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.

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