To successfully navigate unprecedented epidemics of mental illness and substance use, we must address both an enduring workforce crisis and the myriad political and socioeconomic factors that undermine behavioral health, particularly for members of vulnerable populations. Many individuals with serious mental illness or substance use disorders are unable to access effective treatments for their conditions due to a marked shortage of qualified behavioral healthcare professionals and inadequate insurance coverage for the care they provide (not to mention insurers’ repeated failure to abide by parity provisions codified in state in federal law). Stakeholders in public health have rightfully advocated for investments in workforce development and the enforcement of existing parity provisions to eliminate the foregoing obstacles to treatment. These actions are laudable and necessary but insufficient to achieve lasting improvements in behavioral health. Social Determinants of Health (SDoH), the conditions in which people are born, live, learn, work, play, worship, and age, are fundamental constituents of health and wellbeing whose role in the recovery process has finally garnered the attention of public health officials and policymakers (U.S. Department of Health and Human Services, 2023). The value of stable housing and employment are particularly essential to optimal health, but they continue to elude many for whom they promise to deliver the greatest benefits.
Sigmund Freud described love and work as “cornerstones of our humanness” long before their virtues were espoused by the modern recovery movement (Koller, 2018). The proverbial father of psychoanalysis did not include the housing in his prescription for the good life, but it was likely implicit in his assessment of what is required for optimal health (or the full actualization of “humanness”). Although subsequent advances in our understanding of behavioral health have discredited elements of the psychoanalytic model and its epistemic foundation, its most vociferous opponents would acknowledge the importance of loving relationships, meaningful activity, and sanctuary from the elements of human health and wellbeing. Tragically, however, the prevalence of loneliness, unemployment, and housing instability among the most vulnerable segments of our population suggests we have failed to recognize what was obvious to Dr. Freud more than a century ago.
An extensive body of research has affirmed, employment aside, the value of safe, stable, and affordable housing in the recovery process for persons living with behavioral health disorders. A study of the efficacy of a “Housing First” approach for homeless individuals with schizophrenia and bipolar disorder revealed improvements in housing stability and reductions in the use of inpatient hospital services among participants assigned to the experimental group when compared to a control group whose members did not receive expedited access to housing and care coordination services characteristic of the Housing First model (Tinland et al., 2020). Other findings suggest the relationship between housing stability and behavioral health is bidirectional. That is, the presence of a serious mental illness or other behavioral health condition might compromise an individual’s capacity to secure or retain stable housing, whereas a loss of housing through eviction or other circumstances can undermine the mental and emotional health of one who has no preexisting or diagnosable condition (Department of Housing and Urban Development, 2022). Economic factors have produced an inextricable link between housing instability and serious mental illness in the United States, as many individuals with schizophrenia, bipolar disorder, and other severe forms of illness rely on Supplemental Security Income (SSI) to meet their living expenses and are unable to secure housing without a rental subsidy or other source of financial assistance. One analysis determined that the national average studio apartment rent exceeds a single individual’s standard SSI allowance (Fallon, 2023).
Initiatives that promote valuable employment opportunities for those with serious behavioral health conditions promise to ameliorate housing instability and yield other benefits both for recipients and for society overall. Some reports suggest only one quarter (27.9%) of individuals with serious mental illness are employed, but a significant majority express interest in competitive employment (Gühne et al., 2021). Chronic unemployment is associated with financial distress, although its adverse effects are not limited to the economic arena. Employment has been repeatedly proven to promote a sense of purpose, independence, and opportunities for affiliation that might otherwise be lost (Australasian Faculty of Occupational and Environmental Medicine, 2023). In short, employment potentially empowers those whose health status and socioeconomic disadvantages have deprived them of agency. Employment also mitigates the social isolation common among individuals with serious behavioral health conditions, many of whom have become more isolated during the Coronavirus pandemic. The Surgeon General of the United States recently proclaimed loneliness an epidemic with serious implications for public health whose adverse effects are not limited to the emotional or psychological domains. In a comprehensive report on this subject, he cited an association between loneliness and a greater risk of cardiovascular disease, dementia, stroke, depression, anxiety, and premature death (Office of the U.S. Surgeon General, 2023). Individuals with serious behavioral health disorders are predisposed to comorbid physical illnesses that undermine their health and life expectancy, and chronic loneliness has been proven to exacerbate underlying vulnerabilities for which employment may yield salutary benefits. The virtues of employment have been widely acknowledged as to merit their enshrinement in Article 23 of the United Nations Universal Declaration of Human Rights.
The determinants of our national behavioral health crisis are multifaceted, and lasting public health improvements require corresponding complexity and nuance interventions. Few recommend a “one size, fits all” approach to navigating dual epidemics. However, any pathway to success must acknowledge the value of housing and employment and include solutions to a housing affordability crisis and widespread unemployment among individuals with behavioral health conditions. In enacting such a pathway, we honor our social contract, advance the common good, and fulfill our collective commitment to the most vulnerable among us.