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Special Section on Social Integration   |    
Commentary: The Counter-Reformation That Failed? A Commentary on the Mixed Legacy of Supported Housing
Kim Hopper, Ph.D.
Psychiatric Services 2012; doi: 10.1176/appi.ps.201100379
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Dr. Hopper is affiliated with the Center to Study Recovery in Social Contexts, Nathan S. Kline Institute for Psychiatric Research, 140 Old Orangeburg Rd., Orangeburg, NY 10962 (e-mail: hopper@nki.rfmh.org). This commentary is part of a special section on social integration of persons with mental illness, for which Robert A. Rosenheck, M.D., served as guest editor.

Copyright © 2012 by the American Psychiatric Association.

Abstract

The articles in this special section rejoin a conversation about the terms and conditions of social participation that was suspended some time ago. While welcoming the move, this commentary raises some questions about the vehicle. The formidable achievements of supported housing notwithstanding, it still functions as an abeyance mechanism ensuring its occupants a kind of sheltered livelihood. Arguably, then, the larger social questions gathered under the encompassing terms of social inclusion and citizenship will not be fully addressed, and may be occluded, either by declaring supported housing a forward operating base of recovery or by rewriting its original remit as an undeclared experiment in reintegration. To extend its promise will mean first confronting the purposes served by supported housing, by design or default, in its present configuration. (Psychiatric Services 63:461–463, 2012; doi: 10.1176/appi.ps.201100379)

Abstract Teaser
Figures in this Article

One's first response to this special section is relief: at long last, the field appears to be rejoining a conversation suspended in this country some 30 years ago. In the late 1970s, the limits of the Community Support Program (CSP), which had championed social inclusion, became all too apparent. One touchstone was Making It Crazy (1), which documented in unflinching, unforgiving detail just how thoroughly a folk psychiatric divide (“crazies” versus “normals”) governed the lives of ex-patients. It wasn't just stigma or threadbare “natural supports” that were the problem. Disability benefits turned a clinical condition (“chronicity”) into a social status, contriving a livelihood at the cost of second-class citizenship and social exclusion.

But the reappraisal conversation soon faltered, defeated first by politics and then by homelessness, which rippled through the United States on a scale not seen since the Great Depression. A stranger to asylum, here was King Lear's “unaccommodated man” abandoned to the urban heath. Rebuilding community support structures was suddenly beside the point. Survival trumped social inclusion, making shelter the order of the day.

Against that backdrop, the achievements of supported housing as a response to homelessness are formidable indeed, and the reflections that follow are not meant to gainsay them. Suspending the conversation about community in deference to the more urgent one of housing was the right thing to do. Following through on that commitment, largely at the evidence-based urgings of advocates, was a cause for celebration. The state stepped in to enact a partial market correction, creating supply and upgrading demand to make desperately needed housing available to people who are usually at a competitive disadvantage in securing it for themselves. In New York City, the results were evident in declining shelter censuses. Nothing like it had been seen since the social projects of the 1930s.

But no targeted program suffices to rewrite cultural scripts or to undo structures of discrimination centuries in the making. Pervasive social suspicion, “pollution” fears, distancing maneuvers both grotesque and subtle, willful ignorance, wholesale shunning—the intricate choreography of discredit and exclusion that Goffman limned a half-century ago (2)—proved a far more stubborn part of the American experiment than any re-education and rehousing campaign could correct. Recent research confirms the recalcitrant hold of stigma despite the inroads of the neurobiological model (3). The real question remains not symptoms (which can be controlled) but biography (which cannot be rewritten) (4). Supported housing slips the leash of custody and drops institutional signage, but residents must still negotiate an unwelcoming world (5).

The reappraisal of CSP had inaugurated a conversation about membership, about the terms of social regard and participation, about work and schooling, about family (of propagation not nativity) and friendship—about all those markers of belonging that when found missing, set the wheels of stigma in motion. It was, to use a framework in which the debate is being restaged in academic circles today, a conversation about both redistribution and recognition, with politics thrown in for good measure. The hidden injuries of relative deprivation were of no less concern than the subtle slights (institutional and interpersonal) of status subordination. As Rowe and colleagues (6) report in this issue, the success of supported housing raises questions of citizenship in an unusually rich and encompassing sense of the term. Flourishing and freedoms take the stage alongside the more conventional rights and responsibilities of political participation. In the development lexicon lately adapted for use in the mental health field (79), once a claim to membership has been formally validated, what “capabilities” should naturally follow?

However, to promote supported housing as “the cornerstone of any psychosocial recovery system … designed to support community integration beyond simple relocation” (as a recent conference invitation does) may subvert rather than extend its accomplishments. Rejoining social participation and citizenship under the auspices of recovery risks framing these issues under a rubric of (supposed) empowerment rather than (much needed) accommodation. The dominant chords in recovery discourse are hope, self-determination, and a personalized journey, which are commonly sounded in ways that minimize the decisive roles of structure, state, culture, and society. Individual-level agency, not system-level adjustments, sets in motion the “process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (10).

