Housing First: An Evidence-Based Approach Beyond the Medical Model

With a growing consensus that the so-called “War on Drugs” has failed and that mandatory minimum sentences for non-violent drug-related charges should be abandoned, there is the question of what to do with the many billions of dollars that will be saved.  We should be cautious even in asking this question because the War on Drugs is not yet over.  Last Tuesday, Californians passed Proposition 47 making drug possession and non-violent thefts valued at $950 or less misdemeanors instead of felonies.  This is expected to reduce the number of persons sent to California prisons by about 40,000 each year.  California already reformed its mandatory minimum sentencing law to exclude non-violent drug offenses back in 2012. Laws sending far too many people to prison on non-violent drug charges already have been somewhat reformed in Arkansas, Delaware, Georgia, Hawaii, Kansas, Kentucky, Louisiana, Missouri, New Hampshire, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, South Dakota, Vermont, Virginia and West Virginia. However, the verdict is still out on prison reform in 33 other states and the Lee-Durban bill that would abolish Federal mandatory minimum sentences for non-violent drug charges has not yet been passed by Congress.

California will divert the money saved on prisons to drug treatment, schools and victim services. Another proposal for spending the money freed up by prison reform — favored by Pennsylvania Representative Tim Murphy — is to declare a War on Mental Illness. This battle plan targets somewhere between 11 and 16 million Americans for court-ordered outpatient psychiatry, if we do not voluntarily comply with a psychiatrist’s recommendation.  Murphy’s plan also would increase the number of acute psychiatric inpatient beds funded through Federal Medicaid dollars. Murphy believes a large number of Americans “do not recognize they have a mental illness” and so should be coerced into psychiatric compliance.

For each person not sent to a state or federal prison, about $30,000 a year is saved. By starting a War on Mental Illness just as the War on Drugs is wrapping up, some mental health advocates hope to cash in on prison reform. Of course, many Americans might prefer to cash in through lower taxes. So it is essential — if the War on Mental Illness is to succeed — that Rep Murphy create a link in the public imagination between senseless acts of violence and psychiatric diagnosis. Although Murphy acknowledges that there is no empirical data linking psychiatric diagnosis and violence, he hopes to find a link between “untreated serious mental illness” and violence. So he proposes to take funds away from the Federal Substance Abuse and Mental Health Administration’s (SAMHSA) hope-based recovery model and give it instead to the National Institute Mental Health’s (NIMH) “evidence-based medical model.” Despite extensive empirical support for SAMHSA’s Recovery Model, Rep Murphy decries it as unscientific and believes that NIMH’s Medical Model can generate the missing link between psychiatric non-compliance and violence. In the meantime, Rep Murphy is doing his best to create this link in the public imagination by proclaiming his War on Mental Illness every time there a widely publicized act of senseless violence.

To his credit, prominent psychiatrist Allen Frances has distanced himself from Murphy’s attempt to smear those of us with lived experience of extreme states and emotional distress with every highly publicized act of violence.  In an October 24, 2014 Huffington Post blog entitled “Are Religious and Political Extremists Crazy?” Frances wrote: “Our diagnostic system has chosen not to consider fanaticism a mental disorder.” Frances continued:

Experts usually can’t agree whether a political or religious criminal has done bad or is simply mad. Their canceling out suggests that the question is not really a medical decision, more a societal one. We must accept that there is inherent uncertainty in distinguishing the merely strange from the clinically insane.

Jumping to a fake mental disorder diagnosis in everyone who is violent has [a] serious downside. It unfairly stigmatizes the mentally ill, most of whom are not violent. The public and the press must accept that political or religious violence is usually just political or religious, not very often the result of diagnosable mental illness.

In an earlier Mad in America blog, I chided Frances for fanning the flames of Rep Murphy’s War on Mental Illness only to step back and watch a “civil war” begin between SAMHSA’s Recovery Model and NIMH’s Medical Model.  Frances October 24, 2014 blog appears to be an olive branch offered to those of us who believe in the Recovery Model while leaving the door open for at least some violent acts to be due to a “diagnosable mental illness” under the Medical Model. Frances’ aim is to craft a compromise between the Recovery Model and the Medical Model. While I would reject Frances’ compromise as long as it includes psychiatric coercion — as envisioned in the Murphy Bill — I have agreed to consider four elements of Frances’ agenda: prisons, housing, medication and community-support. This is the second in a series of four posts considering these four elements.

