CLINICAL HANDBOOK OF SCHIZOPHRENIA

40. Housing Instability and Homelessness 419TABLE 40.1. Best Practices in Supported Housing• Rental subsidies are provided.• Housing is protected while the person is in crisis.• Consumer choices and preferences are honored.• Assistance is available in obtaining and establishing a home.• The consumer controls his or her personal space and privacy.• The consumer has typical tenant roles and responsibilities.• Individual or team support services have low caseloads.• Support is available 24/7, with frequent contact.• Direct support and assistance are flexibly tailored and provided in vivo.clinical level, recent evidence suggests that approaches in which the same clinicians treatboth disorders at the same time, so-called “integrated” treatment programs, are effectivein reducing substance abuse in this population.Controversy exists regarding the effectiveness of residential programs that permitsubstance use (e.g., the so-called “wet house,” where alcohol is permitted) for peoplewith coexisting substance abuse and mental illness. Supporters of a harm reduction ideologyargue that it is better for people with dual disorders to have a home and access tohelp, especially while actively using substances, than to be on the street getting high andgoing untreated; others believe that a so-called “zero-tolerance” to substance use is thepreferred treatment approach for persons with SMI. No current, definitive empirical evidenceclearly demonstrates the superiority of either approach.TREATMENT GUIDELINESMost of what we have discussed so far relates to the program or systems level. Yet thereare important guidelines for the individual clinician working with people with schizophreniawho are homeless or vulnerable to becoming homeless. These guidelines are generaland should apply to all phases of a patient’s recovery, but clinicians obviously mustadjust their approach to where the patients are in the course of their illness and homelessness.1. Meet the patients “where they’re at.” We mean this both literally and figuratively.Clinicians who treat homeless people should be prepared to work outside on the street, inparks, and perhaps in subway tunnels and other public spaces. Shelters, soup kitchens,and drop-in centers are other settings to meet homeless people. When doing so, cliniciansTABLE 40.2. Treatment Models and Best Practices• Outreach and drop-in centers• Intensive therapeutic case management• ACT• CTI• Supportive housing and Housing First• Integrated dual-disorder (mentally ill and chemically abusing [MICA]) services