Issue #152, Winter 2007

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 more independently. But one San Francisco advocate sees more neglect than support.

By Martha Bridegam

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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?

A 2006 federal study commissioned by the Department of Housing and Urban Development (HUD) found that during 2004 a quarter of tenants nationwide left permanent supportive housing after less than two years of residency. Proof that San Francisco doesn’t have the worst record, the same study found low retention rates in Philadelphia, where 385 of 943 tenants, more than 40 percent, in supposedly “permanent” supportive housing left during the 3 1/2-year study period. Two-fifths of those who left were asked to leave for violating program rules or for being “incapable of maintaining themselves in the permanent supportive housing environment,” which, in my experience, simply means a tenant needs more help than a program wants to provide.

San Francisco’s Care Not Cash, which places indigent single adults in supportive housing, has received harsh criticism from tenant advocates who believe too many people housed through the program leave or are evicted. Care Not Cash ostensibly provides housing and supportive services to people with or without disabilities, but advocates complain that the program’s managers neglect tenants with disabilities and then threaten to evict them when disability-related lease violations arise.

In a November 2006 San Francisco Chronicle op-ed, Iranyi called for an audit of Care Not Cash’s evictions and coerced departures. Although Mayor Gavin Newsom claimed in his 2006 State of the City address that 95 percent of the 2,222 people in the program “remain housed,” Iranyi wrote that her own and others’ anecdotal experience made her “extremely concerned about the number of residents who are forced to move out of managed properties through evictions, threats of eviction, or failure to maintain residency for reasons directly or indirectly related to the resident’s disability/history.”

Local advocates have criticized the practices of the John Stewart Company, a large private property manager, and the Tenderloin Housing Clinic, a nonprofit with roots in tenant activism, although several advocates recognize that Tenderloin Housing has become more sensitive to tenants with disabilities in recent years. Deputy director Debbie Raucher says that Tenderloin Housing has established an eviction-prevention protocol that now calls for holding meetings, issuing warnings, and offering a last-chance opportunity in the form of a “housing retention contract” before it begins eviction. John Stewart Company president and CEO Jack Gardner rejected claims that evictions were excessive in the 10 buildings his company manages for the city of San Francisco. The average building, he says, “experiences only 2.6 evictions per year—80 percent of which are for nonpayment of rent and the balance for behavioral issues.” Nevertheless, he acknowledges that mismatches do exist between tenants’ needs and a building’s available services. He says this happens because managers accept tenants who are a bad fit because of the shortage of supportive housing and the urgency of getting people indoors.

Some San Francisco programs have been successful at keeping seriously disabled tenants housed. The city-operated Direct Access to Housing (DAH)—which houses nearly 900 tenants, all frequent users of city medical or mental-health services—does so by providing one case manager for every 15 to 20 tenants. It also provides exceptional access to medical and psychiatric staff. Marc Trotz, DAH’s manager, says eviction is rare, generally related to health and safety concerns, and pursued only after “pretty extraordinary attempts” have been made to rectify problems.

There is no national standard to define supportive housing. It can take the form of small buildings with onsite services or scattered-site housing with visiting service providers, but the more commonplace type is the “big box,” a large residential hotel or apartment building that houses 50 to 100 tenants and has on-site services. Almost all of San Francisco’s programs are big boxes.

Much of the funding for the nation’s supportive-housing programs comes from federal McKinney-Vento grants, frequently serving people the federal government calls “chronically homeless”: those who are mentally disabled or suffer from addiction. A 2001 paper by the Technical Assistance Collaborative suggested that the McKinney-Vento criteria favor big boxes to the detriment of disabled tenants: “To a certain extent, the complexities of aggregating sufficient capital, operating, and supportive-services resources, and the efficiencies that can be achieved with larger site-based models, have driven the most common models of supportive housing for homeless people. However, these high-density approaches are not favored by most housing advocates for people with significant disabilities.”

Paul Boden, executive director of the Western Regional Advocacy Project (a coalition of homelessness organizations), says neglect of serious mental disability is “more common than not” in a big box. Managers often fill buildings with people who share similar disabilities and assume tenants all have the same needs. Such segregation is still legally defensible, even though the 1999 Supreme Court decision in Olmstead v. L.C. held that people should not have to live in segregated places in order to receive treatment. In this environment, it becomes particularly easy to skimp on service spending and to neglect individual needs. If one tenant needs more help than others, the response is not “What else does X need?” but “Does X belong here?”

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.

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