I was delighted to hear Allen Frances advocate at the Mad in America Film Festival for Housing First. Housing First turns the standard Medical Model of Mental Illness on its head.  Instead of a psychiatric diagnosis being presented as the cause of a person’s lack of housing, lack of housing is recognized as the cause of a person’s difficulty coping with overwhelming circumstances. While the language used by proponents of Housing First — consumers, clients, psychiatric conditions, etc. — does not fit with the person-first human-experience language we in the Recovery Movement advocate, the core principles of Housing First fit well with our recovery values.

In a groundbreaking study published in April 2004 by the American Journal of Public Health, supporters of Housing First explain:

The predominant service delivery model designed to address the needs of [the] chronically homeless population, called the Continuum of Care, consists of several program components. It begins with outreach, includes treatment and transitional housing, and ends with permanent supportive housing. The purpose of outreach and transitional residential programs is to enhance clients’ “housing readiness” by encouraging the sobriety and compliance with psychiatric treatment considered essential for successful transition to permanent housing. This approach assumes that individuals with severe psychiatric disabilities cannot maintain independent housing before their clinical status is stabilized. Furthermore, the model presumes that the skills a client needs for independent living can be learned in transitional congregate living. Research in psychiatric rehabilitation indicates, however, that the most effective place to teach a person the skills required for a particular environment is within that actual setting.

Consumers’ perception of the Continuum of Care offers another divergent perspective. Consumers experience the Continuum as a series of hurdles—specifically, ones that many of them are unable or unwilling to overcome. Consumers who are homeless regard housing as an immediate need, yet access to housing is not made available unless they first complete treatment. By leveraging housing on participation and treatment, continuum program requirements are incompatible with consumers’ priorities and restrict the access of consumers who are unable or unwilling to comply with program terms.

In addition, most consumers prefer to live in a place of their own rather than in congregate specialized housing with treatment services on-site. Most programs have rules that restrict clients’ choices and that when violated are used as grounds for discharging the consumer from the program. For example, despite having attained permanent housing, clients who relapse and begin to drink mild or moderate amounts of alcohol, may be evicted if the program has strict rules about sobriety maintenance. The chronically homeless population is characterized by its frequent inability to gain access to existing housing programs. Individuals in this group often have multiple disabling conditions, especially psychiatric conditions and substance abuse. Most programs are poorly equipped to treat people with dual diagnoses, let alone prepared to address their housing needs. Treatment requires time and commitment and is often not available if a program is under pressure to move clients along a continuum.

The loss of control over one’s life resulting from housing instability, frequent psychiatric hospitalizations, and intermittent substance abuse treatment leaves some consumers mistrustful of the mental health system and unwilling to comply with demands set by providers. Others prefer the relative independence of life on the streets to a fragmented treatment system that inadequately treats multiple diagnoses or addresses housing needs. Paradoxically, consumers’ reluctance to use traditional mental health and substance abuse services as a condition of housing only confirms providers’ perceptions that these individuals are “resistant” to treatment, not willing to be helped, and certainly not ready for housing.

A little background is helpful here. In the late 1980s, advocacy groups — like the Community for Creative Non-Violence and the National Coalition for the Homeless — were successful in passing the McKinney Homeless Assistance Act.  This bill provided $350 million in Fiscal Year 1987 for what the National Coalition for the Homeless described as an amalgam of “fifteen programs providing a range of services to homeless people, including emergency shelter, transitional housing, job training, primary health care, education, and some permanent housing.”  This was an historic achievement because prior to 1987 the problem of homelessness had been viewed as a local — not a Federal — responsibility. The McKinney Act represented an historic shift in public perception and signaled a national acceptance of responsibility for ending homelessness.

This shift in public perception was matched over the next eight years with growing Federal appropriations for programs designed to end homelessness.  The amount appropriated under the McKinney Act grew to $1.49 billion in Fiscal Year 1995.  This was the year that the Continuum of Care was adopted. The Continuum of Care was an attempt to integrate fifteen separate programs into a single cohesive service delivery system. The institutional-industrial complex favors centralized systems and — with so much money at stake — it was time for a more centralized approach.

By 2006, those providing services to people living in the streets had a favorable impression of the Continuum of Care. This should not be surprising since it paid their bills. However a Housing and Urban Development Report designed to assess whether this centralized approach was actually effective found that it was “not able to substantiate these [favorable] impressions with actual performance data“. In contrast, Housing First is supported by solid empirical evidence.

