Among the throngs of homeless people in the streets and shelters across America, the severely mentally ill are arguably the most vulnerable. One in every three homeless people suffers from a mental disorder that is both severe and disabling. People in this group are more likely to remain homeless on the streets and in shelters for longer periods and suffer from multiple health problems that incur high social and economic costs to society. While it is widely acknowledged that the decline of the mental asylum led to the emergence of homelessness in this subgroup, there has been significant progress in finding solutions that warrants greater recognition at the public policy level.
I have been both an observer of the events that have given rise to homelessness and a participant in the quest for solutions that would bring greater stability to the lives of people with severe mental illness. Over the past 35 years, I have worked among clinicians, researchers, and advocates who have been inspired by the challenges imposed by homelessness to devise innovative service and policy interventions and creative housing initiatives. This collective body of work has advanced the evidence base in the care and treatment of the homeless mentally ill, paving the way for continued advances toward ending this American tragedy.
This ten-chapter book is a chronicle that begins with an account of the unintentional rise of homelessness following the far-reaching reforms in post-World War II mental health care, followed by descriptions of the key role of advocacy in spurring a governmental response to homelessness, the characteristics of homeless people with severe mental illness and issues related to their care, the quality of evidence for treatment and housing approaches tailored to the severely mentally ill, the challenge of bringing evidence-based interventions to scale, homeless prevention efforts, and the expanding emphasis on a recovery orientation and early enriched treatment to facilitate social inclusion. Homelessness and severe mental illness are issues that have, over the decades, aroused strong opinions and opposing views in both lay and professional circles, threatening a clear focus on the search for workable solutions. I have striven to bring objectivity to a review of the “state of the science.” Guided by the available evidence, my goal has been to identify what we know about what works for preventing and ending homelessness, and where unanswered questions suggest that greater effort is necessary. Despite significant progress, the lack of evidence in some areas indicates the need to continue an aggressive research agenda. Future progress will require increased public funding and support for mental health services and research, areas that have suffered from changing priorities and persistent budget cuts at all levels of government, particularly after the 2008 recession.
Ending homelessness requires a multidimensional effort that begins with the early, consumer-focused treatment of psychotic disorders in concert with continuing treatment, rehabilitation, and housing support for as long as it may be needed. The idealists of the community psychiatry movement in mid-twentieth century America envisioned that a change in the locus of care from the mental institution to the community would enable people with severe mental illness to achieve a more lasting recovery and live meaningful, productive lives outside the walls of the mental asylum. I hope that greater understanding of homelessness, severe mental illness, and the advances in treatment and housing initiatives can strengthen the public will to ensure that people with mental disabilities have access to the interventions that could help them live successfully in the community, diminishing the chance that they will ever experience shelter or street living.