ON
HOUSING
OPTIONS FOR INDIVIDUALS WITH
SERIOUS AND PERSISTENT MENTAL ILLNESS (SPMI)
The
problem of providing both housing and housing supports to individuals with
serious and persistent mental illness presents significant challenges and
controversies to mental health system planners and clinicians. These challenges result from several key issues:
1.
Access to affordable housing is severely limited in
most communities, so that consumer choice is even more severely limited. Furthermore, consumers may consequently
experience housing negotiations with the mental health system as coercive, in
the sense that provider imposed requirements become conditions for obtaining
any housing at all.
2.
There is
substantial conflict between the preference of many consumers to live in
independent, normative housing, integrated into the community, and the desire
of mental health clinicians, family members, and the community at large to
maximize safety and reduce risk of relapse and dangerous behavior by providing
residential settings that are closely supervised, highly structured group
living arrangements
3.
There is conflict between the view that housing in
the least restrictive setting is a fundamental right for individuals with
disabilities, even if those individuals refuse treatment recommendations, and
the view that providing housing without requiring treatment participation is at
best enabling and at worst medico-legally irresponsible.
4.
Finally, the problem of homelessness among
individuals with serious and persistent mental illness continues to increase,
most prominently among individuals with co-occurring substance use
disorders. However, there is
considerable controversy regarding what types of housing programs and supports
should be made available to meet the needs of these difficult individuals,
particularly with regard to the question of whether such supports should be
offered to individuals (with SPMI) who continue active substance use.
This position statement is
intended to address these controversies by identifying key philosophic
principles for planning and providing housing supports to persons with SPMI, and
then establishing general guidelines for the types of housing options that
should be available in any system of care, and suggested methodology for
planning these options to meet client needs.
1.
Provision of safe, adequate,
and appropriately supported housing for individuals with serious and persistent
mental illness is a priority. AACP believes that provision of housing and prevention of
homelessness must remain a priority of all treatment systems addressing the
needs of individuals with SPMI.
Consequently, the range of housing options, particularly for individuals
with co-occurring substance use disorders, must be developed with that priority
in mind.
2.
Individuals with psychiatric
disabilities should not be institutionalized because of lack of housing
options. The
Olmstead decision creates a clear imperative to develop a range of housing
supports to permit individuals with SPMI access to community-based housing in
lieu of remaining in restrictive institutional settings in the public mental
health system. AACP believes
that there should be the same imperative to provide housing in lieu of
inappropriate institutionalization in correctional facilities or nursing homes.
3.
Housing for individuals with
SPMI is an issue for the whole community, not just for the behavioral health
system. Treatment
systems must take initiative to establish relationships with public and private
housing “providers” in the community (such as local housing authorities) in
order to develop collaborative strategies for enhancing access to a wider range
of housing options.
4.
Housing options should be
designed to promote empowerment and recovery, through creating options that
support consumers’ preferences for adequate assistance to achieve normative
housing and full community integration. Housing choices should not be restricted to segregated mental
health “ghettos”, and consumers should neither be expected to remain
indefinitely in supervised group homes or other artificial housing environments,
nor to move prematurely to more independent settings to satisfy arbitrary
program requirements.
5.
Housing options should be
prioritized to be responsive to consumer choice and preference wherever
possible. Consumers are presumed to be competent to make
housing choices, even if those choices are in conflict with the recommendations
of their caregivers, and are entitled to access to supports in the settings of
their choosing. In addition, choices
regarding participation in treatment, substance use, and living companions
should be respected as much as possible.
6.
Housing support options
should maximize opportunities for individualization and flexibility in matching
housing to consumer needs and preferences. Housing services need to move away from attempting to fit
consumers into pre-existing “slots” in pre-designed models of care, and move
toward flexible wrap-around supports that can be more individually
designed. In addition, housing services
should be designed to maximize the consumer’s ability to maintain continuous
treatment relationships in the context of housing transitions.
7.