According to the 2004 study, Housing First “encourages consumers to define their own needs and goals and, if the consumer so wishes, immediately provides an apartment of the consumers’ own without any prerequisites for psychiatric treatment or sobriety.” Housing First has only two requirements: (1) tenants must pay 30% of their income in rent and (2) tenants must meet twice a month with staff. The 2004 study explains:

Consumers are allowed to make choices—to use alcohol or not, to take medication or not—and regardless of their choices they are not treated adversely, their housing status is not threatened.

The Housing First program sustained an approximately 80% housing retention rate, a rate that presents a profound challenge to clinical assumptions held by many Continuum of Care supportive housing providers who regard the chronically homeless as “not housing ready.” More important, the residential stability achieved by the experimental group challenges long-held (but previously untested) clinical assumptions regarding the correlation between mental illness and the ability to maintain an apartment of one’s own.

Given that all study participants had been diagnosed with a serious mental illness, the residential stability demonstrated by residents in the Housing First program—which has one of the highest independent housing rates for any formerly homeless population—indicates that a person’s psychiatric diagnosis is not related to his or her ability to obtain or to maintain independent housing. Thus, there is no empirical support for the practice of requiring individuals to participate in psychiatric treatment or attain sobriety before being housed.

In addition, contrary to the fears of many providers and policymakers, housing consumers without requiring sobriety as a precondition did not increase the use of alcohol or drugs among the experimental group compared with the control group. Providing housing first may motivate consumers to address their addictions to keep their housing, so that providing housing before treatment, may better initiate and sustain the recovery process.

Today — despite the lack of empirical support — the Continuum of Care remains the dominant way we fund services for those living in the streets.  Although it may not be solving the problem of homelessness, the Continuum of Care provides a steady income stream for the institutional-industrial complex. The Federal Budget for Fiscal Year 2013 provided $1.56 billion for the Continuum of Care. In contrast, Housing First was grossly underfunded.

According to a June 14, 2014 press release from the Department of Housing and Urban Development, the number of homeless persons in 2013 was approximately 610,000, and this number was down from nearly 650,000 in 2010.  These numbers — after more than a quarter century of the McKinney Homeless Assistance Act — are startlingly close to the population in psychiatric hospitals at their height in the 1950s. Beyond the money already allocated to the Continuum of Care, HUD announced in the June 14 press release that it is providing $140 million for Housing First and for rapid re-housing of homeless families with children.  Compared with $1.56 billion for the Continuum of Care, this is pennies for the only approach to reducing homelessness that is actually supported by empirical data. We remain far from the whole scale reform of the institutional-industrial complex that would be needed to truly end homelessness in America.

So what have we learned in the nearly 35 years since advocacy groups began to bring national attention to homelessness? Over those years—since 1981—the President’s nearest neighbor has consistently been a homeless woman named Concepción Picciotto.  Connie is a perpetual presence on the sidewalk in front of the White House where—to this day—she distributes leaflets challenging our conception of those who live in the streets. When I first met Connie, her neck bent forward under the weight of the aluminum pot she wore on her head as a defense against her troubles. Connie was the first person I met who actually covered almost every inch of her body with aluminum foil. Connie was a homeless warrior dressed for battle. She had bravely come to confront the source of her problems: waves that she could feel emanating from the seat of American power — the White House.

Most of those who advocate for the Medical Model of Mental Illness would undoubtedly give Connie a psychiatric diagnosis. However, in doing so, they would miss an opportunity to hear from Connie what she has learned over nearly 35 years of non-violent activism. Connie’s vigil began with a very personal goal of getting relief from her individual oppression. This individualistic approach to solving our problems is shared by many Americans. We invest in all kinds of inventions that we hope will protect us from our pain. How many of them actually work? Who are we to judge Connie’s inventions? Is popping pills to dull our pain actually more rational than Connie’s approach? How many Americans have the courage of Connie to step forward in an attempt to confront the true sources of our pain? How many of us have confronted the seat of American power in such a direct and unflinching way?

I do not intend to romanticize Connie’s lived experience. A May 2, 2014 Washington Post Magazine article asks of Connie’s record-setting vigil in front of the White House: “Why, and at What Cost?” This long article documents the depths of Connie’s struggles. An accompanying video documentary begins with Connie’s own words: “My goal is to make peace and stability in the world so there will be a safe place for the future generations.”

(Editor’s note: the advertisement that precedes this video is part of the Washington Post’s embedded code; the revenue goes to the Washington Post, not Mad in America, which remains an entirely reader-supported endeavor.)

