Psychiatric Residences: Notification, NIMBY, and Neighborhood Relations

The 1988 federal Fair Housing Amendments and the 1990 Americans With Disabilities Act gave mental health administrators the legal authority to forego the notification of neighbors when establishing shared, supervised houses and apartments for persons with severe mental illness ( 1 , 2 ). For many advocates notification represents a violation of consumers' privacy and civil rights and is considered a stigmatizing action that fuels neighborhood hostility ( 3 , 4 , 5 ). Other mental health administrators, however, have continued the practice of notifying neighbors, asserting that the outreach process facilitates community education and integration and diffuses opposition ( 6 , 7 , 8 , 9 , 10 ).

Advocates of both approaches maintain that their method best facilitates neighborhood integration; yet there is limited empirical evidence regarding the associations between notification and short- and long-term neighborhood relations. A few studies conducted primarily in the 1980s within single states found that notification was more likely than nonnotification to be associated with initial opposition ( 11 , 12 , 13 ). Another study was more equivocal and found that neighborhood acceptance was higher when notification originated from an agency sponsor ( 14 , 15 ). None of the studies examined neighborhood attitudes in the years after the sites opened.

It is estimated that neighborhood opposition to special needs housing occurs at one-third to one-half of all sites ( 11 , 16 ). The most frequently voiced reasons for opposition are fears of the effects on quality of life, safety, and property values ( 17 , 18 , 19 , 20 , 21 , 22 ). Much of the literature on neighborhood opposition and the Not In My Back Yard (NIMBY) phenomenon has focused on neighborhood demographic characteristics as predictors of hostility, with housing in low-income, transient, heterogeneous neighborhoods expected to generate the least resistance ( 23 , 24 , 25 ). In an effort to foster positive neighborhood relations, some mental health organizations design neighborhood siting strategies that include "postsiting" activities in the months and years after the site is established to connect residents and neighbors through events such as open houses, social gatherings, and participation in neighborhood associations ( 26 , 27 , 28 ).

The planning and development of supervised residences for individuals with serious mental illness are largely funded by state and federal dollars and involve tens of thousands of consumers annually ( 17 , 29 ). Although a goal of enhanced community integration drives many decisions before and after the neighborhood siting process, there is little empirical evidence to guide practice, and most agencies base their neighborhood notification strategies on their own philosophies and on anecdotal information gathered from various mental health providers ( 7 , 26 , 27 ). This study builds the empirical base for practice by examining the relationships between neighborhood siting strategies (including prior notification and postsiting activities), initial opposition, and longer-term neighborhood relations by using data collected from surveys of mental health administrators and on-site residential staff who discussed the neighborhood strategies employed at 169 recently established shared, supervised residences.

Methods

Data were obtained on the siting processes of 169 shared, supervised homes for persons with severe mental illness that were established in Florida, Illinois, Maryland, Oregon, Pennsylvania, Rhode Island, and Texas. Information on these sites was obtained from interviews with the mental health administrators who had been involved in establishing the residences, from interviews with residential on-site staff, and from census data on the socioeconomic attributes of each site. Shared, supervised residences were defined for this study as houses or apartments with three or more residents with a diagnosis of severe and persistent mental illness and with on-site staff supervision. The states in this study were purposefully chosen to represent a range of geographic regions and because their populations were ethnically and racially diverse.

The sampling frame was composed of lists provided by the Departments of Mental Health from each study state of all private and public organizations that received state funds to administer housing for persons with mental illness. Each organization from those lists was phoned to obtain the name of a staff person who was responsible for siting housing at that agency. Those individuals were contacted for a telephone interview in which they were asked to discuss the siting process of their most recently established shared, supervised residence. Organizations that had not established a residence since 1994 were eliminated from the sample, as were organizations that had no administrator currently on staff that had worked on the locational strategy for that site. The completed interviews represented a response rate of 84% (169 of 201 organizations). The research protocols were approved by the Rutgers University Human Subjects Institutional Review Board.

Structured telephone interviews with the mental health administrators were conducted by graduate research assistants in 2001 and 2002. Before the interview the administrators were asked to retrieve and review their files on the siting process for their most recently established residence and to have them available to reference during the one-hour interview. There are no standardized measures of the constructs used in this study, and the questionnaire was developed by the author in consultation with housing directors at mental health agencies, through a review of the research literature regarding NIMBY and neighborhood integration ( 4 , 6 , 10 , 13 ), and through piloting the questions with ten mental health administrators.

