In 1990, a research team in Boston launched an ambitious experiment with some of the city's sickest residents — the chronically homeless and severely mentally ill. With $13 million in federal funding, the team recruited 118 volunteers from the shelters and randomly placed them in group homes and independent apartments.
The group homes were envisioned as a kind of utopia, in which the mentally ill clients — up to 10 in each of six homes — would become "active agents in shaping their future." By the end of 18 months, they were supposed to replace the paid staff. The project team, led by psychiatrist Stephen M. Goldfinger, formerly of the Massachusetts Mental Health Center and Harvard Medical School, sought to avoid the "community institutionalization" of traditional group homes, where tenants sit all day in front of a TV while medications and meals are prepared for them.
But the devastating effects of substance abuse, not mental illness, wiped out any gains in empowerment for many. Of the 19 percent of project participants who were homeless again at 18 months, all were addicts, and most had been evicted. The group homes allowed alcohol, and the drinking escalated. Some tenants went off their medications and wound up in the hospital. They turned one home into a crack house, engaged in prostitution and stole food and personal belongings from each other, even as the "empowerment coordinator" told the staff not to interfere.
In one home, furniture was carted off and sold to buy drugs. In another, the tenants ran up a $17,000 phone bill dialing 900 numbers for "adult entertainment." A few tenants left in disgust because they wanted to stay sober. Over 18 months, none of the group homes was able to fully cope with cooking, cleaning or taking out the garbage.
And yet, the problems in the group homes masked a piece of good news. Tenants who were withdrawn and detached after years of shelter life began shopping and cooking together, throwing birthday parties, holding meetings and talking things out. Over time, they proved more resilient and less likely to return to the street than those living in independent apartments. Eventually, the worst offenders were expelled, rules were made and the staff began to enforce them.
"We can see that people living in a group home grew to like it more," says Russell K. Schutt, a former team member and a sociologist at the University of Massachusetts in Boston. "It is the people who are accepting of support and willing to live with others who are more likely to be able to retain housing and improve in function."
The delayed but essential benefits of group living pose a dilemma for hundreds of cities across America that have embraced Housing First and other programs that honor client choice above all. They're placing the homeless in apartments of their own as a first step, regardless of their mental state, while the Boston experiment suggests that group living would improve clients' long-term prognosis.
"Housing First is inadequate as a long-term solution to the problem it is intended to solve, and it fails as a means to achieve the full potential of many of those who participate in it," Schutt says.
The Boston McKinney Project clients, who suffered from schizophrenia and bipolar disorder, remain today the most studied homeless people in the world. For 18 months, they were interviewed, observed and examined by social workers, ethnographers, psychologists, sociologists, case managers and housing staff. In 2008, nearly two decades later, Schutt tracked down the housing records for 75 of the original participants and interviewed some of them again.
Now, in the book Homelessness, Housing, and Mental Illness, Schutt takes full measure of the project's success and failure, sparing no bad news. On the negative side, the empowerment concept bombed. The staff in the group homes was ordered to let the tenants figure out how to run them, but two-thirds of the tenants had a lifetime history of substance abuse. Schutt includes a lot of the written record from years ago, and it makes for vivid, if painful, reading.
"Tenants have to learn that they can't just do whatever they want to, and they can't have the houses go to pieces ..." and, "We're just there to keep people from killing each other," a couple of frustrated staffers are quoted as saying. Another adds, "I think people thought that somehow the house was gonna make everything better, and that hasn't happened. People are finding it's not enough to have a roof over your heads."
But despite the problems, which ranged from drug dealers on the premises to cigarette burns on the couches, the tenants had to interact with other people, even if it meant yelling at them. They had to pay in to the house "kitty," make a budget, prepare meals, share the TV and generally pitch in. "I've been having trouble lately, but I have to say that this place makes me feel more like a person here," one tenant said.
Schutt concedes that "the failure of empowerment was kind of heartbreaking, when you read the details. ... Yet one can see that the group process was beneficial."
The process was so beneficial, in fact, that it pokes holes in the accepted wisdom that the mentally ill homeless should get what they want at the outset — that is, a home of their own. The Boston project, overseen by the Massachusetts Department of Mental Health and the Massachusetts Mental Health Center, is still unique in the field because it assigned severely mentally ill homeless people to housing at random, regardless of what type of housing they wanted (usually an apartment) or what type their doctors advised (usually group living).