Over time, Connie’s individualist goals shifted to more social concerns. She was joined in front of the White House by Thomas, a peace activist. Having crossed over the Sinai Peninsula from Egypt, Thomas swam across the Suez Canal into Israel to defy a border he viewed as illegitimate. After being deported back to the United States, Thomas shifted his focus to nuclear disarmament. After Connie and Thomas were both arrested for sleeping on the sidewalk, they joined forces and Thomas helped Connie broaden the scope of her vigil. Their vigil together continued for near thirty years until Thomas died in 2009. During his long friendship with Connie, Thomas was able to secure—with the help of pro-bono lawyers—Connie’s place in front of White House and her right to continue the vigil indefinitely.

When I saw Connie recently in front of the White House, she handed me a pamphlet on global warming. Connie continues to wear a helmet—but not nearly such a heavy one—and her neck seems less bent to me. Connie continues to speak out on the Middle East with a decidedly pro-Palestinian emphasis and she continues to decry nuclear weapons long after most of us have all but forgotten them. Over a nearly 35-year vigil, Connie most certainly has earned the right to be considered a non-violent fanatic for justice and peace.  As Allen Frances reminds us “Our diagnostic system has chosen not to consider fanaticism a mental disorder.”

What of the hundreds of thousands—evens millions—of others who have been living in the streets and in overcrowded and inhumane housing conditions these past 35 years? Not all of us can escape psychiatric diagnosis by becoming non-violent fanatics like Connie.  With my own experience sleeping out in front of the White House — as part of the Community for Creative Non-Violence — as a guide, the formula for recovering from the trauma of homelessness is simpler than many mental health professionals would have us believe. My own recovery was primarily through the path of non-violent activism, but this is not the only path available. A more basic path was taken by my friend Clarence.

Clarence was a veteran of the Korean War. When I met him in the early 1980s, he had recently been released from a government psychiatric hospital. He continued to relive the trauma of the war. He believed he was a General leading troops through the streets of Washington DC. I had no doubt that he could see the troops he described to me. Since the Korean War ended in 1953, I calculated that by the time I met Clarence he had been fighting that war for nearly 30 years. Long-term confinement in a psychiatric institution had not brought him any relief, and now he was homeless.

Clarence came to the Community for Creative Non-Violence drop-in center, a small building that was little more than place to take a shower, get some clean clothes, have a cup of coffee and then head back to the streets. Clarence gradually began to spend more time at the drop-in center volunteering to pass out clean towels to the folks coming through the door. Eventually he became so indispensable at the center that he was given permission to sleep there overnight and guard the premises. I noticed that as his world became more secure and his role in it more valued, he spoke less and less about the war and the waiting troops. He was less distracted and more focused on the task at hand. All of this happened without Clarence ever seeing a psychiatrist or taking psychotropic medication.

When it came time for the drop-in center to be demolished — a casualty of urban renewal — all Clarence’s old troops came rushing back needing his leadership again. They followed Clarence to a new location for the drop-in center and remained with him for months following this transition. Then one day Clarence simply disappeared and I never saw him again.  I wish I could say there was a happy ending. I looked in emergency rooms and checked all the city’s psychiatric hospitals, but I never found him. He must have died as I met him, an unknown soldier caught in the crossfire of a war I could not see but was entirely real to him.

How many other soldiers like Clarence must die before we recognize that a stable place to call home and a valued role in our society — that allows each of us to earn the respect that we deserve as our birthright — is all the armor any of us really needs? I will gladly join anyone willing to advocate for this disarmingly simple approach.

However, today Housing First is woefully underfunded and the institutional-industrial complex remains deeply invested in the Continuum of Care. For example, as recently as 2009 — the same year Thomas died after nearly thirty years of vigiling at the White House — the Massachusetts Department of Mental Health consolidated an array of separate mental health programs into a single Continuum of Care entitled Community Based Flexible Supports. Like the federal consolidation of homelessness prevention programs in 1995, this consolidation of mental health services in 2009 lacks empirical support. The institutional-industrial complex thrives on centralization. Meanwhile Housing First continues to be largely ignored.

Those of us who would join the fight to fully fund Housing First can learn much from Connie and from Clarence. Like Connie, we should shift our focus away from constructing individual armor to protect us from our pain and learn instead to confront societal ills so that our world will be a safe place for future generations.  Like Clarence, we should not give up the battle until every person soldiering through the streets has a secure place to call home and has been allowed to earn a valued role in our society. Only then will we be free from the societal illness that killed my friend Clarence and is slowly killing us all.