The 62 closed- and open-ended items included questions regarding notification, neighbors' responses to the opening of the residence, agency siting philosophy, agency sponsorship of postsiting activities, and current neighborhood attitudes toward the residence. Opposition was measured with a Likert scale that asked respondents to rank the degree of initial opposition from neighbors; scores ranged from 0, no opposition, to 5, extreme opposition. Respondents indicated on a 12-item checklist the ways in which opposition was expressed, including letter writing, phone calls, and vandalism. A follow-up open-ended question asked them to describe the chronology, actions, and intensity of the opposition. Current neighborhood attitudes were measured with a 5-point Likert scale, ranging from 1, very accepting; to 3, indifferent; to 5, very hostile. A follow-up open-ended question asked respondents to describe the behaviors that manifested those attitudes and to provide details of the ways in which consumers and neighbors interacted. Responses to the open-ended questions describing neighborhood opposition and attitudes were each read by two coders, and kappa statistics of .89 to .94 indicated a high magnitude of interobserver agreement in their categorizations of responses regarding actions that marked high to low opposition and behaviors that represented high to low acceptance.

During the interview the administrators were asked to provide a street address for the residence that they were describing and to supply contact information for a staff person who worked on site at the residence. Contact information was provided for 148 sites, and one-hour telephone interviews were completed in 2001 and 2002 by graduate research assistants with 138 on-site staff. The foci of the interviews were current interactions between residents and neighbors (most respondents were not employed as on-site staff during the initial siting). The questionnaire was developed by the author in consultation with mental health housing directors and reviews of the research literature and piloted with five residential staff. The 47 items included closed- and open-ended questions that solicited information about the daily routines of residents, the nature and frequency of interactions between residents and neighbors, and the nature of agency-initiated postsiting activities.

By using the street addresses provided by respondents, municipal and block-level demographic characteristics for the sites were collected from the year 2000 U.S. census on variables that included density, poverty, unemployment, median household income, education, and race.

Analysis

Chi square analyses examined whether differences in neighborhood opposition, attitudes, and interactions were associated with notification or nonnotification. Standardized regression was employed to determine the variables that were predictive of neighborhood opposition, including neighborhood demographic characteristics and notification strategy. For each site address, quantitative data generated from multiple sources were linked, including survey data from administrators and on-site staff, census data, and some qualitative data that had been made numeric. Content analysis was used to examine the responses to open-ended questions, which were read and analyzed for patterns according to the concepts represented by the questionnaire topics and the themes that emerged from respondent comments ( 30 , 31 , 32 ). Data triangulation was used to affirm or elucidate findings on notification, opposition, and neighbor relations by examining responses from administrators and on-site staff and by examining quantitative and qualitative results.

Characteristics of the residences and sponsoring organizations

The 169 residences described by the mental health administrators housed a median of eight residents. At every site a majority of residents were white, with a samplewide average of 15% nonwhite. Of the residences, 102 (60%) were established between 1998 and 2002, and 67 (40%) opened between 1994 and 1997. A majority (150 residences, or 89%) were located in neighborhoods that were within walking distance of a commercial district or public transportation. Among the 152 residences for which block-level poverty levels were available, about one-third (53 residences, or 35%) were in neighborhoods with low block-level poverty rates of 10% or less, and one-third (49 residences, or 32%) were in neighborhoods with high poverty rates of 20% or above.

The 169 mental health organizations represented by the administrative respondents had median annual operating budgets of $5.5 million. A total of 118 (70%) were private nonprofit, 37 (22%) were public (state, county, or municipal), and 14 (8%) were for-profit organizations. Collectively they administered housing to close to 24,000 consumers through almost 3,000 residences.

Results

Notification and opposition

Neighbors were notified at just under half of the sample sites. Of the 169 mental health administrators interviewed, 73 (45%) reported that their agency notified neighbors about the opening of their most recently established shared, supervised residence, and 88 (55%) did not (data missing for eight respondents). Eighty-nine (54%) of the sites experienced no opposition from neighbors, and 75 (46%) had some level of opposition (data missing for five respondents). Opposition was significantly more likely to occur with notification. Forty-three of the 73 agencies that notified neighbors experienced opposition (59%), compared with 30 of the 88 agencies that did not notify (34%) ( χ² =8.75, df=1, p<.003).

