The Need for Mental Health Affordable Housing
By Mark Olshaker
Improves communities and lowers government costs
Virtually any experienced social worker will acknowledge that housing is the critical nexus for all desired outcomes, including jobs, education, health, interpersonal relationships, child-raising and development, and basic happiness and wellbeing. Finding suitable affordable housing can be a difficult challenge under ordinary circumstances. For those with mental health issues, that challenge is intensified on several levels. Yet research over many years suggests that adequate and supportive housing options can have a profound positive effect on those suffering from various forms of mental illness, as well as saving significant amounts of money for government funding agencies and relieving already overburdened medical resources.
Dr. Jacqueline Mondros is dean of the Stony Brook University School of Social Welfare and a board member for National Aging in Place Council (NAIPC). “If you understand the social determinants of almost everything in our field,” she says, “you know there are two critical components: integrated healthcare, which includes behavioral health and social care, a term that originated in Europe but that is being gradually adopted here. It includes housing, transportation, job training, employment, education, antiviolence efforts and so forth. When you look at how states and countries spend their money, those that spend more on social care—in many parts of Europe it’s about two to one—the outcomes are significantly better.”
As early as 2005, the Harvard Mental Health Letter published statistics showing that when living in supportive homes tailored to their specific needs, mentally ill individuals spent 57 percent fewer days per year in psychiatric hospitals, made 58 percent fewer visits to hospital emergency rooms, and had 50 percent lower rates of imprisonment. These figures clearly point to lower expenditure on expensive resources, but they also point to better rates of recovery and ability to live independently or semi-independently in society.
At the same time, it can be difficult to achieve the necessary settings for this kind of progress. According to Healthyplace.com, one of the largest consumer mental health sites on the Internet: “It’s frustrating that supportive housing is difficult to find. Programs are competitive, often with long waiting lists. The housing system is difficult for anyone to navigate; add mental illness to the equation and finding housing can be daunting, overwhelming, and seemingly impossible.”
A Checkered History
The history of housing the mentally ill is not particularly inspiring. For many hundreds of years, they were remanded to dismal lunatic asylums that were little better than prisons, where they were warehoused and controlled through isolation, physical punishment and restraints that did little other than make them more compliant. The most famous asylum in London, Bedlam—a corruption of Hospital of St. Mary of Bethlehem—became synonymous with uproar, chaos, confusion and disorder. By the end of the 19th century, psychiatry was somewhat more sophisticated and the public attitude toward the mentally ill more enlightened and compassionate, but institutions still struggled with ways to house and control large populations who could not seem to be reintegrated into society. This was partially alleviated by the emergence of antipsychotic drugs in the 1930s. Institutionalization for those with marked mental conditions continued to be the norm in the United States until the 1960s and ‘70s, when a deinstitutionalization movement was spurred by stories of patient abuse, new and better psychotropic drugs, well-intentioned social workers and health professionals, and lawsuits arguing for the personal agency of those with mental illness.
Results of this movement were decidedly mixed. While institutional costs were lowered and individual sufferers were released into their communities, Andrew Sperling, legislative director for the National Alliance for the Mentally Ill (NAMI), told National Public Radio, “People with mental illness leave acute or chronic care facilities without adequate provisions for their housing or support, and end up sliding into homeless shelters or the criminal justice system.” Sadly, jails often become default housing for mentally ill persons who either wittingly or unwittingly commit minor crimes.
“We don’t have a healthcare system [directed at everyone]. We have a healthcare industry,” Mondros declares. “We don’t have a mental health system. We have a prison system, a homelessness system and a foster care system. We haven’t really deinstitutionalized; we’ve just changed the institutions.”
The Recovery Pathway
Despite its National Health Service (NHS), the United Kingdom has similar challenges to those here in the U.S. Britain’s Mental Health Network represents NHS providers from across statutory, independent and third-party sectors in working with government, regulators, opinion formers, media and the wider NHS to promote excellence in mental health services. The network, comprising 69 member organizations, put out a briefing in December that has among its findings: “Housing problems can exacerbate mental health conditions, while healthy living environments can significantly improve outcomes,” and, “Good quality housing and support has a vital role to play in the recovery pathway for people living with severe mental health issues.”
