Supportive Housing Works (for most). Don’t Throw the Baby Out with the Bathwater

This post was written by Dr. Emmy Tiderington, Assistant Professor of Social Work at Rutgers, The State University of New Jersey. 

The State of New York’s rush to move mentally ill adult home residents into independent, supportive housing, as detailed in the December 6th New York Times article, “’I Want to Live Like a Human Being’: Where N.Y. Fails Its Mentally Ill”, was in many ways a horrific failure. But, this does not mean that the supportive housing model endangers people and that we should throw the proverbial “baby out with the bathwater”. Supportive housing isn’t to blame—the service system is to blame.

Having worked with people with severe mental illness for years in a New York City supportive housing program and in other community settings, I have seen individuals like those described in this article who struggle to live independently in these settings. But I’ve had many more recipients of these services tell me that this combination of housing and supports saved their lives. Decades of research have shown that supportive housing works for the vast majority of recipients. Housing stability in these programs is high, upwards of 93% in a recent federal demonstration project and far higher when compared with “care as usual” in homeless services. The model is considered a best practice by the federal government and has been employed effectively to end homelessness in many cities across the nation .

There is a small percentage of people who do not succeed in supportive housing and need a higher level of care, as these studies also show. But the U.S. Supreme Court’s 1999 Olmstead v. L.C. decision, which precipitated New York’s and other states’ efforts to move people out of institutional facilities, mandates that communities ensure that people with disabilities are given the chance to live in the “most integrated, least restrictive setting possible” and there is an ethical imperative to give people this opportunity.

States should have taken a lesson from the failures of deinstitutionalization, the period from the 1950s onward during which patients from state psychiatric hospitals were discharged en masse to an inadequate array of community-based services. The poor implementation of this public policy is one of the major contributing factors to the modern era of homelessness, when thousands of people with severe mental illness fell through the cracks and visible street homelessness reemerged as a major social problem in the United States. Deinstitutionalization offers a cautionary tale, whether its 1950 or 2018. Without adequate resources in place, systems cannot keep people safe.

To avoid the tragedies described in the NY Times, New York should have ensured an appropriate array of services existed in the community before transitioning people out of adult homes. While the type of supportive housing used in the adult home transition may not have worked for some, other forms of supportive housing with greater capacity for supervision could have been used to meet the needs of this group. Unlike the scatter-site apartments used in the transition, which scattered people in independent apartments throughout the community, congregate supportive housing buildings with on-site social services are physically set up to allow for more supervision. With robust funding for high-intensity services in this type of setting, people could get the supervision and services they need while living in their own apartment in the community.

For those who cannot make it in any form of community-based housing, available alternatives are necessary. Finding a psychiatric inpatient bed for individuals who meet the legal threshold of being “a danger to themselves or others” in some communities, like New York City, can be extremely challenging. A 2016 Pew report found that the United States is 123,300 psychiatric hospital beds short of what is needed. When there are no beds available, a person is often stuck in a revolving door from a supportive housing apartment to a 48-hour hold in a psychiatric emergency room and then straight back into supporting housing.

To keep people safe in the community and in the “least restrictive, most integrated setting possible”, we need a robust safety net of accessible, appropriate resources. While the adult home transition failed many, and tragically so for some, it did go well for most and should not be a reflection on the quality of care offered by supportive housing. Instead, this failure should shed light on the still inadequate and underfunded social service system for people with severe mental illness. We should use this week’s revelations to illuminate places for improvement rather than blaming a housing approach that has vastly improved the lives of many decades after the injustices of deinstitutionalization.

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Emmy Tiderington, PhD, is an Assistant Professor of Social Work at Rutgers, The State University of New Jersey. She previously worked as a social work supervisor at a New York City-based supportive housing program.

Evaluating the Evidence: Permanent Supportive Housing and Health Outcomes

The faculty at the University of Southern California Suzanne Dworak-Peck School of Social Work, one of the National Center’s regional hub schools, continue to make significant contributions to the field of homelessness research. In September, the Homelessness Policy Research Institute at USC held a research symposium on the impact of permanent supportive housing on health outcomes for people experiencing chronic homelessness. The symposium’s program was built around a recent report from the National Academy of Sciences, which was co-authored by Dr. Suzanne Wenzel, a professor of social work at USC. Dr. Wenzel presented findings and implications from the report at the research symposium. The key takeaways include the following:

  • PSH is effective in keeping people stably and safely housed and has great potential for reducing the number of people experiencing chronic homelessness and improving their health outcomes;
  • Existing data is too limited to demonstrate definitively that PSH contributes to improved health outcomes; and
  • There is a need for more well-designed, high quality research studies to more clearly define the impact of PSH on health outcomes.