Consistent with the literature, opposition among the neighbors in this sample was focused on concerns regarding safety, antisocial behavior of residents, and property values. Opposition at the sites where no formal notification was given typically occurred after neighbors heard about the site informally via channels such as conversations with construction workers at the site, building inspectors, and financiers. Neither rates of notification nor opposition varied significantly over time, with the levels almost constant among those sites established before and after 1998.

Notification rates did not vary significantly across neighborhoods of different income or poverty rates. As noted, research from the 1970s and 1980s named several variables as predictors of low levels of resistance to special needs housing, including low median income and housing values, racial diversity, density, and high levels of poverty and renter-occupied units ( 17 , 20 ). None of these demographic variables were found to be significant predictors of opposition in regression models tested from this sample, and all of the demographic models had low levels of explained variance.

The 169 administrative respondents voiced siting philosophies aligned with their notification strategies. Those who did not notify neighbors were unanimous in maintaining that notification was a violation of mental health care consumers' civil rights and that normal assimilation and positive neighborhood relations were best served by an unannounced siting. Those who used notification most often described their outreach as a means for dispelling myths and fears about mental illness and special needs housing, including frequently expressed concerns about safety and quality of life. Most notifiers also described outreach as a way of connecting residents and neighbors to encourage a greater number and variety of social exchanges.

The following quotes from two mental health administrators illustrate how concepts of notification and neighborliness were variously interpreted by opponents and proponents of notification. An administrator against notification said, "We don't have to notify. Consumers have the same rights as anyone else, and we try to be a good neighbor and let them casually introduce themselves like anyone else might." And an administrator in favor of notification said, "It's just a 'good neighbor' policy to notify and let people know what's happening … especially where you want to get people to work with you, not against you."

Postsiting activities

In the year after the residence was opened, about one-half of the agencies (80 agencies, or 47%) initiated postsiting exchanges with neighbors, such as holding an open house, sponsoring a social gathering, or facilitating the participation of site residents in neighborhood events. Agencies that notified neighbors about the opening of the residence were significantly more likely to engage in such activities. An open house, for example, was sponsored by 51 of the 73 agencies that had notified neighbors (70%), compared with 27 of the 88 that did not notify (32%) ( χ² =23.80, df=1, p<.001). Postsiting activities were most likely to occur in the first few years after the opening of the residence. Only 33 of the administrators (20%) reported that their agency continued to sponsor such neighborhood exchanges beyond the first few years and that their agency regularly and routinely initiated activities with neighbors. Agencies that continued to sponsor neighborhood exchanges were significantly more likely to have notified neighbors of the opening of the site ( χ² =12.84, df=1, p<.001). Consistent with their philosophy on notification, most sponsors of postsiting activities described their efforts as a means to facilitate integration and increase exchanges between site residents and neighbors.

Neighborhood relations

The mental health administrators reported that 42 (27%) of the neighborhoods were currently "very accepting" of the site, 69 (44%) were "somewhat" accepting, 39 (25%) were "indifferent," and six (4%) were "somewhat hostile" (data missing for 13 respondents).

We asked the mental health administrators in an open-ended question to provide examples of how those ranked attitudes were manifested. Acceptance was typically described as nodding, smiling, or exchanging greetings on the street or occasional conversations with site residents. Those in the "very accepting" category were described as having the most substantive exchanges, which primarily involved interactions with staff or benevolent gestures toward the residence. Examples included neighbors who delivered baked goods or home-grown vegetables to the residence, some who helped staff shovel snow or make outdoor home repairs, and a few who stood outside to smoke cigarettes with residents. "Indifference" was marked by the lack of greetings and conversation, and "hostility" was described to include negative facial expressions, the use of hostile language, and complaints to the agency or to local officials.

Very few friendships or relationships between individual site residents and neighbors were described. In interviews with on-site staff (data missing for eight respondents), two-thirds (82 respondents, or 63%) said that no neighbors had visited the residence in the previous year and three-quarters (94 respondents, or 72%) reported that no residents had been invited to a neighbor's home. However, 103 (79%) of the on-site staff said that casual conversations occurred on the street between neighbors and consumers.