The body of the report dives down into some of the social determinants that professionals in both the mental health and housing fields are coming to accept: “People with mental health problems are four times more likely to face a detrimental impact on their health as a result of unsuitable or unstable housing.”
On the other hand, “A healthy living environment can promote better physical and mental health; reduce physical risks; offer hope, control and motivation to plan for the long term; contribute to a sense of community; and facilitate better access to a range of health and welfare services that improve long-term outcomes.”
The sense of community can be vital. Mondros states, “Social isolation is an important determinant. People who don’t have deep social connections are at a much greater risk. So, we want to help them as much as possible to build social networks, and that begins with housing.”
What Mondros is talking about is part of a vital and increasingly robust concept known as “Housing First.” Unlike previous approaches that required clients to be drug or alcohol-free and not overtly acting out before placement, Housing First essentially says, Let’s begin to normalize their behavior in a supportive housing environment, and then tackle everything else.
One of the pioneers of this approach is Tony Hannigan, who taught social work at Columbia University and founded Columbia University Community Services. “The way it got started,” he explains, “is we had a project focusing on single poor people. Unlike the elderly or families with children, they had no constituency. Many were living alone in fleabag hotels with serious mental illness and no access to services. It was a testimony to these people’s stamina that they could survive at all. So, our aim was to combine low-cost housing with supportive services.”
Hannigan relates to his mission on a personal level. He grew up in federally-subsidized housing in Queens, hoping to get training as an auto mechanic. He was able to attend Queens College under a community enrollment program that no longer exists, but which he wishes would be resurrected. He has devoted his professional life to giving back.
The Columbia program grew beyond its original bounds and scope, and in 1993 it became an independent nonprofit entity, retitled the Center for Urban and Community Services, now universally known as CUCS. It is headquartered in East Harlem and holds a contract from the city for all street outreach in Manhattan.
“We focus on the most visibly and vulnerably homeless, and that is often those with mental illness,” Hannigan says. “The underlying concept is that housing is a platform all of us need for stability. If you’re homeless, it’s much more difficult to provide services of any kind. By the very nature of being homeless, you can’t be stable.”
Current studies estimate that one-third of the homeless have some form of serious mental illness. For the chronically homeless, the figure may more than double.
As far as requiring people to be free of drugs, alcohol and questionable behavior before they’re admitted to any kind of subsidized or affordable housing, Hannigan doesn’t see the logic. “If you say someone is not ready for housing, you’re saying he should remain homeless or in a shelter. By definition, the solution to homelessness is to provide housing.”
The action that goes hand-in-hand with Housing First is “Critical Time Intervention,” or CTI. Dr. Daniel Herman, professor and associate dean for scholarship and research at the Silberman School of Social Work at Hunter College of the City University of New York, is internationally known for his efforts to evaluate and disseminate this approach to case management. The American Academy of Social Work & Social Welfare proclaims CTI, “one of the few effective approaches for the prevention of homelessness among high-risk populations.” Experts agree that mental health challenges are among the highest risks, if not the highest risk. Mondros calls Herman’s analyses the “gold standard.”
“We place emphasis on outcomes through intervention at critical times, such as discharge from an institution or a personal crisis,” he says, adding, “Mental illness and homelessness go in both directions. People might lose their homes because they develop a behavioral health problem, or not be able to obtain housing because they have one. Mental illness can develop from poor housing conditions, especially in the formative years. Studies in medical journals say that housing is healthcare, so if we can intervene through the provision of housing, in combination with a level of social service and supportive mental healthcare, we can positively affect the outcome. And it’s been demonstrated time and time again that if supportive housing and specialized services are offered, people will accept them.”
“Supportive housing” is another term that has specific meaning and implication in the social service field, and advocates believe that all but the most severe cases can succeed in these settings. First, the National Alliance on Mental Illness states that stable housing for their constituency should meet four key needs: affordability; the right level of independence; it should meet the individual’s physical needs; and be discrimination-free. HealthyPlace lists the types of appropriate housing, depending on the degree and severity of illness:
- Fully independent living, managing mental healthcare autonomously.
- Fully independent living with a partner and possibly children to care for, but still managing mental healthcare autonomously.
- Living with informal assistance, such as in the home of a family member.
- Living with formal assistance individually.
- Living with formal assistance in a group home with other people with mental illness and around-the-clock assistance from a professional in the broad field of mental healthcare.