You can view highlights of the symposium below or watch a recording of the entire event here.

Story from the Field: Critical Conversations About Housing Justice

This post was written by Mar Kidvai Padilla, an MSSW Candidate at the University of Texas at Austin.

People experiencing homelessness are daily faced with meeting immediate survival needs and coping with the impacts of trauma and illness, both physical and mental, that can escalate into a state of crisis. The social workers providing services to clients experiencing homelessness at Integral Care, where I am completing my first-year internship as an MSSW student at the University of Texas at Austin, show deep empathy and a clear sense that our clients face unnecessary barriers and injustices as they seek permanent housing.

As social workers, we often use a macro perspective to analyze the connections between individual hardships faced by clients and the implementation of local policy, such as Austin’s No Sit No Lie Ordinance that criminalizes resting or sleeping on sidewalks, benches, and in parks. Some of us correlate our specific work and policy advocacy to a larger abstract project of ending homelessness. However, very few of us can articulate our personal vision of housing justice, even as we may understand ourselves to be working shoulder to shoulder with other professionals trying to achieve it.

As an educator and organizer, I know that a shared vision of social justice cannot be taken for granted. Without vision, no accountability between client and social worker can exist, no tactics or strategy can be formulated, and no evaluation of our efforts is possible. As scholar and activist Gloria E. Anzaldúa asserts, “Nothing happens in the ‘real’ world unless it first happens in the images in our heads.”

Thus, we must engage in critical conversations and ask each other:

  • What does a world in which all people are housed look and feel like?
  • What is the global history of housing justice and what markers of our success can we use to assess our progress here and now in late capitalism?
  • What does it say about our society that some people, often disabled individuals and survivors of trauma, are denied housing?
  • How can we eliminate (rather than bandage) the power dynamics that produce housing crises for Black and brown clients at the intersection of multiple oppressions?

To this end, I am planning a workshop for my Macro Field Project to be delivered at Integral Care’s annual Dynamic Development Day (DDD). The session, titled Housing as a Human Right: Exploring Our Visions of Justice, will offer service providers space and time to discuss our ideals, collectively analyze the history of housing rights, and compare housing data and social movements transnationally. Proposing and having the workshop accepted for DDD was exciting, but I recognize, of course, that no vision of housing justice is possible without the centering of people experiencing homelessness. Our theory of change must integrate the understandings and visions of the people most directly affected, so I decided to pilot some of my workshop in the women’s support group I co-facilitate at the Trinity Center, which provides services to people experiencing homelessness.

Introducing the 1970s feminist consciousness-raising groups as a model, I asked clients:

  • Why do people become homeless?
  • What does homelessness say about our society?
  • What are the differences between “homeless people”, “people experiencing homelessness”, and “people denied housing”?

After a robust conversation, I led an art activity in which clients first painted what it would “look, sound, and feel like if everyone has been housed” and then what it would “look, sound, and feel like to work with other people without homes toward this goal”.

I noticed that initially many clients rejected the idea that they were themselves homeless (despite all sleeping on the streets or in shelters) and often blamed homelessness on irresponsibility, moral failures, and drug misuse. When I raised the issue that many people use substances because of unaddressed trauma or mental illness, and that disability keeps many people unemployed, the discussion shifted dramatically. Suddenly, the women began to claim the need for supportive housing for individuals and families, including drug treatment options, not just legal punishment. The group ended with members energized and voicing that they were considering issues from new perspectives, particularly impactful because of the collective nature of these sentiments.

Facilitating this group was illuminating and will help me prepare for my macro project and other future work. First, I will be able to assure DDD participants that these conversations are possible if we check our paternalism when voicing fears that these topics “hit too close to home” for our clients, while also cautioning us from assuming all homeless people’s experiences and feelings are the same. Second, it will help me suggest methods to push beyond stigma, promote cooperation between clients, and open channels for clients to teach providers. Beyond DDD, I would urge all social workers interested in housing justice to initiate these conversations and build shared understandings with each other, but especially with our clients. In this way, we will mutually set the course for our movements.

board-Mar-Kidvai-Padilla (1)About the Author: Pictured left, Mar Kidvai Padilla (pronouns: they/them) is an MSSW Candidate at the University of Texas at Austin. They obtained their MS Ed in 2012 at Hunter College in New York City. They have spent the past 15 years working for freedom in a variety of roles, including as a community organizer, domestic violence hotline operator, human trafficking researcher, elementary school teacher, HIV/HCV tester, harm reduction counselor, and sexual health training manager. They believe housing justice is only possible in a decolonized world that centers Black liberation.

