Homelessness reflects our societal values. People with psychiatric disabilities are generally poor and disadvantaged, and safe, decent housing is often beyond their means. Access to affordable housing and appropriate supports for people with disabilities might easily undergird the social structure of the wealthiest nation on earth; indeed, deinstitutionalization could make sense only in the context of providing affordable housing and supports.
Focusing on identifying characteristics of homeless people or elements of treatment needs thus may obscure more fundamental problems—those flowing from a public policy that was partly a money-saving maneuver trading on a humanistic ethos that condemned institutions as oppressive by definition and ignored the protective function they served. Given the realities of deinstitutionalization, available housing, urban life, and public health care, individuals with severe psychiatric disabilities are at continuous risk for homelessness, as well as other preventable conditions such as incarceration, victimization, and HIV infection.
Nevertheless, as treatment providers and services researchers, we are charged with helping disabled individuals overcome the odds to maintain stable housing. Two excellent articles in this issue, by Mark Olfson and Stephen Goldfinger and their colleagues, continue the research on identifying risk factors and effective aspects of services and housing. One consistent finding in these and many other studies is the potency of a comorbid substance use disorder as a risk factor for homelessness. Individuals with both severe mental illness and a substance use disorder are more likely than others with single disabilities to become homeless; once housed, they find it more difficult to sustain housing. Like homelessness itself, a comorbid substance use disorder is an unintended consequence of a deinstitutionalization policy that paid more attention to closing hospitals than to providing affordable housing that is also safe from the predators of urban street culture.
Although we know that integrating mental health and substance abuse treatments is effective, integrated treatments are rarely available in most states. Bureaucratic ossification, protection of professional turf, and neglect masquerading as managed care have effectively precluded service integration. We can always use more research to refine models of housing and of service integration. But what we really need is leadership to put in place what we already know. Federal agencies must take a strong stand on organizing and financing housing and integrated treatments. State authorities likewise need to overcome barriers and enact effective strategies. And local agencies must overcome resistance to change among providers. Or we can continue the legacy of failure.
