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Blueprint for Change: Ending Chronic
Homelessness for Persons with Serious
Mental Illnesses and Co-Occurring Substance Use Disorders
Chapter 1: Understand the Changing Context of Care and the Nation’s Response
Homelessness has become an enduring presence in American society. Despite
two decades of Federal support, statewide planning, and local initiatives,
an estimated 637,000 adults in the United States are homeless in a given
week, with 2.1 million adults experiencing homelessness over the course of a
year (Burt et al., 2001).
Most studies show that the majority of people who become homeless are
without a place to live for only a short period of time. They usually become
homeless as a result of an unexpected event such as an eviction, natural
disaster, or house fire, and tend to have more social and economic resources
to draw on than those who remain homeless for longer periods of time.
A much smaller group of homeless people either is episodically homeless
(i.e., have many episodes of homelessness but each for short periods of
time) or is chronically homeless (i.e., have few episodes of homelessness
but each for long periods of time). One study of shelter users in two large
cities found that 80 percent were temporarily homeless, 10 percent were
episodically homeless, and 10 percent were chronically homeless (Kuhn and
Culhane, 1998).
The estimated 200,000 people who experience chronic homelessness tend to
have disabling health and behavioral health problems. Recent estimates
suggest that at least 40 percent have substance use disorders, 25 percent
have some form of physical disability or disabling health condition, and 20
percent have serious mental illnesses (Culhane, 2001). Often individuals
have more than one of these conditions. These factors contribute not only to
a person’s risk for becoming homeless but also to the difficulty he or she
experiences in overcoming it. People who experience chronic homelessness
also tend to be slightly older than those who experience shorter homeless
episodes, are non-white, and male (Culhane and Kuhn, 1998). Families and
youth experience chronic homelessness, as well.
The Changing Context of Care
Serious Mental Illnesses
Gone are the days when people with serious mental illnesses spent most of
their lives in large, impersonal state institutions. The locus of care for
people with serious mental illnesses has shifted over the past 30 years from the
state hospital to the community. The number of patients in state psychiatric
hospitals dropped from 560,000 people in 1955 to 77,000 people in 1996 (Bachrach,
1996).
Much of the decrease in the state hospital census can be attributed to
deinstitutionalization, which sought, in part, to address well-publicized abuses
in state hospitals by shifting treatment to the least restrictive setting for
people with serious mental illnesses. Deinstitutionalization was abetted by the
introduction in the 1950s of antipsychotic medication and by the creation of the
Medicaid and Supplemental Security Income (SSI) programs in the 1960s that
provided financial incentives for community care.
However, the realities faced by people with serious mental illnesses in their
communities were in stark contrast to the promise of deinstitutionalization. The
Community Mental Health Centers (CMHC) Act of 1963 was designed to address the
needs of people with mental illnesses in their communities, but the vast array
of needed services and supports never materialized.
In particular, fewer CMHCs than anticipated were created, and those
established offered primarily clinic-based services that frequently were
inaccessible or inappropriate for individuals with the most serious disorders.
As a result, many individuals leaving institutions never connected with
community-based mental health services. Others cycled in and out of jails and
prisons. Without assistance, people with serious mental illnesses were among the
first to be displaced when urban neighborhoods and single-room-occupancy hotels
were gentrified in the 1980s.
By the late 1970s, the Community Support Program (CSP), now administered by
SAMHSA’s Center for Mental Health Services (CMHS), was adopted as the framework
for developing a comprehensive range of services that would allow people with
serious mental illnesses to live successfully outside of institutions. Some of
the elements of the CSP approach included: outreach, income and medical
assistance benefits, 24-hour crisis assistance, psychosocial rehabilitation,
employment services, long-term supportive services, medical and mental health
treatment, family support, residential services, case management, rights
protection, and advocacy. Today, these elements remain as the cornerstone of
comprehensive, community-based systems of care for people with serious mental
illnesses.
Some communities have programs specifically designed to serve people with
serious mental illnesses who are homeless. These programs include emergency
shelters, outreach programs, drop-in centers, transitional housing, and health
care. Outreach programs have been effective in reaching people with serious
mental illnesses who are homeless, especially those who are unable or unwilling
to accept help from more traditional office-based providers. In many cases,
these efforts are literally saving people’s lives.
