Housing for the Mentally Ill:

Housing for the Mentally Ill: Psychological Effect and Sociological Factors That Determine How Mentally Ill People Are Incorporated Into Society

A primarily problem for many individuals who are mentally ill is coping with every day problems that are not directly related to their mental illness and one of these is the securing and maintenance of a residence. Facilities that are local to Tennessee residents attempt to secure patients with housing however obstacles including budget cuts, the rising costs of living and opposition from insurance companies are ever present.

This work intends to examine this phenomenon, expose redundancies and waste, and propose some ideas for solutions. This issue was specifically chosen since it involves both the areas of Psychology and Sociology as the writer of this work is giving consideration to entering this field of research therefore this study will result in a gain in the writers' insight regarding the day-to-day reality of social work and the needs of mentally ill patients who require assistance.

Many aspects of providing Psychological treatment are realized through social involvement. Mental health providers help relieve some pressure by integrating patients into group homes, teaching them to interact accordingly, and building essential skill sets to meet the norms of our society. Social environments have a great impact on Psychological well-being.

Although less than five percent of the total population suffers from severe mental illness, twenty to forty percent of the homeless population is known to have a severe mental illness. (California Psychology Association, 2010) In addition, mentally ill individuals who are homeless are many times arrested for some type of nuisance crime "…yet those who receive comprehensive community mental health treatment stay in such treatment, remain safely housed, and have an incarceration or homeless rate of less than 2%." (California Psychology Association, 2010 )

It is reported by Steinberg (1999) that AB34 in the state of California funds community mental health programs that provide voluntary outreach, access to medicines and a variety of support services for the homeless who suffer from mental illness. An initial investment of $10 million produced millions in savings by reducing hospitalization and incarceration. Because of AB 34's success, the program was expanded in 2000 to 34 cities and counties, helping 4,720 homeless mentally ill individuals. As a result, state and local governments are seeing a $23 million savings through an 81% reduction in jail days, a 66% reduction in hospital days and an 80% reduction in homelessness." (California Psychology Association, 2010)

In a recent National Coalition of the Homeless Fact Sheet, specifically 3% published in June 2008, it is reported that findings in a survey conducted by the U.S. Conference of Mayors show that 7,.9% of the homeless population are individuals that a total of 29.9%. It is additionally stated that despite the large population of homeless individuals, "the growth in homeless individuals is not related to the release of seriously mentally ill people from institutions…" although the "mass deinstitutionalization form mental health facilities occurred over forty yeas ago, yet the promise of community-based programs and outpatient services has not been kept especially toward the homeless and others living in poverty." (NCH Fact Sheet, 2008, paraphrased) It is held that the new wave of deinstitutionalization due to managed care driven rate of unplanned discharge might very well be contributing to the population of individuals who are homeless at the present. (NCH Fact Sheet, 2008, paraphrased)

Mental disorders are such that prevention individuals from the carrying out of "essential aspects of daily life, such as self-care, household management and interpersonal relationships." (NCH Fact Sheet, 2008) Those who are mentally ill and homeless are likely to be homeless for long periods of time and to have less familial contact as well as less contact with friends. Disorders such as schizophrenia are stated to "often misinterpret the guidance of others and react irrationally because of their condition. The mentally ill homeless population is further stated to encounter "more barriers to employment tend to be in poorer physical health, and have more contact with the legal system than homeless people who do not suffer from mental disorder. (NCH Fact Sheet, 2008, paraphrased)

The work of Breakey, et al. (1989) focused on homeless people in Baltimore, Maryland and specifically on their health characteristics. The first stage of the study involved "…298 men and 230 women were randomly selected from the missions, shelters, and jail in Baltimore to respond to a baseline interview that provided extensive sociodemographic and health-related data." The second stage involved a subsample of 203 subjects which were randomly chosen from the baseline survey respondents to have "systematic psychiatric and physical examinations.. Data are presented from both stages. Data from the first stage demonstrate, among other things, the high levels of disaffiliation of this population and their heavy involvement in substance abuse. Data from the clinical examinations demonstrate the high prevalence of mental illnesses and other psychiatric disorders and of a wide range of physical disorders and confirm the high prevalence of alcohol abuse disorders. The high rates of comorbidity of these conditions are demonstrated and data are provided on the subjects' needs for mental health and substance abuse services." (Breakey, et al., 1989)

