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The big-box environment also encourages creaming—choosing people who are the easiest to help. Michael Allen, a Washington, D.C.-based civil-rights lawyer formerly with the Bazelon Center for Mental Health Law, says HUD has encouraged creaming by demanding measurable results in federal homelessness programs, such as tallies of successful graduates who move on to conventional housing. He says property managers pick tenants who are “easiest to serve and [have] the best attitude” and label people with mental disabilities or tendencies to assert their rights as troublemakers. Jennifer Mathis, deputy legal director at Bazelon, says many supportive-housing programs impose such rigid behavioral rules on tenants that “you basically can’t have a mental illness” to stay there.

Boden says some programs foster “inherent creaming by understaffing and under-funding the support portion of the program.” Managers don’t have adequate resources to serve the most disabled, so they reject or evict them. He equates this breakdown in care to “a system where the nurse goes out to the emergency room and sees who’s got the least amount of injury and brings them in because there’s no doctors. Does that make the nurse an asshole? I no longer agree that it does. I used to think it did.”

DAH’s Trotz sees a growing “second wave” of supportive-housing thinking that recognizes the need to “not kick people out on their conditions.” He says within the last year “we had many difficult conversations with our [service] provider community to say ‘let’s raise the bar.’” But, he believes that, while management may agree, change requires “educating down to” property managers and support staff.

If trickle-down enlightenment fails to reform the big-box model, the scattered-site model presents a hopeful alternative. Unlike the big-box practice of segregating tenants according to disability, scattered-site programs rent apartments for their clients in private buildings and provide on-site services as needed. One of the most acclaimed scattered-site programs is New York City’s Pathways to Housing. Run by Dr. Sam Tsemberis, Pathways houses survivors of long-term street homelessness. Tenants receive visits from an expert interdisciplinary Assertive Community Treatment team of medical, psychiatric, and social-work professionals.

Some scattered-site programs, such as JOIN in Portland, Ore., use non-credentialed peer counselors. JOIN’s executive director, Marc Jolin, says his organization doesn’t provide professional counseling, but rather offers “friendship and support.” When problems come up that jeopardize tenants’ housing, says Jolin, “we get to the problems before the landlords figure them out.” If a tenant does have to leave a particular rental, JOIN helps with the move and stays in touch at the next placement—an advantage over big-box programs that cut off services when a tenant leaves.

Tsemberis calls for supportive housing that adopts a “radically consumer-driven” approach that places tenants in charge of their own treatment and services: Instead of providing care that has been tailored for a building, he advocates designing treatment and services that address the needs of the individual. “Say ‘How can I help you?’ and mean it,” he advises. As trust builds, he says, it becomes OK, for example, to ask someone not to pace at night if it bothers neighbors.

Tsemberis and civil-rights lawyer Michael Allen argue for separating housing from mental-health and addiction treatment. Tsemberis says when people are placed in situations where housing and treatment are dependent on one another, they have a tendency to revert to behaviors such as hoarding, withdrawal, and drug abuse. They begin a cycle that can eventually get them evicted, and that only adds to their suffering.

Bazelon’s Jennifer Mathis says, “The supportive scattered-site model seems to be the most successful model, and it’s the least expensive.” Tsemberis estimates that housing and services under Pathways to Housing costs $20,000 to $22,000 per person per year, compared with $28,000 to $35,000 for a New York City shelter cot with services, or costs of $40,000 and up for a supportive-housing residential hotel room with services.

For all its strengths, scattered-site housing for the mentally disabled may not be the perfect approach either. JOIN’s Jolin says, “You can bureaucratize anything, dehumanize anything.” The real need is for mentally disabled poor people to receive services based on what they need, not where they live.