Homelessness: Focus Shifts to Shelters with Integrated Wellness Services

Thernpictures are in textbooks and on the History Channel; tent cities, men cookingrnover open fires in rail yards and hitching rides on the trains to the next townrnin search of a job or a regular source of food. rnThat was the Great Depression, and homelessness was widespread andrnvisible.  </p

After World War II, the economy more or less stabilized and we pretended that homelessnessrnhad gone away.  It hadn't, it had justrnassumed a different profile; it was less common and less apparent.</p

Therernwere scattered homeless panhandling on city streets or rifling through trashrncans and sleeping on parks benches. They were predominantly adults, primarilyrnmale and they were notable mostly because there were so few – or at least sornfew that we could see – and we generally assumed they were lazy, substancernabusers, and/or crazy. They were easy to ignore. In thern1980s, however, their numbers began to rise, and their presence to be felt…</p

According to the National Alliance to End Homelessness, “thernseeds of homelessness were planted in the 1960s and 1970s with de-institutionalizationrnof mentally ill people.” The Community Mental Health Centers Act of 1963, wasrnpassed with the best of intentions, but was never adequately funded.  Beds in public residential institutions forrnthe mentally ill were severely cut – in 1970 there were over 400,000 beds inrnstate and county hospitals in the United States, by 1998 there were 63,526 -rnwithout a commensurate increase in services to deinstitutionalized patients,rnleaving tens of thousands of people to fend for themselves.  Today estimates of the percent of singlernadult homeless with some form of severe and persistent mental illness rangernfrom 16 to 40 percent, with the higher end reflecting studies of thernchronically homeless.</p

Since the 80s, the problem of homelessness has been on a ragged upwardrnarc.  In good times the numbers ofrnhomeless recede a bit, only to increase again when employment lags or inflationrnincreases. The recently released OpeningrnDoors: Federal Strategic Plan to Prevent and End Homelessness, to which wernhave referred several times says, “Economic downturns have historicallyrnled to an increase in the number of people experiencing homelessness.  In the last three decades, however, thernnumber of people experiencing homelessness has remained high even in goodrneconomic times.” </p

Opening Doors places the blame for homelessness on what it calls the convergence ofrnthree key factors:  </p<ul class="unIndentedList"<liThe loss of affordable housing and foreclosures; </li<liWages and public assistance that have not kept pace with the cost ofrnliving, rising costs, job loss and underemployment with resulting debt;</li<liThe closing of state psychiatric institutions without the concomitantrncreation of community based housing and services.</li</ul

Initial responses to the issue of homelessness originated with localrngovernments and non-government organizations (NGOs) and took the form ofrnemergency, stopgap measures. rnDepression-era style soup kitchens started up in neighborhoods where thernhomeless congregated and shelters were opened in church basements and abandonedrnfacilities (ironically sometimes the very mental hospitals that had beenrnclosed, forcing patients into the streets) and armories. Typically these only providedrnovernight housing; clients were sent back out into the streets in the morning.  Many shelters limited the number of visits eachrnweek or month and some were open only in months when temperatures – hot or coldrn- were the most extreme.  Many of the homelessrnavoided shelters, feeling they were dangerous either to themselves or their fewrnpossessions; others were unable to comply with shelter restrictions on drugs,rnalcohol, or tobacco.  Some preferred thernstreets to separation from a friend or family member when a shelter prohibitedrnadolescent males or served only one gender while other families wererninvoluntarily split.  </p

Even as shelters became entrenched as institutions, individuals and agenciesrnworking on the front lines were realizing that temporary shelter did not breakrnthe cycle.  According to Opening Doors, an estimated 17 percentrnof the homeless and 26 percent of individual homeless individuals arernchronically so, spending years “on the streets or cycling betweenrnhospitals, emergency rooms, jails, prisons, and mental health and substancernabuse treatment facilities at great expense to these public systems.”  </p

The solutions are several, but, according to Opening Doors, they are basic: rn“jobs that pay enough to afford a place to live, affordablernhousing, better access to income and work supports, and expanded access to healthrnand behavioral health care, including trauma-informed care.”  Consequently, on the community level, thernfocus has moved toward creating 10-year plans in order to focus funds strategicallyrnon solving the problem through social services and housing. </p

While the original federal response to homelessness was also to treatrnit as a short-term crisis and promote emergency responses such as shelters, asrnthe problem grew larger and more entrenched, the approach became one of arncontinuum of care, “the theory being that people experiencing homelessnessrnwould progress through a set of interventions, from outreach to shelter, intornprograms to help address underlying problems, and ultimately be ready forrnhousing.”</p

Today that thinking too hasrnchanged.  The emphasis is now on what isrncalled a Housing First approach. rnHousing agencies concentrate on getting people into a stable housing situationrnas soon as possible.  It is no longerrnseen as a goal, but as an important part of the solution.  Once housing is secured, the client can bernplugged into appropriate support services. rnThis makes sense from several standpoints; the client has a permanentrnaddress and can thus apply, not only for benefits but also for work.  With the recurring if not constant need to locaternshelter removed, the client can concentrate on other aspects of recovery, andrnfinally, there is the simple psychological benefit of security. </p

Two models of Housing First</ahave evolved.  In the first, housingrndevelopments or apartment buildings are designated as supportive housing withrnservices built into the location itself. rnIn the second, participants are given vouchers to obtain housing in thernprivate sector and support home visit services to address mental health, substance abuse issues.  </p

For the last few weeks wernhave been trying to show that homelessness is a real human and fiscal problemrnin this country, but there is a second, very serious problem in the country andrnthis second problem may provide a solution to the first.  More about this in a future article.   

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