McNiel, Binder and Robinson (2005) report a study that assessed the relationships between homelessness mental disorder and incarceration." Using archival databases that included all 12,934 individuals who entered the San Francisco County Jail system during the first six months of 2000, the authors assessed clinical and behavioral characteristics associated with homelessness and incarceration." The study results report that sixteen percent of the incarcerations were of inmates who were homeless and in eighteen percent of cases the inmates were stated to have been diagnosed with a mental disorder and thirty percent of the inmates who were homeless had a diagnosis of mental disorder during one or more episodes." (McNiel, Binder and Robinson. 2005) The study concludes by stating that individuals who were homeless "and who were identified as having mental disorders, although representing only a small proportion of the total population, accounted for a substantial proportion of persons who were incarcerated in the criminal justice system in this study's urban setting. The increased duration of incarceration associated with homelessness and co-occurring severe mental disorders and substance-related disorders suggests that jails are de facto assuming responsibility for a population whose needs span multiple service delivery systems." (McNiel, Binder and Robinson, 2005)

The work of Combaluzier, Gouvernet, and Bernoussi (2009) reports a study that states findings that the association of homelessness multiples the risk for development of personality disorders and it was also found that many homeless personality-disordered individuals were also affected by drug abuse.

The work of Gilmer, et al. (2010) entitled: "Effect of full-service partnerships on homelessness, use and costs of mental health services, and quality of life among adults with serious mental illness" Reports that adults who are chronically homeless with severe mental illness are heavy users of costly inpatient and emergency psychiatric services."

II. STATEMENT OF PROBLEM

Individuals with mental illness often have a great problem in gaining access to housing and require assistance in obtaining and maintaining a place of residence.

III. PURPOSE OF THE STUDY

The purpose of the study herein is to examine the issue of mental illness as it relates to homelessness among those with psychological disorders and the challenges they face in obtaining housing.

IV. SIGNIFICANCE OF THE STUDY

The significance of this study is the knowledge that it will add to the already existing base of knowledge in this area of research and study.

V. LITERATURE REVIEW

The work of Finnerty (2008) states that homelessness is a problem that affects most societies today. It does not discriminate by geographical location; it can occur in any city of town, in any country in the world. Homelessness is defined as being without a place to live, and therefore living on the streets; living in unstable conditions, such as a shelter, or substandard conditions such as boarding houses." (Finnerty, 2008) Various problems impact homeless individuals and there is a great deal of uncertainty about how individuals without housing should be handled. Exacerbating this problem is that many homeless individuals are affected by mental illness and in fact a report of the National Coalition for the Homeless (2006) states that approximately 20 to 25% of homeless adults are known to suffer from some type of severe mental illness. This results in these individuals comprising the majority of the population of homeless and very vulnerable individuals.

Mental disorders affect the individual in a manner that prevents them from taking care of essential aspects of everyday life. Individuals who have mental disorders "are homeless for a longer period of time and have more problems involving employment, physical health and the legal system compared to homeless people who do not have a mental illness." (Finnerty, 2008) The study of mental illness in those who are homeless is important "because the outcome could affect how to treat this population and what kind of support or aid they should be given." (Finnerty, 2008)

Finnerty (2008) states that approximately 50% of those who are mentally ill and homeless also have "co-occurring substance abuse disorder." (Finnerty, 2008) It is reported that those who suffer from co-occurring mental illness and substance abuse problems are also likely to be homeless. According to the Health Care for the Homeless Clinicians' Network (2000) "Co-occurring mental illness and substance abuse makes it more likely that people will be chronically homeless." (cited in Finnerty, 2008) Factors that are known to contribute to homelessness in those with co-occurring mental illness and substance abuse include factors such as: (1) Financial problems; (2) Loss of family support; (3) Severity of symptoms; and (4) Time spent in institutions such as jails or hospitals. (Brunette, Mueser and Drake, 2004 in: Finnerty, 2008) Padgett and Struening (1991) state that substance abuse and mental disorders "…increase the health care needs of homeless persons, whose primary source of care is often the emergency room.

