To the Editor: I read with concern the article by Martinez and Burt (1) in the July issue, which focused on a sample of homeless adults with co-occurring disorders who were given housing with no requirement for abstinence from substance use. One "successful" outcome noted by the authors was that 81 percent of participants remained housed for at least one year. The fact that people choosing to remain drug users while housed in permanent supportive housing units tended to remain in their apartments should not be viewed as a success. The absence of any mention in this report of people turning their lives around and obtaining gainful employment or leaving to rent their own apartments is a glaring failure, not only of the study but also of permanent supportive housing as a remedy.
The article speaks glowingly of the "low-demand" approach to people with substance abuse issues. With no requirement for sobriety, these individuals most likely continue to use drugs and alcohol. But what of the people with mental health issues? They too will be admitted with the "low-demand" approach, and they will not be required to take their medications or to discontinue using and abusing substances. What we see on the streets every day are individuals with mental illness abusing drugs or alcohol and not taking their medications. The explosive episodes that sometimes result can be deadly to the unsuspecting bystander. The article is very clear in reporting that most of the residents had both mental health issues and drug and alcohol addictions. But the study fell short by not examining the impact of the behavior of residents when these issues are not addressed. In essence "low demand" means low expectation of success.
Is warehousing better than living on the street? Perhaps, but take a look at the big picture. At the end of a resident's stay at the facility before he or she ends up back on the street, the only benefit that can be documented is one of fiscal savings. The revolving door that characterizes the lives of homeless people—in and out of shelters—is only protracted. According to the article, instead of staying for six months in a shelter and winding up back on the street, a homeless person can now expect a one- to three-year stay before ending up back on the street. The authors did not report—and may not know—what became of the study participants after their stay in permanent supportive housing. What percentage were evicted and for what reasons? How many (if any) find sobriety while living in permanent supportive housing, and to what may we attribute this successful outcome? What was the caseworker's level of persistence? Was it a particular faith-based outreach program that caused this life-changing outcome?
The study by Martinez and Burt showed that the housing model was less expensive than its New York counterpart, but it did little to show that permanent supportive housing ends homelessness. Rather it illustrates a myopic view of homeless human beings, relegating them to mere dollars and cents on a chart of the costs of homelessness. The true cost of homelessness is in the lives lost to drugs, alcohol, and mental illness. There is also a great cost to our global reputation as a country where we expect and allow individuals to remain in their addictions, choosing to warehouse them so that the rest of the world will not see our dirty little secrets.
Ms. Reichenbach is a homeless advocate in Hollywood, California.
Martinez TE, Burt MR: Impact of permanent supportive housing on the use of acute care health services by homeless adults. Psychiatric Services 57:992-999, 2006