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Home arrow Language & Literature arrow The open door : homelessness and severe mental illness in the era of community treatment


A solid connection to mental health services has been linked to housing stability among people with severe mental illness, and is an objective at the forefront of public psychiatry. When a person with severe mental disability fails to adhere to treatment and reaches a crisis point that comes to the attention of health services or the criminal justice system (Swanson & Swartz, 2014), a variety of approaches to increase engagement in services have been developed, both coercive or “leveraged,” and voluntary.

Leveraging Entitlements and Housing

There are some situations in which individuals are compelled to relinquish liberty in order to obtain entitlements or housing. In cases of severe disability, concurrent substance use, homelessness, or a history of the inability to manage money, the Social Security Administration can appoint a representative payee to receive the entitlement on behalf of an individual to ensure that basic needs, such as rent and food, are covered. It is estimated that about 700,000 Social Security beneficiaries with psychiatric disabilities have been assigned a representative payee (Rosen et al., 2007). Typically, representative payees are family members, mental health agencies, or housing providers (Dixon et al., 1999; Monahan et al., 2001; Rosen et al., 2007). In some cases, disbursement of funds is linked to sobriety and adherence to mental health treatment (Monahan et al., 2001; Ries & Dyck, 1997).

Only a handful of studies have explored the effect of a representative payee on clinical outcomes. Rosen et al. (2007) observed that use of psychiatric services was greater following payee assignment, but there was no evidence that substance use declined. Rosenheck et al. (1997) found that people who were homeless and suffering from both mental illness and substance abuse experienced fewer days homeless after assignment to a representative payee. The investigation of client satisfaction with representative payee programs is limited. Dixon et al. (1999), however, observed that while client satisfaction was initially low, it grew more favorable over time.

Schutt and Goldfinger (1996) have reported that of shelter-resident mentally ill people in Boston, 92 percent indicated that they wanted to obtain permanent housing even if it meant that they would be required to take psychotropic medication. Although there is a growing sentiment following the Olmstead decision (1999) that housing should be de-coupled from an obligation to participate in mental health services, in some cases medication compliance is tied to the ability of an individual to obtain and retain supportive housing.

Program-based supportive housing programs that have on-site services sometimes require treatment adherence as a condition of acceptance and tenure. Typically, “housing first” programs do not demand that a resident engage in treatment (Tsemberis et al., 2004), although periodic visits by a treatment team are necessary. Currently, grantee agencies in receipt of Shelter Plus Care program funds from the U.S. Department of Housing and Urban Development are required to make supportive services available for the duration of the rental assistance, and grantee agencies may demand that a tenant take part in supportive services such as case management provided through the program as a condition of acceptance and continued occupancy. The grantee agency cannot require that a tenant participate in disability related services, or require that those whose disability is related to mental health participate in mental health services (, 9/2/14).

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