"Housing First" leaves sickest in the cold

When we can more clearly separate “severe mental illness” from “mental health,” it will be easier to also treat those two populations appropriately.

Take homelessness.

“Housing First” is all the rage, and for those who are not severely mentally ill and symptomatic, that plan has great merit. Many are homeless because of poverty, life circumstances that turned against them, substance abuse, or mental health problems. Getting them first into an apartment and then into the care they need may be just the ticket.

But for the homeless who are also severely mentally ill, delusional, psychotic, and lacking insight into their own situation, giving them the keys to their own place isn't the answer. Some already have their own place. Some have family members eager to bring them back to their homes. The problem isn’t a place to sleep at night, it is a brain disease that convinces them that those places are inhabited by monsters or operate as fronts for the CIA.

These people actually need treatment first, often involuntary treatment, to bring their brain diseases into check. Then and only then will they be able to accept proffered offers of housing.

This group, as we have said before, is a small percentage of the total homeless population, but they drain an inordinate amount of resources from the system.

“In the early [1990s], [Dennis] Culhane’s database suggested that New York City had a quarter of a million people who were homeless at some point in the previous half decade. … But only about 2,500 were chronically homeless,” [Malcolm] Gladwell wrote.

Culhane estimated that at least $62 million was being spent each year to shelter those 2,500 hardcore homeless people in New York.

Providing housing first may be just the thing for many homeless. But it won't help the most severely mentally ill. Yes, they are the hardest to help in many ways, but they also deserve our consideration. Someone should launch a “Treatment First” plan to address that very different population.