Variations in attitudes and interactions

The levels of reported neighborhood acceptance, indifference, and hostility did not vary significantly by notification strategy or presence of initial opposition. In addition, neither notification nor opposition was associated with variations in levels of reported interaction among residents and neighbors (neighbors talking or visiting with residents).

There were, however, some variations in reported neighborhood relations based on postsiting activities. Administrators at agencies that had sponsored any postsiting activities were more likely to report that neighbors were, at the time of the interview, "very accepting," and those estimations were highest among those who had sustained such initiatives over several years. For example, 30 of the 112 administrators (27%) whose agencies sponsored at least one postsiting activity in the years after the opening reported that neighbors were "very accepting"; however, only one of the 23 sites (4%) that did not sponsor such activities had such a reaction from neighbors. Among the 33 administrators at agencies that sponsored initiatives in the 12 months before the interview as part of a policy of sustained, ongoing activities with neighbors, 13 (39%) described the attitudes of the site's neighbors as "very accepting," compared with 21 of the 103 agencies (20%) that had not initiated any postsiting activities in the past year ( χ² =5.84, df=1, p<.016).

Discussion

Proponents and opponents of neighborhood notification have long asserted that their siting approach best furthers neighborhood integration, although there has been limited empirical data to support either practice. The study presented here is unique in that it gathered data after the development of the Fair Housing Amendments and the Americans With Disabilities Act on both presiting and postsiting practices across a number of states and because it paired site-specific information from administrators on the initial notification strategy with reports from on-site staff regarding subsequent neighborhood interactions.

Although federal antidiscrimination legislation supports nonnotification, almost half of this sample chose to employ a notification approach, with their reasoning consistently centered on the benefits of outreach in diffusing fears concerning mental illness and facilitating positive interactions with neighbors. Confirming previous studies, such fears and concerns among neighbors were prevalent as almost half of all sites reported initial expressions of opposition, with most focused on safety issues. As found in some previous studies, administrators who used a nonnotification approach were less likely to encounter initial opposition. Thirty percent of the nonnotifiers did report resistance, however, and that was most often generated when neighbors learned informally about the site.

Within this sample, initial resistance was not associated with long-term differences in neighbor relations, as reported levels of acceptance, indifference, and hostility did not vary significantly among sites regardless of whether initial opposition was present or whether neighbors were notified. Notification was, however, the most significant predictor of initial neighborhood resistance, and opposition did not vary by neighborhood demographic characteristics, such as poverty rates, median household income, and unemployment rates.

Aligned with their philosophy of neighborhood outreach, agencies that notified neighbors were more likely to initiate postsiting activities in the months and years after the establishment of the site. In this sample, agencies that sponsored neighborhood exchanges were more likely to report "very accepting" attitudes among neighbors, which were often illustrated as affable contributions of goods and services to the staff and residents. It is possible that the perception among notification advocates that their method enhances neighborhood integration is related in part to their greater tendency to sustain long-term postsiting exchanges and perhaps to the development of stronger relationships between staff sponsors and neighbors. The implications and effects of postsiting initiatives are an area for further research.

The findings generate questions about the nature of the integration sought by advocates of notification and nonnotification. Within this sample early opposition was rarely enduring, and neither initial strategy appeared to make much difference with regard to long-term neighborhood relations. Is there reason to be uneasy about a neighborhood presence that does not attract overt hostility but does not include interaction beyond the most casual? Is sustained agency-sponsored outreach a violation of privacy and self-determination or a way to potentially forge community connections?

The results of the study are limited in application to the seven study states and were subject to the recall of the administrative respondents and the completeness of the case files that they referenced during the interview. Measures of neighbors' opposition and acceptance were dependent on the subjective observations of the administrators and on-site staff, and the study did not gather input from the residents of the shared housing sites.

Conclusions

This study suggests that although mental health administrators who use notification strategies are more likely to encounter initial resistance from neighbors, such opposition is seldom lasting. A majority of consumers are likely to have only casual contacts with neighbors no matter which initial strategy is used. Future research could further examine the role of agency-sponsored postsiting activities in facilitating substantive connections and the factors associated with the most positive and active neighborhood relations.

Acknowledgments and disclosures

This study was funded by grant 5R01-MH-S8327-2 from the National Institute of Mental Health. The author thanks Karen Gutshall, Ph.D., and Amanda Thompson, M.S.W., for their research assistance.

The author reports no competing interests.