Cover Story

A homeless man with schizophrenia, just released from a New York City hospital, moves into transitional housing. He has a steady income from a government-issued stipend and a studio apartment paid for by a university-funded housing program. It's a safe base from which to look for a job. But when he moves in, he finds he can't close the window blinds and he's embarrassed to ask for help. Night falls and the streetlights keep him awake. This goes on for days and he grows increasingly frustrated. He's about to give up on the apartment when a social worker checks in on him to make sure everything's OK.

Everything's not OK, the weary man explains. The streetlights are too bright and he's thinking about leaving. The social worker shows him how to operate the blinds and the man decides to stay.

It was a small gesture, but more like them are desperately needed when it comes to helping the homeless mentally ill regain some stability in their lives, says Dan Herman, DSW, a professor of clinical epidemiology in psychiatry at Columbia University and research director for the Critical Time Intervention model, which seeks to prevent homelessness in people transitioning from hospitals, shelters, prisons and other institutions.

"He might not have figured it out himself and he might not have asked somebody and he might have just left the place," Herman says.

Big gestures are needed, too. With the surge in home foreclosures—up 225 percent since 2006—more people are in unstable housing situations. Getting back on track can be difficult for anyone, but overcoming financial obstacles is even more challenging for people with mental illness. According to the National Coalition for the Homeless, 16 percent of the adult homeless population has a severe mental illness. In some larger cities, such as New York City and Chicago, that number is as high as 35 percent, estimates Paul Toro, PhD, a clinical psychologist at Wayne State University in Detroit who studies homelessness. Depression, bipolar and anxiety disorders and post-traumatic stress disorders are the most common illnesses among this population. About 10 percent of the mentally ill population has schizophrenia, according to SAMHSA's Homelessness Resource Center.

For people without severe mental illness, homelessness is often temporary. But those with mental illness have more trouble finding steady employment, are often in poorer physical health and tend to have more problems with the legal system, says Toro. All these issues contribute to the fact that, without organized support, many of these people will continue to eke out a dangerous existence on the street. And as many psychologists have found, getting housing for the mentally ill homeless is a challenging prospect.

Psychologists' research has found that programs seeking to help mentally ill homeless people need these key ingredients: respect for these individuals, housing options they'd actually like to live in and help securing treatment. When those factors are in place, research suggests, the homeless mentally ill have a launching pad that enables them to live a more self-sustaining lifestyle, and taxpayers have a more cost-effective approach than the current carousel of shelters, emergency care and incarceration.

'Like a piece of meat'

One obstacle to getting homeless people into housing programs is overcoming previous bad experiences they've had with shelters and support programs. Such incidents were documented by a 2007 study in the Journal of General Internal Medicine (Vol. 22, No. 7), which found that, of 17 homeless people surveyed, all of them felt like they were being "being ignored, rushed, brushed aside or treated rudely," according to the study. Thirteen reported they felt discriminated against and that they were dehumanized and disempowered when they visited community health-care centers. When asked about a particular experience with a health-care worker at a shelter, one responded, "[S]he just didn't care. It was like you were a piece of meat." Another said of his experience with shelters, "I got treated [poorly] the first time over there, and I'm not going to get treated like that, I'm not going through that again. I'd rather sit here and die on a bench than go over there."

Determining the kinds of experiences that encourage people to use housing services is the goal of Alisa Lincoln, PhD, MPH, a sociologist at Northeastern University in Boston. She and her colleagues interviewed 16 people living in the Safe Haven, a transitional shelter in Boston that gives residents their own lockable room and allows them to stay as long as they'd like. The residents Lincoln studied had active substance abuse issues and other mental illnesses such as schizophrenia, bipolar disorder and PTSD.

The researchers concluded that homeless people are looking for a place that respects them as fellow humans and adults; a place that feels like home and offers some privacy; and a place that doesn't have too many rules and restrictions. The theme of respect popped up in interviews over and over again, Lincoln says.

"For many people with a serious mental illness, being housed has meant accepting being treated like a child," she says.

