The United Nations has ordained housing as a basic human right that should be secure, habitable, and affordable but this goal remains elusive for much of the world’s population (United Nations, 1991
). In the United States, the severe shortage of low-cost housing that began in the 1980s and continues to the present day set the stage for the ongoing homelessness ‘crisis’ (Lovell & Cohn, 1998
Yet the fate of homeless mentally ill adults is also affected by policies designed to ensure that they are ‘housing ready’ before approval is given for them to have a ‘home’ (Tsemberis, 1999
). This dominant ‘treatment first’ approach provides temporary quarters in transitional housing, i.e., group homes, crisis centers, half-way houses, supervised single-room occupancy hotels (SROs), and psychiatric rehabilitation facilities.
For most homeless persons in the U.S., the status of being without housing is temporary and relatively short-lived (Phelan & Link, 1999
). Indeed, recent research has focused on the small subset of ‘chronically homeless’ who are responsible for a disproportionate share of the costs of care in terms of hospital beds, emergency rooms visits, and incarceration. (Culhane 2001
). This group, afflicted by substance abuse and/or mental illness, is considered among the hardest-to-reach and engage into services (Aidala, Cross, Stall, Harre & Sumartojo, 2005
; Rowe, Fisk, Frey & Davidson, 2002
;Ware, Tugenburg & Dickey, 2004
Epidemiological research on the mentally ill homeless in the United States has focused largely on the ‘demand side’ rather than the ‘supply side’, thus giving priority to studies of characteristics of homeless individuals rather than systems of care (Hopper et al., 1997
). Homeless advocates take a broader view, focusing upon government policies that under-fund the building of low-cost housing in favor of interim solutions such as public shelters and residential programs (Mangano, 2003
). The Federally-funded Section 8 program (recently renamed the Housing Choice Voucher Program) offers recipients a subsidy to rent from private landlords, but is limited both in availability and by landlords’ willingness to accept the vouchers (Allen, 2003
Services for the homeless mentally ill in the United States represent several overlapping systems of care: 1) homeless services (shelters, food pantries, soup kitchens and drop-in centers); 2) the public mental health system (hospitals, residential treatment programs, and outpatient clinics); 3) substance abuse programs (therapeutic communities, inpatient programs, and 12-step groups) for the estimated 50-70 percent who abuse substances (Drake, Essock, Shaner, Carey, Minkoff , Kola et al., 2001
); and, 4) social services and health care programs serving the poor.
Different funding streams, staff expertise and service philosophies distinguish these systems, yet they all share a requirement of clients: gaining access to valued services--especially housing--requires complying with a set of rules and restrictions (Allen, 2003
). From the perspective of the homeless service consumer, these contingencies of care can seem daunting. Accepting them is also a high-stakes gamble since rule-breaking usually leads to expulsion and a return to the streets.
This ‘treatment first’ approach, which dominates the landscape of services for the homeless mentally ill in the United States, can be viewed as rungs on a ladder beginning with a shelter or a drop-in center where persons sleep on cots or chairs and usually have access to meals, bathing facilities and lockers. The next steps up the ladder are a supervised dormitory-type facility—usually a bed plus locker—followed by a shared bedroom in a supervised SRO hotel or group home.
Individuals may enter the system on a higher rung, and those less impaired and more compliant may skip rungs, but reaching the top of the ladder, i.e., getting an apartment, requires one to give evidence over a period of weeks or months of: 1) adhering to the psychiatric treatment regimen (including taking medications); 2) ‘clean time’, or abstaining completely from substance use; 3) agreeing to have a ‘representative payee’ (usually the program) control the client’s disability and other income while in treatment; and, 4) conforming to behavioral requirements such as curfews, random urine testing, and maintaining personal hygiene (Tsemberis, 1999
Persons may sidestep the ladder altogether if they have family help or financial resources to pay for housing or if they are fortunate enough to obtain a Section 8 voucher and accommodating landlord. But a bout of homelessness usually reflects the exhaustion of personal resources, resulting in dependency upon the system.