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Challenges to Bringing Housing to Scale

Housing’s importance in ending homelessness and aiding the recovery of people with severe mental illness is unquestioned. Having a home is conducive to meaningful treatment engagement and is an antidote to the stressful and chaotic existence of life on the streets. Studies of case management with and without a housing component underscore the role of housing in facilitating both housing stability and treatment retention, and in demonstrating that a dual housing and treatment approach is superior to treatment alone, particularly for those whose housing stability has been fragile (Nelson et al., 2007; Rosenheck et al., 2003).


In a nutshell, permanent supportive housing is subsidized housing with treatment and support services. There is no agreed-upon standard model for housing homeless people with severe mental illness to guide both policy and practice (Bentson, 2015). Among providers of mental health and housing services, there are markedly different conceptual approaches on how best to house and treat this population (McHugo et al., 2004; Newman & Goldman, 2009; Torrey, 2014; Tsemberis, 1999). The Substance Abuse and Mental Health Services Administration (SAMHSA) has specified that supportive housing should include the following characteristics: 1

The full rights of tenancy, including a lease in the individual’s name;

2. Assurance that housing is not dependent on service participation;

  • 3. Tenants can choose from a range of services based on their needs and preferences;
  • 4. A tenant’s housing preference is considered, and the choice of potential housing settings is the same as for those without a mental disorder;
  • 5. Housing is affordable, with tenants paying 30 percent of monthly income for rent and utilities;
  • 6. Housing is integrated, with tenants living in scatter-site apartments in the larger community or in buildings where most of the units are not occupied by individuals with mental disorders;
  • 7. House rules are typically limited to the terms and conditions of tenancy required by leaseholders in usual community settings;
  • 8. Housing is not time-limited (SAMHSA, 2010).

In practice, few permanent supportive housing programs have adopted all or even most of SAMHSA’s recommended characteristics, the notable exceptions being Pathways to Housing’s “housing-first” programs and the U.S. Department of Housing and Urban Development-Veterans Affairs Supportive Housing Program (HUD-VASH) (Rog et al., 2014). Housing with treatment and support services is put into practice in numerous ways, and there is considerable variability in both the nature of housing and the range and intensity of support services. Use of scatter-site apartments for permanent supportive housing is dependent on the availability of low-cost apartment units in different markets across the country. Multi-unit housing is an efficient way to deliver services and increase the availability of quality housing for people with mental illness in tight low-cost-housing markets. The cost of construction or renovation of multi-unit housing, however, requires creative funding and skill in addressing the possibility of a “not in my backyard” response from the local community (Advisory Commission, 1991; Beggs, 1993).

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