Principles and Practice in Housing for Persons with Mental Illness Who Have Had Contact with the Justice System

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Introduction

This paper presents an overview of housing options used for persons with mental illness who have had contact with the criminal justice system. Our intent is to synthesize available knowledge regarding types of housing that are available to this population, as well as which types are associated with improved outcomes for consumers. While a number of housing options exist and are currently being developed to serve this population, there is little evaluation research from which to draw conclusions about what works. Hence, we focus on extracting promising practices that can inform housing options or programs for persons with mental illness who have had contact with the justice system.

In the past two decades, a number of circumstances have coincided to result in the dramatic growth in the number of persons with mental illness who have had contact with the justice system and who are at risk of homelessness. These circumstances include the deinstitutionalization of persons with mental illness from psychiatric facilities, large increases in the number of prisoners returning to their communities, cuts in public assistance, and declines in the availability of safe and affordable housing. The confluence of these and other factors has created serious challenges to public safety, public health, and the overall quality of life of individuals and communities nationwide. It has been estimated that thousands of persons with mental illness exit prisons and jails each year (Beck and Maruschak 2001; Harlow 1998).

Correctional facilities are unlikely to provide optimal treatment for persons with mental illness, let alone those persons with both substance use problems and mental illness. And many of these individuals do not receive any type of mental health services while incarcerated-possibly reducing the chances of successful community reintegration. A Bureau of Justice Statistics (BJS) study based on surveys conducted with prisoners and parolees in 1996 and 1997 found that only 60 percent of prisoners suffering from major mental illnesses received mental health treatment while in prison (Ditton 1999). Furthermore, other research indicates that persons with mental illness-and in general most individuals-often are released without any type of aftercare or pre-release planning (Beck and Maruschak 2001; Petersilia 2003; Travis 2005). Another Bureau of Justice Statistics study (Beck and Maruschak 2001) based on data from BJS's 2000 Census of State and Federal Adult Correctional Facilities found that only two-thirds of prisons helped released prisoners obtain mental health services in the community, post release.

Without attention to mental health needs, individuals who have been involved with the criminal justice system may be at high risk of continuing criminal behavior and/or substance abuse. A study tracking 261 persons with mental illness who were released from jail in Ohio found that 72 percent were rearrested within one year (Ventura et al. 1998). Of those arrested, 15 percent were arrested for violent felonies and 23 percent were arrested for violent misdemeanors. Individuals in the study who received case management in the community were less likely to be rearrested than subjects who received no case management. In a longitudinal study of prisoner reentry in Maryland known as Returning Home, mental health status had implications for measures of post-release success (Mallik-Kane 2005). Respondents with a mental health condition were significantly more likely to report drug use or alcohol intoxication post-release than those without such conditions. The study also found that only half of the respondents who had been taking medications regularly in prison were still taking medications four to eight months after release.

Research has also documented the importance of housing as a component of good mental health care (Burt and Anderson 2005; Mayberg 2003; Mechanic 2003). With regard to returning prisoners, research suggests that residential instability and incarceration are compounding factors influencing both later residential instability and reincarceration. A large study examining persons released from New York state prisons found that both having a history of shelter use and a history of incarceration increased the risk of subsequent reincarceration and shelter use (Metraux and Culhane 2004). Furthermore, shelter usage post release increased the likelihood of reincarceration. Those individuals with links to the mental health system had considerably higher proportions of shelter stays and reincarcerations post release than those without links to the mental health system. A few other studies have found that persons with mental illness who experience housing instability are more likely to come in contact with the police and/or be charged with a criminal offense (Brekke et al. 2001; Clark, Ricketts, and McHugo 1999). Furthermore, there is new evidence that returning prisoners view housing as a key component-perhaps even the most important component-of successful community reintegration (Mallik-Kane 2005).

Regardless of mental health status, securing housing upon release from prison or jail is a challenge for many (Roman and Travis 2004). The process of securing housing is often complicated by a host of factors: the scarcity of affordable housing and general lack of service-enhanced housing, formal and informal regulations and prejudices that restrict tenancy and the development of new housing for this population, and strict eligibility requirements for food stamps, veterans benefits and benefits through the Temporary Assistance for Needy Families program (TANF). For persons with mental illness the challenges are compounded. Mental health practitioners repeatedly voice concerns that community-based services for special needs populations only serve a very small fraction of those in need.

For those individuals searching for housing who do not live with family or friends the housing options include home ownership, the private rental market, unsubsidized and subsidized affordable housing, corrections-based housing facilities, transitional (service-enriched) housing (non-corrections-based and non-federally funded), and homeless assistance supportive housing and special needs housing supported through the U.S. Department of Housing and Urban Development (HUD). This report discusses these housing options, with a specific focus on those that provide supportive services.

As stated earlier, the goal of this paper is to synthesize what is known about housing for persons with mental illness who have been in contact with the justice system. We begin this paper with the assumption that persons with mental illness returning from prisons and jails or those with previous justice system contact who are at risk for homelessness would benefit from the provision of housing.

Because housing for persons with mental illness who have had contact with the criminal justice system often comes bundled with services, it becomes difficult to disaggregate housing from services. Further complicating any systematic research synthesis, the specific housing programs vary widely by jurisdiction, targeted population, and a host of other variables-including suite of services. Rather than describing the endless variety of programs, we present the range of broad housing options and describe service approaches along a continuum. Many experts avow that housing is not a program; hence, we utilize the term option or model.

The housing options discussed in detail in this paper are those that provide a place to sleep and provide at least some access to support services intended to increase residential stability and self-sufficiency. This definition excludes case management programs or other community-based programs designed to increase residential stability that do not offer housing. We also exclude those programs that only offer vouchers. We also reviewed housing models that had the explicit goal of reducing criminal behavior-although the overwhelming majority of these models did not have associated outcome data. As described in detail in a later section of the report, we define justice system contact in broad terms-contact may involve incarceration in jail or prison, or arrest with some type of diversionary program provided or probation supervision. The individuals in this population include both those returning directly from jails and prisons and those in the community who have had previous criminal justice system contact.

Despite the lack of evaluation data for housing models that serve persons with mental illness who have been in contact with the justice system, these models generally represent themselves as evidenced based. Our review found few housing models that link the model configuration and services delivered to demonstrated housing-related and criminal justice outcomes. However, many of these models have recently begun to collect a range of outcome data. Furthermore, these models are based on ones that have been demonstrated to be effective in mental health and homelessness prevention practice. In current practice, evidence-based principles for successful housing models that serve those who are mentally ill have been translated into principles hypothesized to work in developing and running housing models for previously incarcerated people with mental illness.

To work through the myriad housing options and the complexity of associated service structures, we organized this paper into five sections:

1. A description of the various reentry points for those who have had contact with the justice system and a discussion of how the housing needs by consumers may differ across the various reentry points.
2. A discussion of housing options along a continuum and key concepts relevant to service provision for persons with mental illness.
3. A summary of evaluation and cost effectiveness findings.
4. A summary discussion of promising strategies or principles in housing that are currently being used to serve persons with mental illness who have had contact with the justice system.
5. An appendix that includes seven short project descriptions of current reentry housing options for persons with mental illness.

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