- Living with formal assistance in a program that involves the use of single apartments that are part of a service.
Other experts, such as those from NAMI, further break the list down into supervised and partially supervised group housing, and supportive housing that provides little ongoing assistance or treatment, but with someone to call and resources available if a problem does arise.
“Whether it is services in the community or dedicated to that building,” Hannigan declares, “the endgame always has to be permanent housing.” He notes, though, that this goal often requires transitional housing—in New York there is a program called Safe Havens—and a full workup on the individual.
The British Mental Health Network report cites several successful examples of permanent housing for the mentally ill. Tile House, in the London Borough of Camden and Islington, has 15 one-bedroom flats, is staffed 24 hours a day, and was designed “to achieve recovery and independence for clients with complex needs which would usually preclude other forms of supported housing from offering the necessary support. These clients may otherwise reside in hospital or in more secure or specialist placements.”
In terms of outcomes, the report states, “The Tile House model is specifically designed to provide value to the NHS by reducing reliance on expensive out of borough care and forensic placements; reducing hospital admissions, both in terms of frequency of admission and length of stay; and improving health outcomes.”
Sean Duggan, chief executive of the Mental Health Network, says, “We know that housing solutions also benefit the health system, freeing up expensive inpatient beds, reducing readmissions and providing much-needed preventable support before tenants reach crisis.”
“Institutions are always more expensive than housing,” Herman notes.
A 2014 evaluation substantiated this assertion. Comparing residents from two years before moving in to the first two years of living at Tile House, hospital bed days were reduced seven-fold. Activities for Daily Living scores increased from 4.05 to 6.37. And costs to the NHS and social care budgets were significantly lower than comparable hospital or care placement, delivering an estimated per-placement yearly savings to the NHS of 21,298 pounds.
Similar results were reported at other facilities under study. Residents of Home View in Blackpool reported a 39 percent increase in feelings of wellbeing, and the cost was about 100 pounds per bed a night, versus 450 pounds for a hospital bed.
What It Takes
The good news is that these developments correspond to a revitalized general awareness in the field. “This goes back to the late 19th century and the awareness of the relationship between housing and public health outcomes,” says Herman. “The salience of that has been rediscovered as part of a renewed focus on understanding the link between safe, affordable housing and health outcomes generally, including mental health. If we’re interested in reducing costs to the system, whether we’re talking about hospitals, prisons, police, etc., we need to be focused on providing the environments that we know produce the best results.”
As with any other significant social issue, however, defining the problem and instituting wide-scale solutions are not the same. “Supportive housing remains in short supply,” Herman notes. “There’s no guarantee of housing for those in need. What we’ve seen so far does little to address the mismatch between the population we have to deal with and availability. We’re not doing very well on a national level to increase supply.”
“Part of what makes it challenging is you open a brand-new building for residents with mental illness and people freak out,” says Hannigan. “But we provide support services to 2,300 buildings and you don’t see anyone standing outside, doing nothing. We did interviews on every street in Manhattan and found that 70 percent of the chronically homeless had serious mental illnesses that interfered with their ability to get off the street. They were lacking executive skills to get themselves into some other situation.
“But once people get into houses and become low-income tenants, they become interested in having friends, meeting boyfriends or girlfriends, getting involved with social situations, finding jobs. We’d ask, ‘How many of you work?’ It would be about 20 percent. Then we’d ask, ‘How many of you would like to work?’ It would be about 80 percent. So, we say, ‘You say you want to work; we’ll help you and do what it takes.’”
“Someone who doesn’t have a place to live can’t shower or wear clean clothes, which means he can’t go for a job interview,” Mondros points out. “He can’t eat right. He can’t refrigerate medicines. He can’t have friends or be close to family. Tony Hannigan’s breakthrough was normalizing people’s lives and not treating them just as cases of mental illness. And the most effective intervention for mental illness is employment. Social workers already knew that. Now we have the data to prove it.”
“Look, most formerly homeless people don’t break out of poverty,” Hannigan concedes. “But with a support network, they can become happier and productive, reunite with family, have friends and not feel embarrassed by their situation anymore. In my grand vision, I’d like to see this addressed nationally. I want to bring down to zero the number of people living on the street. But in the current climate, that’s not going to happen.”
Mondros concludes, “We know what to do. And we now have the big data to prove it. All we lack is the political will.”