The New York Times and ProPublica recently published articles that exposed some of the failures of our supportive housing and community-based systems of care for individuals with serious behavioral health conditions. These articles detailed the plight of some who have “slipped through the cracks,” so to speak. Although most occupants of Office of Mental Health (OMH)-funded supportive housing programs manage their health conditions with relative success and enjoy a greater quality of life than would be available to them within institutions, there are surely some who are unable to secure the services needed to survive, much less thrive, in independent settings. In recent decades the locus of care for our most vulnerable citizens has moved to the community, and alternatives to institutionalization in all its forms has gained considerable popularity within virtually every level and branch of government. It has also garnered support from stakeholders of diverse political stripes. In fact, it is one of the few issues on which conservative and progressive partisans find agreement in a highly polarized political environment. Thus, many individuals who might have been relegated to institutional care in previous eras are living freely in their communities and enjoying the promise and privilege that attend this status. Many, that is. By no means all.
This “movement” is certainly not new. It began more than 50 years ago with the passage of the Community Mental Health Act, one of President Kennedy’s last accomplishments (he signaled his support for it during a joint session of Congress about a month before his assassination). This inaugurated a period of “deinstitutionalization” whereby long-term patients of state-operated inpatient facilities were gradually repatriated to their communities of origin. This Act was accompanied by a promise to reinvest savings derived from the closure of inpatient facilities in community-based systems of care that would provide individuals with severe mental illness, intellectual and developmental disabilities with the services needed to succeed in less restrictive settings.
Even the most casual observers of public mental health policy acknowledge this promise was not kept. The temptation to retain savings in state coffers or to redirect them to other purposes simply proved too great for policymakers, and this trend continued through each subsequent iteration of the deinstitutionalization movement including the most recent one highlighted in the Times and ProPublica pieces. These articles explored the ramifications of a 2014 legal settlement that followed an exposé of substandard conditions within “adult homes” and led to the relocation of many of their residents to Scattered-Site Supportive Housing programs. This settlement was surely borne of noble intent and purpose. Many of the adult homes in which people with serious mental illness languished did indeed provide substandard care. Some were rife with abuse and neglect. Most were developed at the dawn of the deinstitutionalization movement and absorbed many former occupants of state-operated psychiatric centers. They were designed to offer less restrictive accommodations coupled with the clinical and rehabilitative services essential to ensure their residents’ success, but they failed to deliver on their promise for the reason referenced above. Most simply lacked the resources necessary to provide comprehensive care and became little more than de facto “warehouses” for the most vulnerable. The squalid state of many adult homes is a poorly kept secret that has persisted for decades, and it surely would have been exposed many years ago if it had been visited upon a less marginalized population. Author and historian Ron Powers offers one explanation for this injustice in a memoir that describes his sons’ experiences with serious mental illness. It is entitled No One Cares About Crazy People.
When people do care, that is, when tragedies are perpetrated by or upon those with serious mental illness and they happen to attract media attention, fleeting episodes of collective hand wringing ensue and invariably lead to reactive policy pronouncements or proclamations of wrongdoing on the part of a presumed bad actor. Adult homes and their operators became natural targets of public ire and vilification for the manner in which they served those entrusted to their care but they were scarcely alone in their culpability. They were, and are, a logical but tragic consequence of decades of chronic underfunding of our public mental health system.
The legal settlement referenced in the Times and ProPublica investigations was touted as a corrective to these ills, and it was laudable insofar as it enabled many individuals to exit adult homes and to enjoy newfound dignity and an improved quality of life within Scattered-Site Supportive Housing programs. These programs customarily offer independent living accommodations within studio- or one-bedroom rental units available in the open market along with financial assistance and limited support services. But therein lies the rub. The services provided within Scattered-Site Supportive Housing are truly limited and were originally designed for those who had already cultivated most of the skills needed to live independently. OMH funding for this program is scarcely sufficient (and in many cases insufficient) to cover providers’ property costs, let alone the provision of housing support services for vulnerable residents. Therefore, occupants who require more extensive or comprehensive support must access it through other community-based programs, but these programs are similarly ill equipped to meet the needs of an ever-increasing population of individuals with serious mental illness, substance use and physical health conditions. Some highly compromised and vulnerable individuals who experienced neglect within adult homes were effectively condemned to the same fate in Scattered-Site Supportive Housing. Neglect, by any other name or circumstance, remains neglect.
Before we rush to judgment and condemn Scattered-Site Supportive Housing for its failures, however, we must examine it and every other facet of our publicly-funded mental healthcare system in the context of the whole. Again, this provides a welcome and cost effective alternative to institutionalization for many with serious mental illness and other significant life challenges. But it cannot deliver this to everyone in the absence of a truly robust and responsive system of community-based treatment and rehabilitative services. In short, it requires what was promised at the inception of deinstitutionalization – a broad and meaningful reinvestment in the safety net that supports the most vulnerable among us. This is critical to the success of our health and social service systems. It is also the measure by which our society will be judged.