Conference Panel: Housing and Treatment

By Melissa Capers

A man who is homeless and mentally ill is attacked and set on fire. After medical treatment of his injuries, he is discharged back to the streets, where an infection develops that results in the amputation of both his legs.

What do you do when this man tells you that it's hard for him to live indoors, and he wants to go hang out on the streets with his buddies? If you're Joshua Bamberger, M.D., M.P.H., Medical Director of the San Francisco Department of Health's Division of Housing and Urban Health, you provide housing through the Direct Access to Housing (DAH) program—and a bus ticket—so that after spending a day with his friends, this man can make his way back home safely.

Dr. Bamberger shared this story at the "Housing and Treating the Homeless" panel as a way of describing the balance between housing and treatment in San Francisco's DAH program. Safe, permanent housing is a central priority of the DAH program. Homeless persons with mental health and substance use disorders are moved into permanent housing directly from emergency shelters, emergency rooms, mental hospitals, and the street, without a requirement that they engage or remain in treatment.

Treatment is available, residents are safer than they would be on the street, and DAH staff members are trained in a management approach called "active engagement." Going well beyond the traditional landlord role, DAH staff members check on and provide support to residents. They offer services that can include rental assistance and treatment referrals.

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Positive Outcomes

Dr. Bamberger and other panelists presented evidence suggesting that the provision of housing can have multiple positive outcomes for homeless people with co-occurring disorders—including increasing the effectiveness of substance abuse treatment. Several of the programs described during the panel presentation are ongoing and funded by SAMHSA.

Margot Kushel, M.D., M.P.H., and Eric Kessel, Ph.D., of the University of California-San Francisco compared health care usage among residents of San Francisco's DAH housing in the 2 years before and after housing placement. They found a significant reduction in emergency department visits and inpatient medical hospitalizations after placement.

Carole Siegel, Ph.D., and Judith Samuels, Ph.D., of the Center for the Study of Issues in Public Mental Health, in Orangeburg, NY, conducted an analysis of resident outcomes in different types of housing programs as part of a nationwide multi-site SAMHSA Housing Initiative. They found that residents of housing programs that provided access to—but did not mandate—treatment were more likely to stay in housing longer and use crisis services less than residents of structured programs with mandatory treatment.

Susan A. Pickett-Schenk, Ph.D., of the University of Illinois at Chicago, and Ed Stellon, M.A., and Karen Batia, Ph.D., presented findings from Heartland Health Outreach in Chicago. These researchers found that participants who requested but did not receive housing were twice as likely to abuse substances 1 year after treatment as were those who received requested housing services.

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Keeping the Balance

Although the panelists agreed that housing should be a central priority in providing treatment and services for homeless persons with co-occurring mental health and substance abuse disorders, they also agreed that housing alone is not the answer. Residents need a wide range of services. Research and evaluation in this area must continue in order to shape and improve future housing and treatment approaches.

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