The work of Padgett et al. (2006) reports having interviewed a group of women who had been previously homeless. The interviews examine the women in terms of their history of mental illness, substance abuse and traumatic events. It was found that nine of the thirteen women in the study "reported traumatic events, including rape and childhood sexual abuse, violence, or betrayal of trust. A history of substance abuse was reported in nine of the thirteen women. Hawkins and Abrams (2007) conducted a study on mental illness and homeless persons and specifically 39 individuals with mental illness in New York City. These individuals had abused drugs or alcohol and who were homeless. The study found that the majority of these individuals "had few friends or relationships with others." (Finnerty, 2008)

Rosenthal (2007) examined co-occurring disorders among young, recently homeless persons in Melbourne, Australia, and Los, Angeles, United States. The study was inclusive of 162 individuals in Melbourne and 259 individuals in Los Angeles. The individuals in this study were questioned concerning mental health and problems with alcohol and drugs both at the start of the study and six months and one year later. The results of the study state that there was a low rate of co-occurring mental illness and substance abuse among young homeless and "at all three points in time, the majority of the individuals had neither a mental illness, nor problems with drugs or alcohol. One problem with this study is that it only questioned individuals between ages 12-20 years old. Most serious mental illness does not develop until after the age of 20." (Finnerty, 2008)

A report published by the Health Care for the Homeless Clinicians' Network (2000) conducts an examination of "mental illness, substance abuse, and possible treatment policies. Treatment is necessary for those with a mental illness and the longer one goes without treatment, the worse their illness gets and they become more difficult to treat. Treatment is necessary for this group of homeless persons, but is extremely difficult without stable housing." (Finnerty, 2008)

According to HCH Clinicians (2000) "Patients with severe mental illnesses who are housed have fewer complications, and are much less likely to have co-occurring disorders that exacerbate their illness"(p. 2). Homeless people have multiple needs and need individual care and long-term service if they hope to get better." (Health Care for the Homeless Clinicians' Network 2000 cited in Finnerty, 2008)

The work of Liebow (1993) states that life is more difficult for the population of women who are also affected by mental illness and substance abuse as these individuals are those with the greatest need for shelter and health care, however, this group rarely receives shelter or health care service. In fact, Liebow states that the stress of being homeless only serves to exacerbate the problems of mental illness and substance abuse. Finnerty states that studies have found that "mental illness makes homelessness even worse and increases the likeliness that one will remain homeless. Other studies have found that treatment is necessary to overcome homelessness." (cited in Finnerty, 2008)

It is reported that The Criminal Justice Task Force Report on Mental Health and Criminal Justice in Tennessee made recommended through the Office of Housing and Homeless Services that TDMHDD "work toward increasing appropriate housing options for persons with serious mental illness who are engaged with the criminal justice system." (Tennessee Department of Mental Health and Developmental Disabilities, 2010) Findings of the THDA SJR 279 Housing Report (2000) states the following conclusions: (1) Approximately 15% of persons with severe and persistent mental illness receiving case management are housed inappropriately. One can assume that this percentage might be considerably higher among other segments not receiving services at all, such as homeless persons' (2) In all areas of the state and among every subgroup of the population surveyed, the primary barrier to appropriate housing was insufficient income to pay for monthly expenses; (3) The type of housing most appropriate for the majority of the consumers surveyed is independent living units; (4) A large proportion of persons awaiting release from regional mental health institutes cannot be discharged because there are not enough spaces available in appropriate licensed facilities. (Tennessee Department of Mental Health and Developmental Disabilities, 2010)

It was established by the National Technical Assistance Center for State Mental Health Planning's Housing for Persons with Psychiatric Disabilities: Best Practices for a Changing Environment that there is a responsibility of the state and community mental health systems to focus on housing "as a necessary component of recovery and community support; (2) The focus of housing planning should be on "permanent housing that is affordable." (3) Planning for housing and planning for support of people needing recovery should be closely linked. (4) The most effective method to the promotion of recovery and re-integration into society is a combination of professional services that are staffed both by individual with and without a history of psychiatric disabilities combined with peer support and consumer operated services and natural support systems in the community. (5) The leadership of the state mental health agency needs to view assistance for rental as an integral part the strategy of a design to increase access to integrated housing. (6) Rental assistance activities should be developed in the context of an overall housing policy that supports a variety of activities designed to increase the availability of integrated housing. This includes the development of state policy in regards to housing and residential services. (7) Housing discrimination against people with psychiatric disabilities is a major national problem that requires urgent attention. (8) Legal protections and tools, such as those found in the Fair Housing Amendments Act, Section 504 of the Rehabilitation Services Act, and in provisions of the Americans with Disabilities Act, are often overlooked within both mental health and housing systems and should be utilized as important tools for assisting people with psychiatric disabilities to meet their housing needs. (9) Education, information, and training in these protections are of critical importance to consumers and family members as well as to housing and mental health staff. (10) State and local mental health agencies should develop partnerships with housing finance and development agencies to increase housing access and supply. (11) State mental health agencies should support the development of knowledge and skills necessary for accessing mainstream housing resources. (12) Creative use of mainstream housing resources both new and existing (e.g., Community Development Block Grant, HOME funds), should be a priority of mental health and housing authorities. (13) The leadership of the state mental health agency must view rental assistance as part of a larger strategy designed to increase access to integrated housing. (14) Rental assistance activities should be developed in the context of an overall housing policy that supports a variety of activities designed to increase the availability of integrated housing. Helpful activities include assembling groups of stakeholders to assist in the development and oversight of state policy regarding housing and residential services. (Tennessee Department of Mental Health and Developmental Disabilities, 2010)

