For Persons with Chronic Mental Illness: Recovery while (Still) Homeless?

Did you know that among the large population we in the United States have of homeless people, approximately 30% are people with serious mental illness! Yes, at least 30%. Fifty percent, if you count those that also have substance abuse disorder. These homeless, along with those individuals with mental illness in prison and jails, are the forgotten of our world … even at times, forgotten by the advocates of mental health policy and care. They are out of view and out of mind.  Do we assume we can’t do much or shouldn’t do much for these forgotten?


Or do we realize we can end homelessness?

The chronically homeless live in a cycle of surviving on the street, being admitted to hospitals, shelters, or jails and then going back to the street. Trying to get around and survive each day puts a tremendous amount of pressure on the individual’s mental and physical health.

Sam Tsemberis Ph.D. had a belief and an idea, and it began as his listened to those in need. His belief is that housing is a basic human right. In 1992 he founded Pathways to Housing which developed the Housing First model which provides immediate access to permanent supported housing for individuals who are homeless and who have psychiatric disabilities and substance use disorders.

“The traditional structures in place to ‘help’ the homeless population often make things worse, especially for those that have serious mental illness.  Shelters and transitional living programs often require people to pass sobriety tests and other hurdles before they can be considered for housing programs.  Housing is considered a reward for good behavior, instead of a tool to help stabilize …. ‘Living in the street’ one Pathways to Housing client said, ‘It makes you crazy.’”

“Providing someone who is chronically homeless with a home first gives them the stability that they need to begin the process of recovery.”

I couldn’t agree more … recovery is hard enough when you have a stable homeOne of the unique features of the Housing First model is that participation in treatment or sobriety as a precondition is not required for housing. The Pathways website continues:

“Housing First (HF) provides access to mental health treatment. The clients participated in support services as long as they need them, but participation in a structured program is NOT a requirement for clients to keep their housing. Clients must only agree to meet with a member of their ACT team five times a month. Multi-disciplinary Assertive Community Treatment teams (ACT) provide clinical, vocational, and health services that are client-driven. These teams are available on-call 24 hours a day, seven days a week. The team provides most services in the clients “natural environment”, usually that person’s apartment, neighborhood, or workplace. Regardless of the treatment or service, staff members work collaboratively with each client to articulate goals as defined by the client and to help move that individual toward recovery and a full and meaningful life.”   (

Housing First programs are now in several cities and states in the United States (Washington DC, Vermont, Pennsylvania, Utah, Lubbock, TX, Oklahoma City, San Francisco).

Canada adopted the Housing First program in 2014.  They had previously tested the program over four years in five cities (Vancouver, Winnipeg, Toronto, Montreal, Moncton) and had real success. Canada’s report on their test programs, NATIONAL FINAL REPORT: Cross-Site At Home/Chez Soi Project is especially encouraging.

Housing First had been successful there in at least five major ways. Here are a few highlights from the Canadian report:

Housing First rapidly ends homelessness. Canada found, across all 5 cities, that Housing First participants obtained housing and retained their housing at much high rate than usual. In the last six months of the report’s study, 62% of HF participants were housed all of the time, 22 % some of the time, and 16 % none of the time. Whereas among participants not using Housing First 31 % were housed all the time, 23 % some of the time, and 46 % none of the time.

Housing First is a sound investment.  Significant cost savings were realized for the 10 per cent of participants who had the highest costs at study entry. Over the two-year period following study entry, every $10 invested in Housing First services resulted in an average savings of $21.72.  Even services to those with moderate needs realized a savings of $3.42 for each $10 invested.

It is Housing First, it is not housing only. Most participants were actively engaged in support and treatment services through to the end of follow-up. The general shift away from crisis and institutional services to community-based services that was seen at 12 months continued for the duration of the study.

Having a place to live with supports can lead to other positive outcomes above and beyond those provided by existing services. Traditional service delivery provides positive outcomes too, but these positive outcomes are significantly greater under Housing First.

Housing First can be implemented in cities of different sizes and among different ethnoracial and cultural groups.  And now the Housing First model has an extra challenge in Yellowknife, Canada, 250 miles south of the Arctic Circle: Temperatures below -40 F are common, it’s a close-knit community, and more than 90% of the homeless are aboriginal people. “It will require a non-western approach to address this western-made problem of homelessness.” (Pathways to Housing website).


Let’s look next at a successful use of the Housing First model here in the United States – Lubbock Texas:

Moreover, Pathways to Housing is listed on SAMHSA’s
National Registry of Evidence-based Programs and Practices.

Giving homeless people housing first; and in fact giving each person their own apartment (!) sounds expensive, and I might add, innovative. Actually, the individuals contribute 30% of their income to the rent as is agreed upon within HF. Plus this housing is provided in apartments scattered throughout a community. This “scattered site” model fosters a sense of home and self-determination, and it helps speed the reintegration of Pathways clients into the community.

Sometimes as one person you think you can’t make a difference with what you do, but individuals can make a difference!  Let’s praise those who have……like Joyce Burland and the creation and implementation of NAMI’s Family to Family Education program……like Bev Young with the founding of NAMI itself in Madison, WI back in the late 1970”s……..and like Sam Tsemberis with the founding of Pathways to Housing and its model program Housing First now being duplicated across Canada and America.


When I began this article, I asked “…do we realize we can end homelessness?”  Yes we can, and in doing so we truly serve people with mental illness now living on our streets.

Mental illness can and should be followed by recovery and healing.  Join me in advocating for programs that have been shown to work and proven to be workable for those in our society most needing of our help.