One resident in the study stated that, "When [a Safe Haven staffer] brought me over and she told me I would have my own room and I would have my own key to the room, that clicked in my head. I don't care how bad it is, I don't care who lives there or anything else, it's got to be better than where I was."

Interestingly, even when they settled into the Safe Haven, residents still chose to occasionally sleep outside. The Safe Haven only requires residents to spend two nights a week at the shelter during their first month there.

"Some slept outside because they still had a network and a community on the street, but it seemed that people mainly slept outside because they were slowly adjusting from living outside to living inside," Lincoln says.

She says her research shows that unless shelters are willing to tailor their housing programs to seriously mentally ill homeless people's needs, then they are likely to remain homeless. Just to stay alive on the streets, people develop fierce independence, she says, so programs that don't respect that independence will often fail. Her research was published in an April 2009 article in the American Journal of Orthopsychiatry (Vol. 79, No. 2).

Kicking bad habits

The promise of housing can be especially beneficial for those homeless combating substance abuse, which frequently overlaps with other mental illnesses, says Joseph Schumacher, PhD, a clinical psychologist at the University of Alabama at Birmingham. He has studied drug addiction among the Birmingham area homeless for 18 years. To treat them, he uses contingency management therapy, which provides work opportunities and housing in exchange for sobriety. The primary intervention was providing apartments to people so long as they passed a urine drug test.

"It ended up working," Schumacher says: After six months, approximately 55 percent of residents who received contingency management treatment remained abstinent, compared with nearly 30 percent of residents receiving behavioral day treatment over the same span of time.

The strength of that program hinges on the fact that even if they falter and fall back on drugs, they are never kicked out of the program entirely, Schumacher says. If someone shows up with a drug-positive urine test, mental health workers provide same-day counseling and program workers place them in safe shelters. They can reapply for the housing program the next week.

"You always have the opportunity to come back and try again," he says. "That's key to a behavioral intervention."

For the last decade, most of the contingency management studies involving homeless people came out of Schumacher's lab. But in 2007, a group from the New York University School of Medicine in New York City found parallel results using a contingency management program to reduce cocaine and alcohol use in homeless people staying at a New York City homeless shelter, adding support for the technique's efficacy (American Journal of Drug and Alcohol Abuse, Vol. 33, No. 2).

Schumacher's model isn't without criticism, though. Paul Toro says that based on his own experiences with housing programs, he prefers a housing-first model rather than Schumacher's abstinence-first because he believes it's more important to get people off the streets than off drugs. Once homeless people are in stable situations, they are more likely to be able to break their addictions, he says.

Saving lives and money

Other research suggests that helping mentally ill homeless people find permanent housing also helps society by lowering costs in the long run. A 2006 study by the Denver Housing First Collaborative found that the public cost of caring for Denver's homeless, which includes emergency care, shelter, detox programs and incarceration, was $43,239 per person annually. Moving those people into permanent homes reduced that figure to $11,694 annually, saving the city $31,545 per individual. That more than covers the $13,400-per-year it costs to house each individual. A similar 2006 report by Portland's Community Engagement Program found that providing housing to homeless people dropped public costs from $42,075 to $17,199 per person.

"It's a bargain for society to keep them off the streets and get them into a stable situation," Toro says.

Herman and his colleagues working with the Critical Time Intervention have found similar results: Homeless people are most likely to stay in stable housing when programs identify the person's specific needs and develop individual plans for addressing them, he says.

The challenge ultimately is in organizing someone's potential support structures, from formal services such as housing, income support and medical care, as well as more informal ones, including getting periodic help from family members, religious and neighborhood communities, even "the local guy who runs the news stand on the corner," Herman says. The trick is to make sure people stay on track once they get started in the right direction.

"The most effective approaches require some workers—social services workers, mental health workers, outreach workers—to go out to the places where these people are," he says. "The best thing may not be to say, 'Won't you come with me, and we'll get you psychiatric help,' because that might not be at the top of their priorities. But you might say, 'We can offer you a place to sleep, we can offer you a place to wash up, to see a doctor, to deal with sores on your feet.'"