While, certainly, success stories exist, the numbers of people in need far
exceed the capacity of programs that provide the intensive outreach and case
management services required. Many people with serious mental illnesses receive
fragmented and uncoordinated treatment, housing, and support services, if they
receive them at all. They may cycle in and out of hospitals, jails, shelters,
and life on the streets at enormous cost to both themselves and their
communities.
Substance Use Disorders
In the not so distant past, "public inebriates" typically were sent to the
drunk tanks of local jails to dry out. In 1956, the American Medical Association
declared alcoholism a disease, lending support for medical treatment instead of
incarceration. The 1971 Uniform Alcoholism and Intoxication Treatment Act, also
known as the Hughes Act, officially decriminalized public drunkenness and
mandated a medical treatment approach.
Instead of being jailed, homeless people who were alcoholics were sent to
publicly funded detoxification programs where they could receive some form of
treatment (Stark, 1987). However, studies of detoxification programs for
indigent people reveal that few individuals leave with referrals for treatment,
and the majority of those who are given referrals do not use them. These results
led the researchers to conclude that the [Hughes] Act had replaced the revolving
jail door with a "padded revolving door" (Sadd and Young, 1987).
Though medical treatment is still a mainstay for individuals with substance
use disorders, this approach has its drawbacks for people who are homeless.
Treatment is expensive, residential stays are short (often, no more than 28
days), and, without adequate discharge planning, individuals frequently return
to the streets (McMurray-Avila, 2001). People with substance use disorders in
day treatment programs may have no place to sleep at night. The combination of
poverty and addiction are significant barriers to adequate housing, an issue
that will be explored further in Chapter 2.
In the 1970s, the social model emerged in California as an alternative
treatment approach for alcoholism and other substance use disorders. Social
model programs are peer-oriented rather than professionally led and focus on the
need for behavior change through experiential learning and shared responsibility
(McMurray-Avila, 2001).
One study that assessed the effectiveness of social-setting detoxification
for homeless individuals with severe alcohol dependence found that this approach
was as safe and effective as hospital detoxification (Haigh and Hibbert, 1990;
Zerger, 2002). Because social model programs are less costly than medical
treatment, they primarily serve indigent individuals. However, they struggle to
secure funding from public agencies, and their services are rarely deemed
reimbursable by third-party insurers (Zerger, 2002).
Many individuals who are homeless have both substance use disorders and
serious mental illnesses. A growing body of research supports the concept of
integrated treatment for these individuals; that is, treatment for both
disorders provided concurrently by the same clinician or team of clinicians in a
single setting (Drake et al., 1998). Such treatment is particularly beneficial
in helping individuals recover from substance use (Oakley and Dennis, 1996).
However, few such programs exist. The significant unmet need for both mental
health and substance abuse treatment means that those with the fewest resources
are least likely to receive appropriate care.
The Federal Response
Ending chronic homelessness among people with serious mental illnesses and/or
co-occurring substance use disorders is an achievable goal. The Stewart B.
McKinney Homeless Assistance Act of 1987 (P.L. 100-77)—known today as the
McKinney-Vento Act—was the first and, to date, the only comprehensive Federal
legislation to address homelessness. The Act included a number of provisions
designed specifically to provide health and mental health care to people with
serious mental illnesses and substance use disorders who are homeless.
Amendments to the McKinney Act—made in 1988, 1990, 1992, and 1994—for the
most part, have strengthened the provisions and expanded the scope of the
original legislation (National Coalition for the Homeless, 1999). Since
enactment of the McKinney Act, the Substance Abuse and Mental Health Services
Administration (SAMHSA) of the U.S. Department of Health and Human Services, and
the U.S. Department of Housing and Urban Development, have funded innovative
housing and service programs, and research and demonstration projects to
determine how best to serve people with serious mental illnesses and substance
use disorders who are homeless. These programs served as a catalyst for further
development of the evidence-based practices presented in this report.
