background image
earlier about efficiency apply here: although supportive services for people with
serious impairments are valuable in their own right, they should be justified on
grounds other than the prevention of homelessness, from which perspective most
such services will be wasted.
Among mentally ill individuals, it is not even clear that the most important
variables predicting homelessness indicate a lack of supportive services. A project
in San Diego examined the relative role of housing subsidies and intensive services
for homeless people with severe and chronic mental illness (schizophrenia, bipolar
disorder, or major depression). Participants were randomly assigned, in a 2
2
design, to access versus no access to Section 8 certificates and to traditional versus
comprehensive case management (Hurlburt, Wood, & Hough, 1996). Results indi-
cated a large effect of Section 8 certificates, but no effect of comprehensive case
management. Almost 60% of participants with access to the certificates achieved
stability in independent housing at the end of the study, compared with 31% of par-
ticipants without access. In the study by Zlotnick et al. (1999) cited above, in which
subsidized housing and regular income from entitlements predicted housing stabil-
ity, but case management did not, about half of the respondents had substance use
disorders or dual diagnoses.
15
The available epidemiological studies suggest that the prevention of home-
lessness among individuals with serious impairments--like its prevention among
people not so afflicted--should focus on access to subsidized housing and/or to
income that allows the individual to rent housing on the open market. Indeed, risk
factors for homelessness and protective factors against it among people with seri-
ous mental illness may matter primarily because they affect a person's access to
housing. For example, the difficulty that many people with serious mental illness
have in developing and maintaining relationships may reduce the likelihood of
The Prevention of Homelessness Revisited
113
15
A review of clinical research demonstration projects undertaken with Stewart B. McKinney
Homeless Assistance Act Funds concluded that programs offering a range of housing alternatives cou-
pled with case management services could effectively engage and stably house homeless individuals
with severe mental illness (Shern et al., 1997). The experimental manipulation in these studies involved
the type and intensity of services offered. Across five cities, 7488% of the experimental groups were in
community housing at the final follow-up (which ranged from 12 to 24 months). Excluding data from a
substudy of a street sample in one city, across four cities with data, 78% of those in community housing
were deemed stable; that is, they had not moved in the last follow-up period. Results were very similar
across the diverse interventions. Just as interesting, 6080% of the control groups who received less in-
tensive services were also housed in the community. Thus, as noted previously for homeless families,
the intensive services made less difference than might have been expected.
Additional strategies for the primary and secondary prevention of homelessness among people
with severe mental illness and/or substance abuse were evaluated as part of a cooperative agreement
funded by the Center for Mental Health Services and the Center for Substance Abuse Treatment
(Rickards et al., 1999). Strategies included various models for providing housing and services, interven-
tions in which a representative payee helps a consumer to manage money, and family education and re-
spite care. Preliminary results suggest that experimental programs that controlled access to housing
were more effective than control programs that did not. The types of services provided did not differen-
tiate more and less successful programs (Teague, Williams, Clark, & Shinn, 2000).