#152 Winter 2007-08 — Community Development at 40

When Supportive Housing Isn’t

The rationale behind supportive housing for people with mental disabilities is that pairing individualized services with permanent housing will help them live independently. But one San Francisco advocate sees more neglect than support.

The combination of housing and services doesn't always address the unique needs of homeless people with mental illness, and too often supportive-housing tenants find themselves back on the street.

It’s a scene reminiscent of a madhouse in another century: a tenant suffering pain from untreated physical illness, malnourished, mentally frozen by anxiety, sits in a room heaped with third-hand possessions and garbage. A property manager stands in the doorway, grimacing at the smell, demanding a cleanup, and threatening penalties. The tenant feels like a prisoner. The manager acts like a warden.

This scene plays out regularly in supportive-housing projects for recently homeless people in present-day San Francisco. The tenants are not prisoners, but instead are threatened with eviction, which almost guarantees a return to homelessness. They are not physically threatened, but instead suffer from neglect, which managers often attribute to the tenants’ failure to use available services.

Supportive housing for homeless people is meant to prevent just these kinds of crises. Properly run supportive housing provides individualized services to help disabled people live independently. Possible services include case management, medical and psychiatric care, housekeeping, home health assistance, medication and appointment reminders, addiction treatment, meal programs, and life coaching. The idea is to stabilize tenants, both for their own sake and to save public dollars by avoiding the more expensive institutions such as jails, hospitals, and homeless shelters.

Many supportive-housing programs I know well don’t make these services accessible enough to people with serious mental disabilities. In the 15-odd years I’ve been an advocate for very poor people in San Francisco, I have been through several eviction-threat scenes with clients, and have heard of many, many more from colleagues and clients, and clients’ friends and neighbors. It seems accepted as normal that some mentally disabled supportive-housing tenants are neglected and allowed to fail.

I have handled some of my clients’ case management and home care myself to prevent their eviction because their assigned “case managers” didn’t. I have cleaned and decluttered rooms, negotiated with property managers, advocated with public and nonprofit service providers, coaxed tenants to accept state-paid home-care workers, made reminder calls before medical appointments, and more. This tells me that supportive services do help. It also tells me supportive housing typically fails any tenant needing careful follow-up.

Most supportive-housing programs in San Francisco provide services primarily by employing case managers to connect tenants with outside nonprofit and government service providers, though sometimes there is a visiting nurse or other medical professional on site. Medical staff, when available, can be godsends, and case managers are often good-hearted. However, case managers face frequent crises—fights, suicide threats, health inspectors, cops, paramedics, and coroners. And there’s always paperwork. They have very little time to engage with each tenant.

Disconnects result. Instead of having a therapist visit a depressed tenant, a case manager gives the tenant a phone number for a mental-health office that the tenant might never call. A case manager arranges for a home-care worker to clean a tenant’s room, without realizing the tenant feels too ashamed of her untidiness and is too fearful of management spying to let the worker inside. Such failures are easily blamed on the severity of the tenant’s disability or the tenant’s exercise of the right to refuse services. It’s easy to say that the tenant rejected the home-care worker, rather than that the counselor failed to persuade her to open the door.

Supportive staff sometimes can be culpably indifferent. Volunteer social worker Judi Iranyi works with a bipolar, speed-addicted client who for years has been homeless and in declining health. The client was evicted from a supportive-housing building after missing a rent payment because an unexpected deduction from her disability check left her short of funds. The building’s case manager never asked why the rent was unpaid. When Iranyi questioned the case manager later, the response was, “Well, I’m here. She didn’t come.” That is, the bipolar addict bore the burden of approaching the case manager, whose duty was merely to sit behind a desk.

San Francisco programs are no worse than most others around the country; in fact, some are likely better. I’ve spoken with advocates for the homeless and mentally ill around the country who find my stories match their experiences, and some national studies suggest the problems I describe are widespread. Any nationwide figure is imperfect, but the supportive-housing industry’s cheerful claims about retention rates — percentages of tenants who stay — suggest too many are leaving. In a recent newsletter published by the federal Interagency Council on Homelessness, director Phil Mangano commented that, “Permanent supportive housing works for vulnerable and disabled populations�. Today communities across the country are targeting this technology to those experiencing chronic homelessness and achieving 80 to 85 percent retention rates on average.” The unanswered question is: Why do 15 to 20 percent leave?


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