Residential Support for Individuals with Mental Illness: Its History and Hopes for the Future

The availability of housing for adults living with mental illness in Westchester County, New York, has seldom been scarcer than it is at this time, and for many it is altogether inaccessible. I understand many readers will be surprised by such a bold assertion and some may dismiss it as mere hyperbole. In fact, there are 11 social service agencies in this county (of which mine is one) that operate a broad continuum of supportive and subsidized residential units for individuals with mental health conditions. I imagine the staff of these agencies, their clientele, and the vast array of community stakeholders with which they have developed partnerships may take umbrage at my negation of their efforts. To be sure, residential services are often indispensible to individuals who lack the psychological or financial resources essential to the maintenance of long-term stability and self-sufficiency, and the beneficiaries of these services are undoubtedly fortunate to have accessed them during an era of veritable austerity. Nevertheless, countless residents of Westchester County with chronic mental health conditions languish in shelters or private and state-operated psychiatric facilities. Others reside with aging parents or in substandard homes for adults. Many are incarcerated, and some have sought temporary refuge from chronic homelessness in inexpensive rental units or room and board facilities that often operate illegally and lack basic amenities. To these individuals my assertion carries the resonance of a universal truth.

Such a tragic state of affairs is not the inevitable consequence of a global economic recession or a prohibitively expensive real estate market, although both of these factors figure prominently in this seemingly intractable problem. The origin of our housing crisis and its disproportionate impact on some of our most vulnerable citizens may be located in seemingly progressive public policy initiatives that failed to deliver on their promises.

The Kennedy Administration’s establishment of the Community Mental Health Centers Act of 1963 marked the inauguration of the “deinstitutionalization” movement through which longtime denizens of state-operated inpatient psychiatric facilities were subsequently discharged en masse to their communities of origin. Such an initiative would have been unthinkable if not for certain developments, not least of which was the arrival of psychotropic medications that offered partial relief to some of the most severely afflicted patients. This movement was laudable in its intention and ambitious in its scope, and it achieved notable successes in the years that followed its implementation. It acquired additional momentum through President Carter’s Commission on Mental Health and the subsequent enactment of the Mental Health Systems Act in 1980, initiatives that led to an infusion of federal funds into community-based mental health programs that sought to fulfill the needs of individuals with mental illness in more natural environments. These developments enabled thousands of individuals to emerge from the shadows of institutionalization and to secure housing and continuing treatment in less restrictive settings. Public attitudes towards individuals with mental illness evolved in concert with these changes, and concepts such as “rehabilitation” and “recovery” entered our lexicon as many who were formerly relegated to a lifetime of institutionalization realized newfound opportunities for full reintegration into the fabric of community life.

Despite its initial promise, however, the deinstitutionalization movement foundered during the decades that followed as changes in public policy deprived it of its initial momentum. Through the Regan-era repeal of the Mental Health Systems Act and related developments the federal government abdicated much of its responsibility for the direct financing of services. Responsibility for the financing and provision of care devolved from the federal government to its state and local counterparts during the final decades of the 20th Century. These developments might not have been altogether unfortunate insofar as state and local governments are customarily more equipped than federal bureaucracies to respond to the needs of their constituents. Nevertheless, a confluence of other developments and policy failures at various levels of government has added to the burden of individuals with mental illness who have sought essential housing and support services outside of institutional settings.