A recent study conducted by Dennis Culhane and colleagues and published by the Fannie Mae Foundation states conclusions that supportive housing, described as "permanent housing with attendant social services" has always been considered to be "prohibitively expensive" however, it is stated that this type of housing "…has emerged as a good investment because it is shown to substantially reduce the use of other publicly funded services." (Tennessee Department of Mental Health and Developmental Disabilities, 2010) It is stated that New York City "…established a comprehensive supportive housing program for homeless people with severe mental illness. A major study of the program calculated that long-term homeless people with severe mental illness used an average of $40,500 a year in public shelter, corrections, and health care services. For those placed in the permanent supportive housing program, the reduced use of acute care services nearly offset the costs of the supportive housing." (Tennessee Department of Mental Health and Developmental Disabilities, 2010) In fact, evaluations of other programs similar to these have discovered that retention rates for supportive housing programs are 80% and that these lead to "significant reductions in hospitalizations and shelter use." (Tennessee Department of Mental Health and Developmental Disabilities, 2010)

Evaluations of similar programs nationally have found that most supportive housing programs for homeless people with mental illness boast retention rates of 80% up to one year following placement, while leading to significant reductions in hospitalizations and shelter use. Furthermore, there are non-financial benefits to the provision of supportive housing including "the benefit from residents of supportive housing being more likely to secure voluntary or paid employment and an improved quality of life." (Tennessee Department of Mental Health and Developmental Disabilities, 2010)

In addition it is noted that there is a "social value of reduced homelessness" as well as the provision of a greater level of social protection for those who are disabled. Individuals who are placed in housing are very likely to reduce their use of hospital services since they are in a much better position to take part in outpatient programs. Access to housing additionally has the potential to greatly reduce the length of stays in the hospital for these individuals. (Tennessee Department of Mental Health and Developmental Disabilities, 2010, paraphrased) It is reported as well that a study conducted by Rosenheck, Kasprow, Frisman and Liu-Mares in 2003 on the cost-effectiveness of supported housing for those who are homeless and have mental illness states findings that "…Supported housing, integrating clinical and housing services, is a widely advocated intervention for homeless people with mental illness." (Tennessee Department of Mental Health and Developmental Disabilities, 2010)

Primary benefits of the U.S. Department of Housing and Urban Development and U.S. Department of Veterans Affairs HUD-VA Supported Housing program included outcomes of 35 to 36% fewer measures of psychiatric or substance abuse status or community adjustment." (Tennessee Department of Mental Health and Developmental Disabilities, 2010) Comparison data form the Lewin Group states that when comparing the difference in services the following findings are stated: (1) One day in a mental hospital costs $607.00; (2) One day in jail costs $90.00 per day; and (3) One day in supportive housing cost $30.00,

(Tennessee Department of Mental Health and Developmental Disabilities, 2010)

It is clear that the benefits to those who are homeless and suffer from mental illness through supportive housing will also serve to benefit the community and society at large in the reduction of costs needed to assist and support these individuals who are homeless and who suffer from mental illness. The Lewin Group states "While everyone who is homeless for the long-term obviously does not spend 365 days a year in jail -- there is evidence that too many spend almost all their time bouncing among institutions without becoming stable. A recent study in New York City found 909 people who each spent on average 397 days out of two years in either shelter or jail." (Tennessee Department of Mental Health and Developmental Disabilities, 2010) It is additionally stated by the Lewin Group that the benefits of supportive housing are obvious "…to the taxpayer, as a more humane solution, and to encourage people to be as independent and engaged in work and community as possible." (Tennessee Department of Mental Health and Developmental Disabilities, 2010)

It is reported that a separate study published by the Corporation for Supportive Housing states the following findings: (1) not only is supportive housing effective for ending cycles of homelessness it further serves to improve the "performance and impact of services provided by mainstream systems such as healthcare, child welfare, and criminal justice"; (2) because of the lack of integration in the present systems for health care, mental health, housing, criminal justice and child welfare along with addiction treatment, these are not effective in assisting those with complex health and social services needs. However, a supportive housing system has the potential to produce "far superior, long-term results with minimal addition costs to existing programs." (Tennessee Department of Mental Health and Developmental Disabilities, 2010)

