Blueprint for Change: Ending Chronic Homelessness for Persons
with Serious Mental Illnesses and Co-Occurring Substance Use Disorders

Preface

Helen was referred to the Thresholds (Chicago) Mobile Assessment Unit (MAU) by a local shelter. Shelter staff described her as "depressed, refusing to change her clothes, and flat." Helen had been staying at the shelter for four months and described herself as homeless for the last three years. Though guarded, Helen revealed that she had experienced audio hallucinations since age eight, had prior substance abuse treatment, had never received mental health treatment, and had a history of physical abuse as evidenced by a large scar on her face.

Helen didn’t want mental health services, but she did want her own place to live and a copy of her birth certificate. She accepted a bed in the Thresholds Safe Haven, a low-demand supportive residential program housed in the local YMCA. She got her birth certificate and continued to work with MAU staff on basic living skills such as shopping, hygiene, and food preparation. She also began seeing a psychiatrist at a mental health clinic located in the YMCA. Unfortunately, Helen stopped taking her medication and was hospitalized during a psychiatric crisis.

When she returned to the Safe Haven, Helen made some different choices. She stopped drinking alcohol, stayed on her medication, and began to attend housing and social meetings held at Safe Haven. Over the next year, she began receiving disability benefits and started working with a Thresholds Assertive Community Treatment (ACT) team. She joined outings to the Museum of Modern Art and attended a microwave cooking class.

The day came when Helen wanted to move to a large studio apartment in a Thresholds group home. She said she was ready to "cook her own meals again" and "get some space." Staff and other members celebrated with her at her graduation party. In the 15 months the MAU, Safe Haven, and ACT staff worked with Helen, they came to view the scar on her face as both a reflection of her many internal scars and as a testament to her endurance. On graduation day, all you could see was her smile.

More than a decade after the Federal Task Force on Homelessness and Severe Mental Illness called it "unacceptable" for people with serious mental illnesses to live in unsafe and threatening conditions, more than 630,000 individuals are homeless in this country on any given night (Burt et al., 2001). About half of all adults who are homeless have substance use disorders, and many have co-occurring mental illnesses, as well. Yet, the outlook is far from bleak. Federal demonstration programs and the experience of hundreds of community-based providers offer a rich reservoir of evidence-based and promising practices.

For example, recent studies reveal that the cost of providing permanent, supportive housing for people with serious mental illnesses is more than offset by savings incurred by the public hospital, prison, and shelter systems (Culhane et al., 2001). When nothing is done, people with serious mental illnesses and/or co-occurring substance use disorders who are homeless often cycle between the streets, jails, and high-cost care, including emergency rooms and psychiatric hospitals. This is inhumane, ineffective, and costly.

Further, research reveals that people with serious mental illnesses and/or co-occurring substance use disorders who are homeless, once believed to be unreachable and difficult-to-serve, can be engaged into services, can accept and benefit from mental health services and substance abuse treatment, and can remain in stable housing with appropriate supports (Lam and Rosenheck, 1999; Morse, 1999; Lipton et al., 2000; Rosenheck et al., 1998). Clearly, the time has come to end homelessness among people with serious mental illnesses and/or co-occurring substance use disorders. We know what works. Now we must put what we know to work.

The Substance Abuse and Mental Health Services Administration (SAMHSA) and its Center for Mental Health Services, in collaboration with SAMHSA’s Center for Substance Abuse Treatment (CSAT), have developed this Blueprint for Change to disseminate state-of-the-art information about ending homelessness for people who have serious mental illnesses, including those with co-occurring substance use disorders. This edition of the Blueprint does not fully consider the growing knowledge base that addresses homelessness among people with substance use disorders who do not have a serious mental illness. A future edition will cover this in greater depth. This document is more than a review of current and past research. It offers practical advice for how to plan, organize, and sustain a comprehensive, integrated system of care designed to end homelessness for people with serious mental illnesses and/or co-occurring substance use disorders.

This effort comes at a time of increased national attention to the needs of our most vulnerable citizens. SAMHSA has received increased funding to help end homelessness among people with mental illnesses and substance use disorders, and recently submitted a report to Congress on the prevention and treatment of co-occurring disorders. SAMHSA also is participating in an interagency effort among the Departments of Health and Human Services (HHS) (SAMHSA’s parent agency), Housing and Urban Development (HUD), and Veterans Affairs (VA). These Departments have joined in an historic collaboration to provide $35 million for the development of appropriate housing and supportive services for people who are chronically homeless, and together are sponsoring a series of policy academies for state and local policymakers to improve access to mainstream resources for this population.

It is important that efforts to end homelessness address the substance use treatment needs of the population, given that recent estimates that nearly half of persons who are homeless have substance use disorders (Culhane, 2001). The Administration has expressed its commitment to reduce drug use, build treatment capacity, and increase access to services that promote recovery from substance use. It has pledged $1.6 billion over the next 5 years to do so. SAMHSA is not alone in these efforts. Across the country, states and communities are unveiling their own comprehensive plans to end homelessness. These plans focus on increased affordable housing opportunities, improved housing and service coordination, and better partnerships with mainstream systems and providers. Efforts to end homelessness can be modeled and supported at the Federal and state levels, but the real work takes place in the communities where people live.

The human and financial toll of homelessness for people with serious mental illnesses and/or co-occurring substance use disorders is incalculable. Equipped with cost-effective solutions that work and the will to implement them, states, communities, and providers can begin the difficult but necessary work of systems change to the benefit of persons with serious mental illnesses and co-occurring substance use disorders. This Blueprint provides the knowledge and the strategies to do so.

More detailed information on the research and practices featured in this report can be found in the References; many citations include web sites that contain documents or additional information. In addition, the Resources section includes contact information for some additional Federal, state, and national resources on homelessness, mental illnesses, and co-occurring substance use disorders. While inclusion on the resources list does not imply endorsement by SAMHSA or HHS, readers are encouraged to contact these organizations for more information or for technical assistance on specific topics. Additional information on homelessness and mental illnesses and substance use disorders is available on the SAMHSA web site at www.samhsa.gov.

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