For instance, state expenditures on mental health services in 1997 were 30% lower than in 1955 when adjusted for population growth and inflation (Alakeson, Pande, & Ludwig, 2010). In addition, the application of a managed care model of service delivery for individuals with mental illness has led to stringent limitations on the quality and scope of services available to them (Mechanic, 2007). These developments have frayed the social safety net for some of our most vulnerable citizens, especially when considered in relation to the aforementioned policy changes at the federal level. Regulatory changes in the realm of housing policy have had similarly deleterious effects. For example, housing programs sponsored by the Department of Housing and Urban Development (HUD) are invaluable to many with mental illness, yet these programs have become increasingly scarce for these individuals in the wake of budgetary retrenchments and policy revisions. Since 1992, HUD has permitted many public housing authorities to alter the eligibility criteria for housing developments that were previously available to both elderly and disabled individuals. Under revised guidelines, many of these developments are now reserved for the sole occupancy of elderly individuals and are no longer available to younger applicants with mental illness and other disabilities (Newman & Goldman, 2009). Moreover, as even the most casual observers of housing policy are aware, the availability of the Section 8 Housing Choice Voucher Program has become increasingly scarce to all of its potential recipients, including those with mental illness. This program provides substantial rent subsidies that enable many to secure safe and affordable housing. Insofar as individuals with serious mental illness are frequently unemployed or underemployed, many rely on federal disability benefits that provide little more than a subsistence level of income. By some estimates, an average rent payment (for an individual who receives no subsidy and pays rent at the prevailing market rate) constitutes 96% of a monthly Supplemental Security Income benefit (Newman & Goldman, 2009). It is therefore unsurprising that homelessness among individuals with serious mental illness has increased significantly as dwindling public funding and adverse policy developments have effectively conspired to produce this result. Indeed, some authors have suggested the deinstitutionalization movement is more aptly characterized as one of “trans institutionalization,” as former patients of state-operated psychiatric treatment facilities now occupy homeless shelters and correctional facilities at alarming rates (Sheth, 2009). By some estimates, one third of homeless persons suffer from a severe mental illness, and more individuals with mental illness languish in jails and prisons than receive treatment in state-operated hospitals. Perhaps most frighteningly, during the final decade of the 20th Century 400 prisons were erected as 40 mental health facilities closed (Sheth, 2009). The legacy of deinstitutionalization is a sordid one, indeed.

Its failures notwithstanding, the deinstitutionalization movement has fostered the development of a continuum of residential care to meet the diverse needs of its recipients. This fact is most evident in Westchester County where a variety of organizations have emerged to address these needs in partnerships with stakeholders in both the public and private sectors. As indicated previously, 11 separate agencies administer a variety of programs that include supervised community residences, semi-supervised apartment programs, rent-subsidized apartments for single individuals and families, Single Room Occupancy (SRO) facilities, and innumerable other units that embody elements of various residential models. Some are available to any individuals who satisfy general criteria pertaining to their mental health status, whereas others are designed to serve specific subpopulations (e.g., homeless individuals, those with comorbid psychiatric and substance abuse conditions, etc.). Some researchers claim residential programs for individuals with serious mental illness have developed without an evidentiary basis of support, and they suggest additional research is needed to assess their efficacy in achieving desired outcomes (Rog, 2004). Nevertheless, it is unsurprising that these programs should proliferate in the absence of an evidentiary basis or a coherent public housing policy, as the rate of deinstitutionalization in recent decades has necessitated the rapid development of community-based alternatives. To the extent that research on residential programs has progressed its findings have been largely inconclusive (Rog, 2004). Some studies (Lipton, Siegel, Hannigan, Samuels, & Baker, 2000) have suggested that more intensively supervised programs (e.g., group homes or community residences) enhance the stability and community tenure of participants, whereas others have failed to demonstrate differential effects with varying levels of residential support (Newman & Goldman, 2009). Some have found that certain subpopulations, specifically individuals with comorbid psychiatric and substance abuse conditions and those who had recently been discharged from state-operated psychiatric facilities, were less likely to achieve demonstrable progress in stability and community tenure (Hurlburt, Hough, & Wood, 1996). Other studies determined that individuals who receive contemporaneous residential and case management services are more likely to achieve successful outcomes (Newman & Goldman, 2009). Nearly every study surveyed revealed some beneficial effects of affordable and supportive housing on residential outcomes, regardless of the nature and intensity of residential and case management services provided (Newman & Goldman, 2009; Rog, 2004). Perhaps not surprisingly, these studies suggested the availability of such housing is the most significant determinant of success for individuals with mental illness when success is defined as increased stability and community tenure.

In view of these (seemingly obvious) findings, it is incumbent upon policymakers to allocate additional resources to expand the stock of affordable housing. Any initiatives that alleviate our housing shortage would likely have corresponding effects on rates of homelessness, hospitalization, and incarceration among individuals with serious mental illness. Our social safety net, as it currently exists, is in grievous disrepair and has inflicted incalculable suffering on many of our most vulnerable citizens. It has also exacted an enormous financial toll, as the “trans institutionalization” of individuals with mental illness is hardly cost effective when compared to costs associated with the provision of affordable housing and residential support services. Significant policy initiatives currently under consideration include a radical redesign of the New York State Medicaid Program and the establishment of Regional Behavioral Health Organizations and Health Homes for individuals with serious mental illness and other chronic health conditions. All of these initiatives are targeted to enhance the quality of care delivered to these populations while reducing costs associated with institutionalization. These initiatives must include provisions for the expansion of safe and affordable housing with appropriate support services if they are to achieve their ultimate aims and restore the promise of a movement that began nearly 50 years ago.

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