The U.S. Department of Housing and Urban Development Office of Policy Development and Research publication in 2007 and entitled "The Applicability of Housing First Models to Homeless Persons with Serious Mental Illness" reports a study that included nine programs that incorporated the key features of the Housing First model. Those locations are stated to include locations in Columbus, Ohio; San Francisco, California, Seattle, Washington; Philadelphia, Pennsylvania; Los Angeles, California; New York City, New York; San Diego County, California; and Long Beach, California. Pathways to Housing, DESC and REACH were selected for this study since they are committed to provide service to homeless people with chronic mental illness and because they "emphasize placement into permanent housing without requirements for sobriety and treatment compliance. It is reported that the program elements that emerged as important in contributing to the success of the programs were those as follows: (1) Access to a substantial supply of permanent housing; (2) Making a provision of housing that clients like; (3) Wide array of supportive services to meet the multidimensional needs of clients; (4) Service delivery approach that emphasizes community-based, client-drive services; (5) Staffing structure that ensures responsive service delivery; (6) Diverse funding streams for housing and services. (U.S. Department of Housing and Urban Development Office of Policy Development and Research, 2007)

The Housing First approach is stated to be theoretically different from approaches "that transition people with serious mental illness from the streets to permanent housing…" as these programs involves the provider making the assumption that "homeless people with severe mental impairments require a period of structured stabilization prior to entering permanent housing, often involving stays in a series of housing settings along a continuum of increasingly independent living. Entering the continuum often requires that the homeless person commit to a service plan and agree to abstain from using drugs or alcohol." (U.S. Department of Housing and Urban Development Office of Policy Development and Research, 2007) The symptoms of the client that are related to mental disorder or substance abuse may become worse at times requiring increases in the level of service provision or institutional care, which may either halt temporarily or reverse the individuals' progress toward living independently. There are two groups: (1) those unable to succeed in a more structured approach to services; and (2) those resistant to accepting services which are stated to be "the primary targets for the Housing First approach." (U.S. Department of Housing and Urban Development Office of Policy Development and Research, 2007)

Primary characteristics of the Housing First approach are stated to include the following: (1) The direct, or nearly direct, placement of targeted homeless people into permanent housing. Even though the initial housing placement may be transitional in nature, the program commits to ensuring that the client is housed permanently; (2) While supportive services may be offered and made readily available, the program does not require participation in these services to remain in the housing; (3) The use of assertive outreach to engage and offer housing to homeless people with mental illness who are reluctant to enter shelters or engage in services. Once in housing, a low demand approach accommodates client alcohol and substance use, so that "relapse" will not result in the client losing housing; and (4) The continued effort to provide case management and to hold housing for clients, even if they leave their program housing for short periods. (U.S. Department of Housing and Urban Development Office of Policy Development and Research, 2007)

The Pathways to Housing approach is one that separates housing and treatment services in an arrangement where clients rent the apartments and the Pathways to Housing holds the lease and landlords have no direct relationship with the program. It is stated to be a "low demand approach" in that the program does not prohibit substance use as a condition for obtaining or retaining housing. The only requirement for the program is that the client spends thirty percent of their income for rent and this is generally done through a representative payee money management program. The second requirement is that the client participates in two home visits by their case manager each month. (U.S. Department of Housing and Urban Development Office of Policy Development and Research, 2007, paraphrased)

Conclusions of the Housing First Program study states that "despite the history of homelessness and severe mental illness of the clients served in the three Housing First programs 84% (n=67) of the clients tracked for this study remained enrolled in the Housing First program at the 12th month. Forty three percent remained in the Housing First housing for the full 12 months, 41% were 'intermittent stayers' and left during the 12-month period but returned and 15% left the housing or died within the first 12 months." (U.S. Department of Housing and Urban Development Office of Policy Development and Research, 2007) It is stated that the differences among stayers, intermittent stayers, and leavers are modest, but some patterns emerge. Leavers and intermittent stayers more often entered the Housing First program from the streets and were more likely to experience temporary program departures. Furthermore, it is reported that leavers and intermittent stayers "experienced higher levels of impairment related to psychiatric symptoms during their last month in housing compared to month 12 for stayers." (U.S. Department of Housing and Urban Development Office of Policy Development and Research, 2007)