CLINICAL HANDBOOK OF SCHIZOPHRENIA

288 IV. PSYCHOSOCIAL TREATMENTas nursing homes, board and care homes, and other residential care facilities, or are confinedto skid row urban areas, a process that has been called ghettoization. Supportedhousing seeks to end the social segregation of people with psychiatric disabilities in unnecessarilyrestrictive settings and to improve housing options, so that people are notforced to live in substandard conditions.Supported Housing as a Response to Epidemic HomelessnessPeople with prolonged psychiatric disabilities have a disproportionately high risk ofhomelessness according to epidemiological studies, and are greatly overrepresentedamong the population living in shelters and on U.S. streets. Research findings vary widelyon the proportion of the homeless population that experiences serious psychiatric problems,ranging from 20 to over 90% of any given homeless study population, as assessedby clinical ratings, self-report, or other methods. Significant psychiatric history or currentimpairment is commonly found among 20–30% of homeless study cohorts.People with psychiatric disabilities have at least a tenfold excess risk of homelessnessabove that of the general population. It is estimated that 1 in 20 adults who experiencesevere psychiatric disabilities is homeless in the United States. Once homeless, peoplewith psychiatric disabilities fare very poorly, even when compared to other people whoare homeless. They experience worse physical health, have fewer subsistence needs met,poorer objective and subjective quality of life, and higher rates of victimization than doothers, and are more likely to live on the streets and remain homeless longer.Why do people with severe psychiatric problems carry such a high risk for homelessness?Disproportionate homelessness has been attributed to lack of adequate social planningunder the policy of deinstitutionalization, the lack of transfer of resources from statehospitals to communities, and inadequate development of community-based residentialprograms. Psychiatric disabilities contribute to the problem through the life-disrupting,episodic nature of many major psychiatric disorders; the lack or loss of daily living skillsdue to serious impairment; the high incidence of co-occurring substance abuse disorders;and the heightened vulnerability to stress and social isolation that often typify the lives ofthose with such disabilities. Studies have shown that multiple foster care or institutionalplacements during youth strongly correlate to later diagnosis of psychiatric disorder andto homelessness.These risk factors result in the need for a range of supportive services and specializedreasonable accommodations if people are to succeed at community living. Unfortunately,housing assistance programs, mental health services, and social service programs generallyremain fragmented and difficult to negotiate. Differing eligibility criteria across mentalhealth, substance abuse, social services, and public housing programs further contributeto the problem.Social-structural concerns are also blamed for widespread homelessness. These problemsinclude increased competition for a declining number of affordable housing unitsand the general lack of affordable housing for people with low incomes. People with seriouspsychiatric disabilities are among the poorest of the poor. Their personal income isoften limited to Supplemental Security Income (SSI)—the Federal entitlement programthat provides an income to people who are assessed to be permanently disabled. Thissubsistence allotment generally does not exceed 25% of local median incomes. Studies ofhousing affordability reveal no housing market in the United States where a person on SSIcan afford a modest efficiency or one-bedroom apartment, using Federal income–housingcoststandards. People who rely on SSI for their income are too poor to obtain decenthousing without other forms of assistance.