Framing Conversations about Affordable Housing

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The FrameWorks Institute has published a series of studies investigating the most effective ways to communicate about seven social justice issues: criminal justice, human services, affordable housing, education, budgets and taxes, parenting, and aging. This blog post summarizes some of the key points from their Affordable Housing report, which summarizes why housing advocates’ efforts to gain support for affordable housing are backfiring and what to do about it. Interested readers are encouraged to check out the full document available here.

Housing advocates are relying on a growing public anxiety about the rising costs of housing, and some have been able to gain support from policymakers and city leaders for new housing proposals. There has been support on the federal level as well; the Supreme Court has issued rulings related to negative effects of current policies on housing costs.

However, a large base of public support is not present, which is essential in maintaining and sustaining these changes over the long term. Why is support lacking? In part, this is due to a large sense of individualism present in America and the resulting belief that housing is an individual’s responsibility to attain rather than a shared, public concern. Vivid stories about individual troubles that are widely used to foster support, even when presented with housing facts and data, tend to decrease public support and fail to elicit the intended sympathy for the individual’s story.

These message backfires can be understood as following within six common themes:

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Image retrieved from frameworksinstitute.org.
  1. The Mobility, Personal Responsibility, and Self-Makingness Backfire: This backfire occurs because the public tends to believe that people struggling for money and housing are lazy and unwilling to move to a place where housing is more affordable, are irresponsible and unwilling to accept responsibility for and solve their own problems, have made bad decisions, and are managing their money poorly.
  2. The Separate Fates and Zero-Sum Thinking Backfire: The public tends to fail to see how an issue relates to their own personal interests or circumstances and may see this issue as competing with their own interests. Public services for one person are generally viewed as taking away something from themselves.
  3. The Thin Understanding of Cause and Effect Backfire: This occurs because of a limited understanding of the causes and effects of housing problems. The solutions necessary to address these problems and improve outcomes are also thinly understood.
  4. The Crisis and Fatalism Backfire: When housing messages focus on urgency and crisis, people feel powerless against the severity and weight of the problem, which causes them to view the problem as too large and unsolvable. This may trigger blame for the government and skepticism of the government’s ability to address these issues, amplifying the sense that it is an individual’s responsibility to secure housing.
  5. The Not-in-My-Backyard and Natural Segregation Backfire: As issues of racial and economic segregation within the context of housing are raised, the public falls back on a “we solved that” narrative, seeing discrimination as a thing of the past, as well as believing that racial and economic segregation is natural.
  6. The Facts Don’t Fit the Frame Backfire: Facts and data that refute incorrect beliefs or assumptions, and point out benefits that new policies might bring, frequently lead people to hold onto their misperceptions about data and policies more strongly and only accept arguments that confirm their views. This phenomenon is known as confirmation bias.

The Frameworks Institute studied why these messages backfire and tested potential reframes to increase support. The most effective strategies to gain support for affordable housing and to avoid these backfires are summarized with 10 recommendations:

  1. Tell stories that balance the people, places, and systems perspectives.
  2. Don’t directly contest the public assumptions about mobility, consumer choice, and personal responsibility. Instead, explain the role of systems in shaping outcomes for people and the communities in which they live.
  3. Tell a “Story of Us” rather than a “Story of Them.”
  4. Bring the connection between housing and other issues into sharper focus.
  5. Help people connect the causes and effects of housing insecurity.
  6. Make it clear that where you live affects you.
  7. It’s okay to raise challenges of the past, but focus on the kinds of change that leads to better outcomes.
  8. Use robust examples that show how new housing policies work.
  9. Avoid leading or over-relying on the terms “housing” or “affordable housing.”
  10. Widen the public’s view of who is responsible for taking action and resolving outcomes.

By understanding how and why current methods of gaining public support for affordable housing are backfiring, as well as how to more effectively communicate these messages, progressive social change is achievable. Housing advocates are encouraged to use these recommendations to foster public support for initiatives and policies.

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Blog Post Author: Kelsey Whittington, MSW, is a former graduate assistant for the National Center for Excellence in Homeless Services. She now lives in California, where she is doing a fellowship with the VA.

