Supported Housing and the Lamppost—or Supported Housing in the Spotlight?

To the Editor: Hopper's eloquent argument in the May issue regarding supported housing's failure to remedy the social exclusion of people with serious mental illness (1) places the spotlight on one approach to the exclusion of other approaches that are far more powerful and commonly found. This purported failure, moreover, is heightened by his equating supported housing with institutions of control over the poor: “It is no reproach to note the structural kinship of supported housing and abeyance mechanisms” (1). Yet “abeyance mechanisms” such as prisons and long-stay hospitals bear a much closer resemblance to the opposite of supported housing—that is, to congregate care settings where residents share close quarters under strict house rules. By comparison, supported housing, which offers consumers their own apartment on the basis of their preferences, is a form of personal liberation.

Of course, liberation does not mean salvation. And recovery from mental illness cannot be achieved (as Hopper notes) by an individual's force of will. Social isolation is but one entrenched problem that the newly housed must confront. Cumulative life adversity—a benign-sounding term that obscures the raw brutality of being beaten or sexually assaulted—is an all-too-common precursor to the adult problems of mental illness, substance abuse, homelessness, and poor health (2). Social networks depleted due to drugs, incarceration, premature death, and mutual estrangement reduce opportunities for reuniting, and finding new social relationships is more difficult when trust in others is in understandably short supply (3).

For a small minority of homeless adults who cannot or do not wish to live independently, there is no likelihood that supervised congregate care will disappear anytime soon. Indeed, philanthropic donations and government funding have overwhelmingly favored visible edifices over the smaller scale and “invisibility” of scatter-site living (an ironic commentary on the greater presumed potential for social integration associated with such edifices). Yet the preponderance of research shows that consumers of psychiatric services prefer having their own domicile over living with strangers who share their troubled histories (4). Shouldn't this play some role in considering what has gone wrong and what is going right (or at least going in the right direction)?

To be sure, supported housing is not a panacea, but its limitations lie more in the larger context than in its raison d'être. This recalls the oft-told parable of the drunken man looking for his keys under the lamppost “because that's where the light is” when he had actually dropped them in the vast dark area around him. Hopper and others who are seeking to broaden the conversation beyond individual agency are spot-on. But looking for the keys (to social inclusion) under the street light (of supported housing) puts the emphasis in the wrong place and narrows the focus to the least problematic of what is a complex and troubling reality.