CLINICAL HANDBOOK OF SCHIZOPHRENIA

294 IV. PSYCHOSOCIAL TREATMENT• There is provision of direct assistance in obtaining housing and establishing ahome.• Consumers control personal space and are accorded personal privacy.• There is an emphasis on supporting the person in achieving success at typical tenantroles and responsibilities.Rental subsidies allow people to experience shortened hospital stays, to exit homelessnessfaster, to maintain involvement with mental health services, and to improve thequality of the housing that they attain. The lack of rental assistance keeps people homelesslonger and extends hospital stays. Unfortunately, the low rent levels allowed underFederal rental subsidy programs often do not allow people to live in neighborhoods withhigh-quality housing, and people often have to contend with unsafe neighborhoods, evenwhen their rent is subsidized. Over time people do attain a sense that their supportedhousing environment is their home.Effective housing development strategies lie beyond the scope of this chapter, and informationis contained in technical assistance documents rather than in formal peer reviewliterature. Housing finance has its own language, and mental health agency staffmembers must master technical housing development techniques and language to participateeffectively in expanding the availability of low-income housing options.While many mental health agencies have become involved in low-income housingdevelopment or advocacy, a clear separation of housing management and service deliveryis encouraged in a supported housing approach. This separation ensures that (1) housingis the person’s home rather than primarily a service environment; (2) typical guidelinesconcerning tenant responsibilities are followed rather than being confounded with clinicalissues; (3) tenant rights and evictions are handled properly; (4) stigma is avoided, andparticipation in community life is more fully supported, and (5) unethical dual relationshipsdo not arise.Who Can Be Successfully Served in Supported Housing?Many studies to date have indicated that supported housing is effective even for peoplewho are considered “most difficult to serve”—including people with severe disorders andmultiple recent involuntary hospitalizations. Approximately half of all people with psychiatricdisabilities who are homeless also have a substance use disorder. Dual diagnosishas been found to make housing stability more difficult to achieve, increases the risk ofhomelessness, and lengthens the time people are homeless. People with substance abuseare more likely to leave supported housing, sometimes in the early days or weeks after entry.Housing and supports are seen as critical resources that support effective dualdiagnosistreatment. Specialized approaches that have been advocated involve active engagement,crisis intervention, persuasion, relapse prevention, and adequate housing.Some ethnographic research indicates that stable supported housing is causally associatedwith diminishment of problematic substance use over time. Such research indicates thataccess to decent housing is one quality-of-life factor that serves to reduce substance abusein persons who were formerly homeless.One form of supported housing has been found to be highly effective for personswith a dual diagnosis of mental disorder and substance abuse, even though the programdoes not demand abstinence as a precondition for tenancy. The Pathways to Housing orHousing First program model (Tsemberis & Eisenberg, 2000) does not demand that peopleundergo treatment or achieve abstinence from drugs or alcohol use prior to placement