By the end of 18 months, Schutt reports, the attention span of project participants and their scores on many tests of cognitive ability improved significantly across the board. But the residents of group homes who were not addicts also made marked progress in the ability to plan, reason, make decisions and adapt to circumstances. Meanwhile, their peers in independent apartments — even with the support of doctors and case managers — declined markedly in these measures of real-world functioning. "For people who have been suffering from a severe mental illness and have been homeless for long periods of time, moving into a house on their own doesn't mean meeting the neighbors, going to work during the day, having a social group they're involved in," Schutt says. "That kind of isolation is clearly detrimental."
The book shows that for the mentally ill, starting out in a group home — one with both some autonomy and some staff support — can lead to more success in independent living later on. People may insist on going it alone straight out of the shelters, against their doctors' wishes, Schutt says, but it's ironic: The more adamant they are, the more likely they'll lose their apartment and find themselves on the street again.
"It leaves policy on the horns of a dilemma," he says. "Housing policies now are based on the notion that preferences are sacrosanct and fixed, and if somebody wants to live independently, they should get that. Our guests viewed getting an independent apartment as 'winning the lottery,' but their self-confidence proved ill founded. We can all misconstrue what we need."
The project provided another obvious lesson, Schutt says: Substance abusers should be separated from non-abusers in group living because "whatever the appeal of empowerment, it could not overcome the force of addiction." Also, he says, the staff in group homes must be actively engaged in helping tenants get the treatment they need.
The most recent national homelessness census, taken on a night in January 2009, counted 643,000 homeless Americans, 40 percent of whom were sleeping on the street. A survey of 27 cities last year by the United States Conference of Mayors found that, on average, 24 percent of homeless adults are severely mentally ill.
According to the National Alliance to End Homelessness, 240 cities and counties in the U.S. have funded plans to end homelessness in 10 years. Many of these plans include a program called Housing First, which places mentally ill homeless people in subsidized, independent apartments in the community, with support services if they want them.
In How to House the Homeless, a new book from the Russell Sage Foundation, psychologist Sam Tsemberis, the founder of Pathways to Housing, the creator of Housing First and the subject of a profile in the March-April 2009 issue of Miller-McCune, cites retention rates of between 78 and 88 percent in Housing First programs over one to five years. The programs have grown from a few dozen to a few hundred in the past five years, he says. "Rarely does a social service, housing or mental health intervention see such rapid growth and dissemination," Tsemberis writes.
But Schutt argues that it's not enough to try to keep people housed in the short term. The Boston project accomplished this with an 83 percent retention rate over 18 months, despite problems with substance abuse. But homelessness for the severely mentally ill increases over time, Shutt says, and it increases the most for those who don't get a group living experience early on.
"How do you restore community and social ties among people who have lost them?" he asks. "The most effective policies aren't going to be one size fits all."
Schutt finds that the Boston project participants averaged 60 nights in shelters or on the streets during the first 18 months. But the risk was lower for those in the group homes. Only 20 percent of group home residents re-experienced some homelessness — a key indicator of their future staying power — compared to 35 percent of those in independent living.
When he looked at the housing records of 75 of the original project participants in 2008, 18 years later, Schutt found that their rate of homelessness had increased by 60 percent, to 66 nights per year, on average. Again, those in independent living fared the worst: 58 percent re-experienced some homelessness, compared to 36 percent of those who had been originally assigned to group homes.
Why did so many tenants spend nights back on the street? It's a common pattern with the mentally ill, Schutt says. They may go off their medications or become fearful of their surroundings and seek the familiarity of the shelters. For people living in independent apartments, their only social connections may be drinking companions or drug users on the street. Empowerment for the mentally ill homeless remains elusive, Schutt says, but society should not stop trying. As a staff employee in the group home put it, how do you bring them "from where they are, across the 'Grand Canyon,' to where they can be on their own"?
"We do best as a society when every member has the opportunity to function at his or her fullest potential, and when every member feels a part of a meaningful community," Schutt says. "Finding housing for homeless persons is the start of this process, not its end."