Housing support options
should be designed in a culturally competent manner, and promote integration
into community environments that support consumers’ cultural and linguistic
preferences. This
follows directly from the prior two principles. Cultural flexibility in housing services is enhanced by
emphasizing individual and small group arrangements in scattered site
apartments with flexible supports, in comparison to more traditional group home
models.
8.
Individuals who are
transitioning from the child and adolescent system to the adult system are a
particular priority population for housing services. Specific supports are needed to promote the
development of independent living skills within a safe context. Other age-based transitions (e.g., those
which result from an aging and potentially medically infirm SPMI population)
also require specific planning and attention.
9.
For individuals who are NOT
competent to make the full range of independent choices, caregivers must
proactively establish the need for protective services and provide appropriate
safety and supervision in the least restrictive possible manner.
This can range from payeeships for those
whose areas of lack of competence are primarily in the area of money
management, to fully supervised environments for individuals with significant
cognitive compromise or demonstrable likelihood of dangerous behavior in unsupervised
settings.
10.
Individuals should have
access to a full range of treatment options in association with housing, and
treatment requirements (if any) should be individualized based upon client need
and preference as much as possible. Housing options should not routinely require arbitrary
participation in pre-arranged treatment.
Treatment options should include participation in stage-specific substance disorder
treatment, and access to a range of options for medical care.
11.
Within the context of
consumer choice, providers should proactively offer assistance to promote
safety, prevent relapse, and build recovery.
Simply
because consumers are not required to participate in treatment does not mean
that assistance should be withheld, or offered only passively. Housing support staff can work actively to
encourage consumers to make the best possible choices without rejecting them
for making the wrong ones.
12.
Within the context of
consumer choice, abstinence from alcohol and drugs is consistently encouraged,
but housing options should not be denied because a consumer continues to use
substances and/or is unwilling to accept abstinence as a goal. For this reason, housing options should include
abstinence-expected housing, abstinence-encouraged housing, and consumer choice
housing. These options will be
described further below.
13.
Public sector systems should
develop mechanisms to encourage providers to provide the full range of housing
options to consumers who continue to engage in risky behavior. The premise of consumer choice housing is
that risk of harm will be reduced for these individuals if basic needs are met
and opportunity to engage with treaters is provided. Nonetheless, providers may be exposed to significant risk of
liability for individual instances of harm that may occur. Consequently, AACP recommends that public
systems facilitate initiatives for shifting liability for such programs from
individual agencies to broader risk pools.
14.
Clinical decisions regarding
housing recommendations should be based on evidence based best practice
whenever possible. More
research is clearly needed to identify which housing models are most
appropriately matched to consumers with particular needs or
characteristics. Housing programs
should therefore incorporate program evaluation efforts into program design
whenever possible.
Housing supports and housing programs can vary along
multiple dimensions. AACP recommends maximizing choices and flexibility along as many of
these dimensions as possible.
1.
Independent vs. group living
2.
Wrap-around flexible support
(supported housing) vs. staff model support (e.g., group home).
3.
Consumer lease vs. program
owned
4.
Scatter site vs. congregate
living
5.
Programming optional vs.
required/integrated
6.
Loosely structured vs.
highly supervised
7.
Medical care off site vs. VNA
vs. on-site nursing care
8.
Self-medication vs.
medication monitoring vs. med administration
9.
Consumer choice re:
substances vs. abstinence encouraged or expected
10.
Permanent housing vs.
transitional vs. temporary (shelter).
The AACP
position statement is as follows: In
any service area or catchment area, there must be provided a full range of
housing options for individuals with SPMI, including those with active
co-occurring disorders.
First,
a significant body of literature has established that individuals with SPMI
predominantly prefer to live independently in normative, scattered site
housing, with few requirements, and access to flexible supports as needed. When such supports are made available with
sufficient intensity, these supported housing models produce significantly
better outcomes at lower costs than more rigid group home models.
Consequently, AACP recommends
maximizing availability of supported housing.
Assessment of supported housing requirements begins with assessment of
consumer preferences and their perceived needs for support.