In the process, the arduous institutional work of rewriting rules and allocating resources (flexible income support, secure health insurance, school and work options, and even shared decision making) that is needed to make good on recovery as a political project tends to be sidelined, when it is acknowledged at all. By the same token, the social complications of reclaiming a life are awkwardly ignored. (In some programs, romantic commitments or becoming a parent can jeopardize tenancy.) Part of the problem is simple mental health parochialism: even with a Presidential charter and a commission fully cognizant of the necessity of cross-sector coordination (11), recovery has remained an essentially in-house discussion, confined largely to the ranks of clinic workers and activated peers in the community. Public mental health has never been very good at playing well with institutional others; but a disinclination to reach out today amounts to a refusal to see what its own project requires.

So what should one make of the limited accomplishments of supported housing? Are they the once-promising leading edge of a major social reclamation project or something more modest and in keeping with the original ambitions of supported housing (12)? Let's acknowledge its contributions to stabilizing a life, offering “ontological” security (13), and providing an anchor from which to claim a place in the world. Still, the limits of that achievement—with individuals confined to social margins even while embedded in urban centers—are also instructive. For Mizruchi (14), such compensatory programs serve as “abeyance mechanisms” (or holding actions) for the socially unfit, removing potentially troublesome populations from the social mix without fully disenfranchising them. The lack of any real dissension about this policy, let alone active protest, that some have noted (Rosenheck RA, personal communication, May 23, 2011) may indirectly attest to the familiarity and acceptability of such strategies.

Therefore, it might be sociologically naïve to construe supported housing as a bid for conditional belonging, a kind of social probation. Containment, no less than sanctuary, is its purpose. In Goffman's original formulation, stigma designated not only the social act of exclusion but also the moral reasoning that went along with it. So stigma and discrimination are not merely linked; discrimination is the (freshly justified) point of stigma, the functional (if unacknowledged) reason for its deployment (15). From this vantage, supported housing programs are effectively tilted in favor of social defeat, if only because they leave the bulk of the work of reintegration to individual initiative. Blocking access to scarce resources that are needed to open up real opportunity is how abeyance mechanisms are supposed to work: they warehouse redundant individuals without calling undue attention to their disutility. Occasional departures from this model (such as supported employment) constitute useful exceptions, whose limited availability serves to advertise possibility while cautioning prudence. Supported housing's champions are not blind to such limitations (13,16); the question is how to interpret them.

It is no reproach to note the structural kinship of supported housing and abeyance mechanisms. To purport otherwise, to retail it as the first step in an ambitious program of reintegrative moves, is to extend its reach far beyond its original remit. And it may be at cross-purposes with what, sociologically, is encoded in its practice: that social reintegration is a matter of sufferance on our part, not earned membership on theirs. To seek to renegotiate the terms of some vague implied contract, or contrive to interpret it as having promised social inclusion all along, is either an inspired piece of strategic misreading or an exercise in bad faith.

Stigma may weather and eventually fade, but in the short term it concedes nothing without a struggle (17) or some countervailing claim to moral worth (18). For those in whose interest stigma is deployed, it reinforces a host of social distinctions and privileges, without the trouble of having to articulate them, and ratifies useful misrecognitions. Urban neighborhoods under assault from commercial advertising, gentrification, and housing shortages may not welcome queue-jumping renters bearing state subsidies. An increasingly nonunionized labor force can hardly be expected to champion moves to return otherwise (un)occupied adults to the ranks of job seekers, especially if the latter are promised preferential placement. Like the introduction of compulsory secondary education in the 1930s, Supplemental Security Income provides a functional alternative to work and eases market competition for jobs. But high school only delays labor market entry; it doesn't foreclose it altogether. Thus a better abeyance analogy might be prisons, which ensure supported housing and alternative employment for millions of otherwise hungry job seekers.

In any event, to rejoin the tabled debate over social inclusion will require more than reimagining the remit of supported housing. It will mean confronting what stands in the way of that larger project, and that will require returning to the primal scene of exile to interrogate the larger purposes it serves.

This work was funded in part by grant P20 MH078188 from the National Institute of Mental Health.

The author reports no competing interests.

Estroff  SE:  Making It Crazy .  Berkeley,  University of California Press, 1981
 
Goffman  E:  Stigma .  New York,  Simon and Schuster, 1963
 
Pescosolido  BA;  Martin  JK;  Long  JS  et al:  “A disease like any other”? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence.  American Journal of Psychiatry 167:1321–1330, 2010
[CrossRef]
 
Goldman  HH:  Progress in the elimination of the stigma of mental illness.  American Journal of Psychiatry 167:1289–1290, 2010
 
Rosenfield  S:  Labeling mental illness: the effects of received services and perceived stigma on life satisfaction.  American Sociological Review 62:660–672, 1997
 
Rowe  M;  Clayton  A;  Benedict  P  et al:  Going to the source: creating a citizenship outcome measure by community-based participatory research methods.  Psychiatric Services 63:445–450, 2012
 