A Framework for Services
The McKinney Act also established the Interagency Council on the Homeless
(now the Interagency Council on Homelessness) to provide Federal leadership for
activities to help homeless individuals and families. Comprised of the heads of
major Federal departments that manage programs for people who are homeless, the
Council convened the Federal Task Force on Homelessness and Severe Mental
Illness in the early 1990s. When the Task Force released its 1992 report,
Outcasts on Main Street, it provided a national strategy and a comprehensive
framework for addressing homelessness among people with serious mental
illnesses, many of whom have substance use disorders.
In particular, the Task Force recommended that Federal agencies help states
and local communities develop integrated systems of treatment, housing, and
support services for people with serious mental illnesses who are homeless.
The framework for services outlined in Outcasts on Main Street—which
included such key elements as outreach, case management, and a range of housing
options—has withstood the test of time and rigorous evaluation, not only for
people with serious mental illnesses but also for those with substance use
disorders and co-occurring mental illnesses and substance use disorders, as
well.
Federal demonstration programs, particularly those of SAMHSA’s Center for
Mental Health Services and Center for Substance Abuse Treatment (CSAT), and the
experience of hundreds of community-based providers, have demonstrated that
residential stability is a goal desired by, and attainable for, most people with
serious mental illnesses and substance use disorders who become homeless. Key
Federal efforts designed to prevent and end homelessness for people with serious
mental illnesses and substance use disorders are highlighted below.
McKinney Research Demonstration Programs
Homeless Adults with Serious Mental Illnesses. Begun in 1990, this
program was designed to test hypotheses from earlier research studies by
developing effective service models for people with serious mental illnesses who
are homeless. The five resulting projects were among the first longitudinal,
experimental-design studies of housing and service interventions for this
population. Each site was required to provide or arrange for outreach, intensive
case management, mental health treatment, staff training, and service
coordination. Results indicated that even people with the most serious mental
illnesses who are homeless, once thought to be unreachable and
difficult-to-serve, can be reached by the service system, can accept and benefit
from mental health services, and, with appropriate supports, can remain in
community-based housing (CMHS, 1994).
Homeless Adults with Substance Use Disorders. Between 1988 and 1993, the
National Institute on Alcohol Abuse and Alcoholism (NIAAA), in consultation with
the National Institute on Drug Abuse (NIDA), funded two rounds of demonstration
projects. In all, 23 projects were funded to provide and evaluate
community-based alcohol and drug abuse treatment and rehabilitative services for
individuals with substance use disorders who were homeless or at imminent risk
of becoming homeless. Results indicated that individuals with substance use
disorders who are homeless need (1) services that address their tangible needs
for housing, income, and employment; (2) access to flexible, low-demand
interventions; and( 3) long-term continuous treatment and support.
Researchers found that short-term treatment was ineffective with this group
(McMurray-Avila, 2001).
SAMHSA/CMHS Homeless Programs
Access to Community Care and Effective Services and Supports (ACCESS).
The ACCESS program was designed specifically to test the hypothesis that
integrated service systems will improve individual functioning, quality of life,
and housing outcomes for people with serious mental illnesses who are homeless.
Begun in 1993, the 5-year demonstration program featured 18 communities in 9
states that were provided funds to enhance services, particularly outreach and
case management, for the target population. One community in each state was
designated the experimental site and was given additional funding to support
systems integration activities.
Results revealed that systems integration has a positive impact on housing
outcomes for people with serious mental illnesses who are homeless. In
addition to improved residential stability, individuals who received case
management, treatment, and support services showed a marked decrease in mental
symptoms, drug use, and minor criminal activity, and an increase in number of
days worked (Rosenheck et al., 1998; CMHS, 2001a).
Supported Housing Initiative. Begun in 1997, the Supported Housing
Initiative was a two-phase, multisite study designed to examine and compare the
effectiveness of various housing approaches for people with serious mental
illnesses, many of whom were or had been homeless. Researchers compared a
supported housing approach to other housing models on a number of outcome
measures, including residential stability, housing satisfaction, quality of
life, and empowerment. Findings from this study will identify key ingredients of
the housing models, their effectiveness, and their relative costs to help inform
policy and service program design (CMHS, 2001b).