Second, despite the aforementioned literature, there
remains a significant minority of individuals with SPMI who prefer a group home, or whose level of impairment leaves
them unable to care for themselves in an independent setting.
Consequently, AACP
recommends that group home models remain available to the extent that the
aforementioned needs assessment establishes a cadre of individuals who prefer
such settings or who require such settings.
Third, psychiatric housing programs
(which provide or support a place to live for individuals with psychiatric
disability, in order to prevent homelessness) must be distinguished from
addiction (or psychiatric) residential treatment programs (which provide
episodes of treatment in a residential setting, usually with defined
expectations or requirements). Both are
important components of a comprehensive system of care.
In most service areas, the addiction treatment system provides a range of addiction residential treatment programs and sober housing programs (e.g., Oxford House model programs), all of which need to be abstinence-expected programs, in order to protect the integrity of the addiction recovery support provided. Individuals who enter these settings are seeking a sober recovery environment, not merely housing, and expect these requirements to be enforced. Ideally, all such individuals have a plan for housing in the event that they fail to meet program requirements and are prematurely discharged.
The mental health system, by contrast, provides mainly
housing support programs for individuals with SPMI. Many of these individuals have co-occurring substance use
disorders, but vary in their willingness to define substance use as a problem
and/or identify sobriety as a goal, even though they may desire assistance to
maintain stable housing. Some of these
individuals are simply unable or unwilling to limit substance use, even when
all housing supports available require such limits; these individuals
frequently become homeless as a result.
Consequently, the range of
housing supports and programs for individuals with SPMI (with or without
co-occurring disorder) who need housing assistance due to psychiatric
disability, and who are at risk of homelessness, MUST include the following
choices:
a.
Abstinence-expected (“dry”) housing: This model is most appropriate for individuals with comorbid
substance disorders who choose abstinence, and who want to live in a sober group
setting to support their achievement of abstinence. Such models may range from typical staffed group homes to
supported independent group sober living.
In all these settings, any substance use is a program violation, but
consequences are usually focused and temporary, rather than “one strike and
you’re out”.
b. Abstinence-encouraged
(“damp”) housing. This model is most
appropriate for individuals who recognize their need to limit use and are
willing to live in supported setting where uncontrolled use by themselves and
others is actively discouraged.
However, they are not ready or willing to be abstinent. Interventions focus on dangerous behavior,
rather than substance use per se. Motivational enhancement interventions are
usually built in to program design.
c.
Consumer-choice (“wet”)
housing. This model has had demonstrated
effectiveness in preventing homelessness among individuals with persistent
homeless status and serious psychiatric disability (cf. Tsemberis &
Eisenberg, “Pathways to Housing Program” in Psychiatric Services, April,
2000). The usual approach is to provide
independent supported housing with case management (or ACT) wrap-around,
focused on housing retention. The
consumer can use substances as he chooses (though recommended otherwise) except
to the extent that use related behavior specifically interferes with
housing retention. Pre-motivational and
motivational interventions are incorporated into the overall treatment
approach.
In many systems, the latter option is unavailable,
despite its potential value for preventing or ending homelessness.
Consequently, AACP specifically endorses the consumer choice housing model as a valuable component of the system of care. Consumers with psychiatric disabilities who need housing support, including those who have “failed” sober group living, should not be left homeless simply because of inability or unwillingness to maintain abstinence.
In any system of care, a systematic process of assessment is required to determine the needed housing array.
AACP recommends utilization of a formal tool, like the LOCUS , for
assessing housing “needs”, in combination with assessment of consumer
competence, consumer choice, and family/caregiver choice, in order to determine
the best housing option for each consumer.
When the choice of a competent consumer conflicts with provider
recommendations, consumer choice should be given priority, assuming necessary
wraparound supports are available.
Conclusion
The AACP is hopeful that
this document will prove valuable to any system attempting to design a
comprehensive array of housing supports for individuals with SPMI. We welcome feedback regarding how this
document can be improved or amended to more adequately accomplish its purpose.