Like this post?
Check out this one Kelsey wrote about the Frameworks Institute’s study about effectively communicating messages about Human Services.

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Using Critical Time Intervention as a Scalable Solution to Crisis Homelessness

We have made meaningful progress over the past decade in addressing chronic homelessness in the United States, as evidenced by a 35% reduction between 2007 and 2016 in the number of persons experiencing chronic homelessness on a single night. The significant expansion of permanent supportive housing (PSH) over this time period is rightly credited as driving this progress and helps illustrate what is possible if resources are directed towards evidence-based, housing-focused solutions.

Yet, PSH should not be understood as a one-size fits all solution to homelessness. With annual costs that can exceed $15,000, it is a resource-intensive intervention, and it may not be feasible or necessary to provide such an intensive intervention to all persons experiencing homelessness. Alternative solutions that are less resource intensive, but equally effective as PSH, are therefore sorely needed for the bulk of the homeless population who experience short-term or “crisis” homelessness. For these individuals (who make up about 85% of the overall sheltered homeless population), an episode of homelessness is often triggered by an event such as an eviction, dissolution of a relationship, or transition out of an institutional living arrangement, such as foster care, prison, inpatient hospitalization, or substance abuse treatment. Unfortunately, progress in addressing crisis homelessness has not kept pace with that made on chronic homelessness: after subtracting out reductions in chronic homelessness, between 2007 and 2015, there was only a 6% decline in homelessness among single adults.

Fortunately, the emergence of a new paradigm in the homelessness assistance sector focused on housing stabilization, coupled with recent Medicaid policy developments, provides a unique opening for substantial progress to be made in reducing crisis homelessness. Recognizing this opportunity, my colleague Dennis Culhane and I recently presented a proposal to leverage the evidence-based intervention Critical Time Intervention (CTI) as a means to expand the availability of rapid re-housing—a promising new strategy that focuses on providing short-term, highly flexible assistance to help homeless households quickly achieve housing stabilization—for persons experiencing crisis homelessness.

Adapting CTI into a large-scale rapid re-housing intervention would make for a sound and feasible policy response to crisis homelessness for several reasons. First, the CTI and rapid re-housing conceptual and program models align nearly perfectly, meaning that a CTI-based rapid re-housing program model would be fairly straightforward to implement. Second, CTI has a strong evidence base as an effective intervention for reducing homelessness, and an integration of rapid re-housing and CTI could therefore amplify the impact of existing rapid re-housing programs. Third, recent guidance issued by the Centers for Medicaid and Medicare Services (CMS) suggests that most of the services at the core of a CTI-based rapid re-housing program could be reimbursed by state Medicaid programs, thereby providing the necessary funding to scale-up the approach with federal resources.

Implementing a CTI-based rapid re-housing at a large scale would have benefits at multiple levels. First, at the individual level, the housing stability and connections to community-based treatment and supports afforded by CTI would lead to improved health, economic, and social outcomes. Second, from the perspective of health care systems, and Medicaid in particular, the expansion of CTI-based rapid re-housing services could lead to more efficient and effective use of health care dollars.  Third, the implementation of our proposal would have a number of potential benefits to society, the most notable of which would be a substantial reduction in overall homelessness. Society would also benefit from reduced utilization of criminal justice system resources, public assistance, and other public services, as CTI has been linked with reductions in such services.

To be sure, there are challenges that would need to be addressed in implementing this idea. These include the need to appropriately tailor CTI for those experiencing crisis homelessness; having a trained workforce in place to deliver CTI-based rapid re-housing at scale; determining the best mechanism for states to include CTI in their Medicaid benefit package; and resolving how to pay for the temporary financial assistance component of rapid re-housing.

Fortunately, there is important work already being done to address these challenges and figure out how best to integrate CTI and rapid re-housing. Most notably, in a project supported by the Melville Charitable Trust, the Center for the Advancement of Critical Time Intervention is partnering with the National Alliance to End Homelessness to develop and test an integration of CTI into rapid re-housing programs in Connecticut. Such work is crucially important and holds great promise. To make real progress in addressing crisis homelessness similar work should be actively encouraged.Byrne_photo

About the Author: Tom Byrne is an Assistant Professor of Social Welfare Policy at the Boston University School of Social Work.  He is also an Investigator at the U.S. Department of Veterans Affairs’ National Center on Homelessness Among Veterans.