CLINICAL HANDBOOK OF SCHIZOPHRENIA

418 VI. SPECIAL POPULATIONS AND PROBLEMStroduced. On one side of the debate are advocates for the “continuum” approach, whichincludes a slow, planned progression from street to shelter to transitional residence tosupportive housing and, finally, to permanent independent housing. This philosophy assumesthat “housing readiness” skills are required before housing is offered. This supportsan approach in which clinicians aim first to stabilize the patient through psychiatricand substance abuse treatment, build skills and obtain supports necessary for housingstability, then seek permanent housing as the final step in the process.On the other side of the debate, an innovative approach called “Housing First”moves homeless people with SMI and sometimes those with coexisting addictions, fromthe street directly into housing, typically independent or shared apartments located in anormal residential (i.e., nontreatment) setting. It assumes that with adequate supports,such as a payee to see that the rent is paid and an ACT team providing home visits, practicallyanyone living on the street can function in permanent housing. The assumptionunderlying this approach is that by obtaining housing before other services, people improvesignificantly simply by virtue of being off the street, and they are then more amenableto other interventions, including psychiatric and substance abuse treatment.Pathways to Housing, a New York–based organization, pioneered this approach andhas reported surprisingly high housing retention rates. Others too have shown that providingaccess to affordable independent housing (e.g., via Federal Section 8 vouchers) is away to honor the housing preferences of people with schizophrenia. Unfortunately, governmentalsupport of this housing subsidy program has been inconsistent in recent years,leading, at times, to long waiting lists for these vouchers.The Housing First approach certainly warrants strong consideration as a model forhousing homeless people with SMI. Of course, for a Housing First program to succeed, acommunity must have available, affordable housing stock. A key element to HousingFirst, therefore, is actively seeking out low-income housing and maintaining good allianceswith landlords in the community.In June 2001, the New York State Office of Mental Health (NYS OMH) hosted aBest Practices Conference that included a workshop on best practices in the field of supportedhousing. The workshop identified several emerging best practices (see NYS OMHwebsite at www.omh.state.ny.us/omhweb/omhq/q0901/SuppHouse.html) in supportedhousing. The NYS OMH views supported housing as an approach whose intent is toensure that individuals who are seriously and persistently mentally ill may exercise theirright to choose where they are going to live, taking into consideration the recipient’s functionalskills, the range of affordable housing options available in the area under consideration,and the type and extent of services and resources that recipients require to maintaintheir residence within the community. (NYS OMH website: Supported Housing ProgramImplementation Guidelines, Sec. IIA, “The Supported Housing Approach”)The recommendations for best practices in supported housing from the Best PracticesConference are summarized in Table 40.1.INTEGRATED DUAL-DISORDERS TREATMENTThe recent development of approaches that combine services for substance abuse and severemental disorder is one reflection of better systems integration as agencies on all governmentallevels recognize the ineffectiveness of maintaining totally separate agencies thattreat either mental illness or substance abuse, but not both, in an integrated way. At the