Forty years ago, vast numbers of individuals with psychiatric disabilities lived in public and private hospitals – some for brief periods, but many others for years, and for a few others a lifetime. The movement away from long-term hospitalization – begun in the 1970s with the advent of more effective psychotropic medications, the emergence of funding for community life, and a growing civil liberties movement among consumers – led to a decade of deinstitutionalization policies in which the widespread shift of people – from protective hospitals to the challenges of community life – drew both wide praise and great concern. Many people made the most of community life, but many others found themselves isolated and uncared for.
Over time, community mental health providers fashioned an array of response to the housing needs of those with serious mental illnesses, but what was once considered innovative is now under question. Two broad changes in a ‘best practice’ approach have occurred:
- type of housing – where once group living circumstances appeared to offer great hope for consumers in adjusting to community life, more individual and more permanent approaches are preferred today; and
- promoting community inclusion – where once it was thought that being in the community (rather than in the hospital) was itself sufficient to achieve community inclusion, today more assertive efforts are seen as needed for many consumers.
Type of Housing
In the early years of the deinstitutionalization movement, many individuals were discharged, following long years in state hospitals and with few remaining family ties, to communities with little preparation for where they would actually reside. Over time, a variety of residential programs were developed:
- group homes – generally operated by non-profit social service or mental health agencies, group homes – as small as four persons, in moderately sized boarding homes, and in facilities as large as a hundred persons – began to provide both housing and rehabilitation;
- shelters and sro’s – in larger cities, shelters for the homeless began to take in more and more people with psychiatric disabilities, and single room occupancy hotels (in larger cities) sometimes provided shelter to 200 – 300 former hospital patients in a single setting;
- apartment programs – in time, social service agencies began to downsize their housing supports, sometimes finding a cluster of individual apartments, shared by 2 or 3 people, sometimes simply supporting individuals in finding their own apartments; and
- family living – yet, perhaps 50% of adults with psychiatric disabilities continue to live at home – with parents or siblings or children, and programs to support family members have grown in recent years.
Overall, however, the major philosophical shift in the provision of housing has been from one that provided temporary housing – initial supports, or a continuum of types of housing as the individual gained more confidence and competence – to one that began with permanent housing, and varied the type and intensity of support the individual needed to remain in a home of their own. This approach, generally referred to as ‘housing first’ emphasized the psychological and practical.
Over the past three decades, mental health housing has become integrated with other more traditional mental health services in various configurations of different living arrangements and service delivery systems. Mental health services-based housing operates under the premise that the combination of permanent housing and flexible, individualized, and accessible support services are an effective way to maintain residential stability, facilitate improved psychosocial outcomes, and foster maximum integration with the larger community.
This predominant view, now held by most mental health professionals, where housing, combined with professional and social network support is the core of the rehabilitation process for people with psychiatric disabilities living in the community. Yet presenting this approach to housing as a unified technique belies fundamental differences within this movement in which the ambivalence toward integrating housing and mental health services emerges. Two distinct approaches exist toward configuring and juxtaposing housing and services. One approach, residential treatment, modifies a traditional medical perspective by locating community-based housing together with services, while the second approach, known as supported housing, uses “normal” community housing as its model and keeps housing separate from mental health services.
Promoting Community Inclusion
There was a sense, in the early years of deinstitutionalization, that merely being in the community and no longer warehoused at the state hospital would ultimately – and effortlessly – promote greater community inclusion: people in boarding homes and apartment programs would begin to interact with their neighbors, join local clubs, volunteer at the civic association, attend a nearby church or synagogue, and ultimately go back to work. Much of this turned out to be wishful thinking: some people did pick up the threads of their lives and resume the roles and functions of the past, or simply build new lives for themselves, but many others found that their opportunities for re-connecting to the community was limited, or shied away from interactions for fear of discrimination and rejection, or found their days taken up with day programs and psychosocial rehabilitation center activities. Indeed, some reported a greater sense of isolation and neglect than when they had been in the protective environment of the hospital.
Over time, there has been a gradual recognition that life ‘in’ the community does not necessarily guarantee a sense of belonging ‘to’ the community – a sense of inclusion. More assertive initiatives are needed – both to encourage and support individuals with psychiatric disabilities who want to begin to re-connect to the non-mental health world around them and to expose and support community members who need to re-learn one of the more subtle meanings of ‘community.’ In this sense, housing is both an important determinant of the possibilities for community inclusion while only a starting point.