Homelessness: Focus Shifts to Shelters with Integrated Wellness Services

The pictures are in textbooks and on the History Channel; tent cities, men cooking over open fires in rail yards and hitching rides on the trains to the next town in search of a job or a regular source of food.  That was the Great Depression, and homelessness was widespread and visible. 

After World War II, the economy more or less stabilized and we pretended that homelessness had gone away.  It hadn't, it had just assumed a different profile; it was less common and less apparent.

There were scattered homeless panhandling on city streets or rifling through trash cans and sleeping on parks benches. They were predominantly adults, primarily male and they were notable mostly because there were so few - or at least so few that we could see - and we generally assumed they were lazy, substance abusers, and/or crazy. They were easy to ignore. In the 1980s, however, their numbers began to rise, and their presence to be felt...

According to the National Alliance to End Homelessness, "the seeds of homelessness were planted in the 1960s and 1970s with de-institutionalization of mentally ill people." The Community Mental Health Centers Act of 1963, was passed with the best of intentions, but was never adequately funded.  Beds in public residential institutions for the mentally ill were severely cut - in 1970 there were over 400,000 beds in state and county hospitals in the United States, by 1998 there were 63,526 - without a commensurate increase in services to deinstitutionalized patients, leaving tens of thousands of people to fend for themselves.  Today estimates of the percent of single adult homeless with some form of severe and persistent mental illness range from 16 to 40 percent, with the higher end reflecting studies of the chronically homeless.

Since the 80s, the problem of homelessness has been on a ragged upward arc.  In good times the numbers of homeless recede a bit, only to increase again when employment lags or inflation increases. The recently released Opening Doors: Federal Strategic Plan to Prevent and End Homelessness, to which we have referred several times says, "Economic downturns have historically led to an increase in the number of people experiencing homelessness.  In the last three decades, however, the number of people experiencing homelessness has remained high even in good economic times."

Opening Doors places the blame for homelessness on what it calls the convergence of three key factors: 

• The loss of affordable housing and foreclosures;
• Wages and public assistance that have not kept pace with the cost of living, rising costs, job loss and underemployment with resulting debt;
• The closing of state psychiatric institutions without the concomitant creation of community based housing and services.

Initial responses to the issue of homelessness originated with local governments and non-government organizations (NGOs) and took the form of emergency, stopgap measures.  Depression-era style soup kitchens started up in neighborhoods where the homeless congregated and shelters were opened in church basements and abandoned facilities (ironically sometimes the very mental hospitals that had been closed, forcing patients into the streets) and armories. Typically these only provided overnight housing; clients were sent back out into the streets in the morning.  Many shelters limited the number of visits each week or month and some were open only in months when temperatures - hot or cold - were the most extreme.  Many of the homeless avoided shelters, feeling they were dangerous either to themselves or their few possessions; others were unable to comply with shelter restrictions on drugs, alcohol, or tobacco.  Some preferred the streets to separation from a friend or family member when a shelter prohibited adolescent males or served only one gender while other families were involuntarily split. 

Even as shelters became entrenched as institutions, individuals and agencies working on the front lines were realizing that temporary shelter did not break the cycle.  According to Opening Doors, an estimated 17 percent of the homeless and 26 percent of individual homeless individuals are chronically so, spending years "on the streets or cycling between hospitals, emergency rooms, jails, prisons, and mental health and substance abuse treatment facilities at great expense to these public systems." 

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

While the original federal response to homelessness was also to treat it as a short-term crisis and promote emergency responses such as shelters, as the problem grew larger and more entrenched, the approach became one of a continuum of care, "the theory being that people experiencing homelessness would progress through a set of interventions, from outreach to shelter, into programs to help address underlying problems, and ultimately be ready for housing."

Today that thinking too has changed.  The emphasis is now on what is called a Housing First approach.  Housing agencies concentrate on getting people into a stable housing situation as soon as possible.  It is no longer seen as a goal, but as an important part of the solution.  Once housing is secured, the client can be plugged into appropriate support services.  This makes sense from several standpoints; the client has a permanent address and can thus apply, not only for benefits but also for work.  With the recurring if not constant need to locate shelter removed, the client can concentrate on other aspects of recovery, and finally, there is the simple psychological benefit of security.

Two models of Housing First have evolved.  In the first, housing developments or apartment buildings are designated as supportive housing with services built into the location itself.  In the second, participants are given vouchers to obtain housing in the private sector and support home visit services to address mental health, substance abuse issues. 

The effectiveness of homeless prevention and treatment initiatives, however, still suffers because responsibility is so scattered.  A 2005 study by the Congressional Research Service of the Library of Congress found federal programs operating in the U.S. Departments of Housing and Urban Development, Health and Human Services, Veterans Affairs, Homeland Security, Labor, Education, and Justice.  On the state and local levels there are housing finance agencies, state and locally operated shelters, mental health and school based programs to name just a few, plus  countless initiatives operated by NGOs.  Many of these public and private programs mix state and private funds with a multiplicity of funding from the federal agencies named above. 

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