Projects for Assistance in Transition from Homelessness (PATH). CMHS
provides ongoing leadership for people with serious mental illnesses who are
homeless through its administration of the PATH formula grant program. PATH was
created under the McKinney Act to provide funds to each state, the District of
Columbia, Puerto Rico, and four U.S. territories to support service delivery to
individuals with serious mental illnesses, including those with co-occurring
substance use disorders, who are homeless or at risk of becoming homeless.
Through outreach, case management, screening and assessment, staff training,
alcohol and drug treatment for people with co-occurring disorders, and support
services in housing, PATH-funded providers nationwide have set a standard for
the delivery of services to people with serious mental illnesses who are
homeless. In 2001, with an allocation of nearly $36 million, 399 local
PATH-funded organizations served more than 64,000 people with serious mental
illnesses.
SAMHSA/CSAT Homeless Programs
In 2001, CSAT received $10 million to administer the Homeless Addiction
Services Initiative that supported grants to local nonprofit and public entities
for the purpose of developing and expanding substance abuse services for people
who are homeless. In 2002, CSAT, in coordination with CMHS developed and
expanded community–based mental health and substance abuse treatment services
for people who are homeless through the Grants for the Benefit of Homeless
Individuals (GBHI). To date, CSAT and CMHS have jointly funded approximately 19
million in grants under GBHI. These funds support local public and nonprofit
agencies for up to three years to provide either substance abuse services,
mental health services, or both, allowing communities the flexibility to provide
the services they believe to be most urgent. Both CSAT programs will enable
communities to expand their capacity to provide treatment to people with mental
illnesses and substance use disorders who are homeless, and to learn more about
effective interventions.
SAMHSA Collaborative Demonstration Programs
Co-occurring Disorders. SAMHSA’s CMHS and CSAT
initiated a study in 1993 to test the effectiveness of different approaches to
treating people with co-occurring mental illnesses and substance use disorders
who are homeless. Cross-site findings indicated that an integrated approach
is superior to a parallel or a sequential approach to treatment for co-occurring
mental health and substance use disorders. Integrated treatment for
co-occurring disorders reduced alcohol and drug use, homelessness, and the
severity of mental health symptoms (CMHS and CSAT, 2000a).
Preventing Homelessness. In 1996, CMHS and CSAT launched a two-phase,
3-year initiative to document and evaluate the effectiveness of homelessness
prevention interventions. These interventions focused on people with serious
mental illnesses and substance use disorders who were formerly homeless or
at-risk for homelessness, and who were engaged with the mental health and/or
substance abuse treatment system(s). Prevention activities included supportive
housing, residential treatment, family support and respite, and representative
payees and money management. Results revealed that participants in the
intervention programs showed improved treatment outcomes and residential
stability. Programs that could offer direct access to housing, as opposed to
linkage and referral, had the strongest housing stability and retention outcomes
(DeLeon et al., 2000; Bebout et al., 2001; Tsemberis and Eisenberg, 2000;
Coughey, 2000; Policy Research Associates, 2001.)
Interventions for Homeless Families. Begun in 1999, CMHS and CSAT jointly
fund and administer the Homeless Families Program. The 5-year program is
designed to document and evaluate the effectiveness of time-limited, intensive
interventions for providing treatment, trauma recovery, housing, support, and
family preservation services to homeless mothers with mental illnesses and/or
substance use disorders caring for their dependent children. A 3-year outcome
evaluation phase, which includes both cross-site and site-specific studies of
the interventions, began in 2001. Findings from the program will identify
effective approaches for moving families from homelessness to housing, and for
providing treatment and supports to help maintain residential stability and
recovery (CMHS and CSAT, 2000b).
Understanding the Population
Research and practice reveal that communities can reach out to people with
serious mental illnesses and substance use disorders; engage them in treatment;
and create local partnerships to increase availability and access to affordable
housing, employment, and treatment and supports to help prevent and end
homelessness. Understanding how to do so, however, begins with knowledge about
why people with serious mental illnesses and substance use disorders are
vulnerable to becoming homeless and why they have a difficult time exiting
homelessness. The next chapter examines individual vulnerabilities and systemic
barriers in more detail.
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