CLINICAL HANDBOOK OF SCHIZOPHRENIA

CHAPTER 40HOUSING INSTABILITYAND HOMELESSNESSALAN FELIXDAN HERMANEZRA SUSSERAs deistitutionalization proceeded in the 1960s and 1970s, the typical length of stay inpsychiatric hospitals shortened dramatically, whereas the number of admissions to theseinstitutions increased. This so-called “revolving door” reflected the inadequacy ofcommunity-based services to keep those with severe and persistent mental illness from therecurring cycle of relapse and rehospitalization. During this period, however, most localitieshad sufficient supplies of affordable, if not desirable, housing, such that homelessnessamong mentally ill people was relatively rare. Beginning in the early 1980s, economic factors,combined with a rapidly shrinking pool of inexpensive housing throughout much ofthe country, contributed to a dramatic rise in the number of homeless people with schizophreniaand other severe and persistent mental illnesses. Ever since, the problem of “thehomeless mentally ill” has become a widespread and vexing phenomenon, capturingbroad concern and ongoing attention from citizens, advocates, mental health professionals,and public officials.In addition to its dramatic impact on morbidity and mortality, homelessness and residentialinstability impede the ability of mentally ill people to access and benefit fromneeded treatment. Furthermore, it contributes to deterioration in social functioning andattenuation of social bonds and family support. To minimize homelessness and its associatedadverse outcomes, it behooves clinicians in a variety of treatment settings to developan understanding of the relationship between severe mental illness (SMI) and homelessness,and its implications for the delivery of psychiatric and allied services.Over the past 20 years, experience gleaned from innovative clinical programs, combinedwith a growing body of descriptive and intervention research, has provided aclearer yet still evolving picture of the complex needs of this population and an initial understandingof the kinds of service approaches that may be most effective. In this chapter,we first summarize findings on the prevalence of homelessness among people with SMIand the key factors associated with risk of homelessness in this population. We then dis-411