorders

Background and Purpose: Individuals with co-occurring serious mental illness and substance use disorders (CODs) face disproportionate housing instability, yet the mechanisms driving this disparity remain poorly understood. Prior research has largely focused on objective dimensions of housing stability such as housing tenure and homelessness episodes, but less is known about what facilitates and hinders subjective housing stability, encompassing both the physical conditions of housing and the lived experience of autonomy, safety, and connectedness. This study examined barriers and facilitators of subjective housing stability among individuals with CODs receiving Assertive Community Treatment (ACT) services.

Methods: The author conducted semi-structured interviews with 24 ACT clients with CODs and three focus groups with 22 ACT staff members across three agencies serving urban, suburban, and rural communities in a large Northeastern metropolitan area, following a modified grounded theory approach. Analysis progressed through open, focused, axial, and theoretical coding following Charmaz's constructivist grounded theory approach, with constant comparison and theoretical sampling guiding the development of higher-order themes. The author ensured rigor through triangulation across data sources and analysts, maintenance of an audit trail, and ongoing reflexivity throughout data collection and analysis.

Results: Control over housing stability emerged as the central organizing concept from analysis. Three themes were identified. First, constrained choice: structural forces including housing market discrimination, substance use stigma, and concentrated poverty eliminated meaningful housing options, stripping clients of agency before tenancy began. Second, coercion and compliance: once housed, institutional practices including punitive substance use policies, linear graduation pressures, and surveillance-oriented service relationships required clients to surrender autonomy as the price of remaining housed. Third, and most consequentially, the paradox of agency: stripped of control over both access to and experience of housing, clients performed compliance with system demands as their primary strategy for maintaining stability rather than exercising genuine self-determination.

Conclusions and Implications: Housing stability for individuals with co-occurring disorders is shaped by control over where one lives and over how one lives there. Expanding equitable access requires dismantling discrimination and stigma embedded in housing eligibility and placement practices. Housing and behavioral health providers should examine where compliance demands serve therapeutic goals versus where they function as mechanisms of control, and restructure practices accordingly. Interventions that secure access without supporting autonomy risk producing housing retention without recovery.