Ware  NC;  Hopper  K;  Tugenberg  T  et al:  Connectedness and citizenship: redefining social integration.  Psychiatric Services 58:469–474, 2007
 
Ware  NC;  Hopper  K;  Tugenberg  T  et al:  A theory of social integration as quality of life.  Psychiatric Services 59:27–33, 2008
 
Watson  MK;  Bonhan  CA;  Willging  CE  et al:  “An old way to solve an old problem”: provider perspectives on recovery-oriented services and consumer capabilities in New Mexico.  Human Organization 70:107–117, 2011
 
 SAMHSA announces a working definition of “recovery” from mental disorders and substance use disorders.  News release .  Rockville, Md,  Substance Abuse and Mental Health Services Administration,  Dec 22, 2011. Available at www.samhsa.gov/newsroom/advisories/1112223420.aspx
 
Goldman  HH:  How do you pay the rent? Social policies and the President's Mental Health Commission.  Health Affairs 22(5):65–72, 2003
 
Hopper  K;  Barrow  S:  Two genealogies of supported housing: implications for outcome assessment.  Psychiatric Services 54:50–54, 2003
 
Padgett  DK:  There's no place like (a) home: ontological security among persons with serious mental illness in the United States.  Social Science and Medicine 64:1925–1936, 2007
 
Mizruchi  E:  Regulating Society .  Chicago,  University of Chicago Press, 1987
 
Phelan  JC;  Link  BG;  Dovidio  JC:  Stigma and prejudice: one animal or two? Social Science and Medicine 67:358–3672008
 
Yanos  PT;  Felton  BJ;  Tsemberis  S  et al:  Exploring the role of housing type, neighborhood characteristics, and lifestyle factors in the community integration of formerly homeless persons diagnosed with mental illness.  Journal of Mental Health 16:703–717, 2007
 
Parker  R;  Aggleton  A:  HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for practice.  Social Science and Medicine 57:13–24, 2003
 
Hopper  K;  Wanderling  J;  Narayanan  P:  To have and to hold: a cross-cultural inquiry into marital prospects after psychosis.  Global Public Health 2:257–2802007
 
References Container
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References

Estroff  SE:  Making It Crazy .  Berkeley,  University of California Press, 1981
 
Goffman  E:  Stigma .  New York,  Simon and Schuster, 1963
 
Pescosolido  BA;  Martin  JK;  Long  JS  et al:  “A disease like any other”? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence.  American Journal of Psychiatry 167:1321–1330, 2010
[CrossRef]
 
Goldman  HH:  Progress in the elimination of the stigma of mental illness.  American Journal of Psychiatry 167:1289–1290, 2010
 
Rosenfield  S:  Labeling mental illness: the effects of received services and perceived stigma on life satisfaction.  American Sociological Review 62:660–672, 1997
 
Rowe  M;  Clayton  A;  Benedict  P  et al:  Going to the source: creating a citizenship outcome measure by community-based participatory research methods.  Psychiatric Services 63:445–450, 2012
 
Ware  NC;  Hopper  K;  Tugenberg  T  et al:  Connectedness and citizenship: redefining social integration.  Psychiatric Services 58:469–474, 2007
 
Ware  NC;  Hopper  K;  Tugenberg  T  et al:  A theory of social integration as quality of life.  Psychiatric Services 59:27–33, 2008
 
Watson  MK;  Bonhan  CA;  Willging  CE  et al:  “An old way to solve an old problem”: provider perspectives on recovery-oriented services and consumer capabilities in New Mexico.  Human Organization 70:107–117, 2011
 
 SAMHSA announces a working definition of “recovery” from mental disorders and substance use disorders.  News release .  Rockville, Md,  Substance Abuse and Mental Health Services Administration,  Dec 22, 2011. Available at www.samhsa.gov/newsroom/advisories/1112223420.aspx
 
Goldman  HH:  How do you pay the rent? Social policies and the President's Mental Health Commission.  Health Affairs 22(5):65–72, 2003
 
Hopper  K;  Barrow  S:  Two genealogies of supported housing: implications for outcome assessment.  Psychiatric Services 54:50–54, 2003
 
Padgett  DK:  There's no place like (a) home: ontological security among persons with serious mental illness in the United States.  Social Science and Medicine 64:1925–1936, 2007
 
Mizruchi  E:  Regulating Society .  Chicago,  University of Chicago Press, 1987
 
Phelan  JC;  Link  BG;  Dovidio  JC:  Stigma and prejudice: one animal or two? Social Science and Medicine 67:358–3672008
 
Yanos  PT;  Felton  BJ;  Tsemberis  S  et al:  Exploring the role of housing type, neighborhood characteristics, and lifestyle factors in the community integration of formerly homeless persons diagnosed with mental illness.  Journal of Mental Health 16:703–717, 2007
 
Parker  R;  Aggleton  A:  HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for practice.  Social Science and Medicine 57:13–24, 2003
 
Hopper  K;  Wanderling  J;  Narayanan  P:  To have and to hold: a cross-cultural inquiry into marital prospects after psychosis.  Global Public Health 2:257–2802007
 
References Container
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