Homelessness, Mental Illness and Citizenship

© Blackwell Publishers Ltd. © Blackwell Publishers Ltd. , Cowley Road, Oxford, OX JF, UK and Main Street, Malden, MA , USA.

S P A 0144 –5596V. 35, N. 1, M 2001, . 14–31

Homelessness, Mental Illness and Citizenship

Michael Rowe, Bret Kloos, Matt Chinman,Larry Davidson and Anne Boyle Cross

Abstract

Assertive mental health outreach to homeless persons, which operates under the premise that mental

illness must be understood and treated within the individual’s social and economic environment,

points towards the goals of community membership and “citizenship”—a connection to the rights,

responsibilities, roles, and resources that society offers through public and social institutions and

informal “associational life”—for homeless persons. We argue that the concept of citizenship is

a useful framework for approaching these goals. We review the principles of assertive mental

health outreach and relevant aspects of contemporary citizenship theory; present a case example

of outreach leading to a “citizenship project”; and discuss the potential benefits and pitfalls of a

citizenship framework, including strategies and recommendations for program administrators,

researchers and policy makers.

Keywords

Homelessness; Mental illness; Citizenship; Outreach

Introduction

Two related arguments provide the rationale for the conceptual frameworkof citizenship we discuss in this article. The first is that assertive mentalhealth outreach to homeless persons leads, implicitly if not always in prac-tice, to the challenge of linking these individuals to their communities and tosociety as a whole. The second is that the passage from exclusion to inclusion,implied in the transition from the marginalized and stigmatized condition ofhomelessness to the normative condition of having a home, requires the in-volvement of community members and institutions in addition to that of socialservice providers. Few policy and programmatic responses to homelessness,

Address for correspondence: Michael Rowe, Assistant Clinical Professor, Department of Psychiatry,Yale University School of Medicine, Institution for Social and Policy Studies, P.O. Box , New Haven,CT , USA.

© Blackwell Publishers Ltd.

however, include systematic efforts to address the issues of whether homelessindividuals can become full members of the communities in which they hopeto find housing and of whether the non-social-service community can playa significant role in responding to homelessness other than by contributingtax dollars.

We think the concept of “citizenship” provides a useful framework foraddressing the challenge of linking mentally ill homeless persons to their com-munities. We define citizenship as a measure of the strength of individuals’connections to the rights, responsibilities, roles and resources that societyoffers to people through public and social institutions (Rowe ) and tothe informal, “associational” life of neighborhoods and local communities( McKnight ). We further define three preliminary levels of citizenship:full citizenship, with strong instrumental and expressive connections tomainstream institutions, rights and responsibilities; second-class citizenship(in this case, “client-” or “patient”-hood), with marginal connections to thoseinstitutions, rights and responsibilities; and non-citizenship, in which theindividual is severed from, or has limited contact with, mainstream society(Rowe ; Wolfensberger and Tullman ). Mentally ill homeless personscan be described as falling into the third category, since they labor under thedual stigma of homelessness and mental illness.

In the remainder of this article, we review the principles of assertivemental health outreach and its relationship to the community integration ofhomeless individuals; place our approach to citizenship within the contextof some recent social science scholarship on citizenship; give a brief casehistory of assertive mental health outreach leading to a “citizenship project”;and discuss the potential benefits and pitfalls of a citizenship framework asone response to homelessness and mental illness, and propose strategies andrecommendations for program administrators, researchers and policy makers.

Assertive Mental Health Outreach

Many homeless individuals avoid contact with mental health professionalsbecause of previous negative contacts with mental health clinics (Segal et al.) or difficulty gaining access to care (Koegel ). Many deny their mentalillness. In addition, office-based clinics often discharge as “non-compliant”those individuals, including homeless persons, who come into the office occa-sionally but fail to show up for regularly scheduled appointments. In theearly s some urban mental health clinics, building in part on the Assert-ive Community Treatment (ACT) model of care for individuals who hadbeen discharged from state psychiatric hospitals but were difficult to managein the community (Dennis and Monahan ), began to provide assertivemental health outreach to these individuals.

The workplace of mental health outreach workers (workers) spans relativelytame shelters and soup kitchens and relatively unknown streets and highwaybridges. Workers meet potential clients where they are, both geographicallyand existentially (Cohen and Marcos ; Lamb et al. ). They have ahealthy respect for clients’ strengths as survivors of homelessness (Ridgway; Chafetz ; Martin ; Vaccaro et al. ). They do not insist, at


least initially, that they accept mental health treatment, but help them toobtain food, emergency shelter and clothing ( Interagency Council on theHomeless ). They slowly build trust with individuals in order to “engage”or make a therapeutic connection with them and persuade them to acceptmental health treatment (Swayze ; Brickner ; Susser et al. ;Morse et al. ). Because mentally ill homeless persons have multipleneeds, workers must offer an array of other services such as substance abusetreatment, medical care, housing, and help in obtaining a job or incomesupport. Homeless individuals, in turn, see workers not only as treatmentproviders but as a home base and conduit to ongoing treatment and rehabil-itation services (Cohen and Tsemberis ).

Daily presence on the streets educates workers to the effects of povertyand homelessness on their clients’ lives. Their witnessing of homelessness is aprofoundly unsettling experience for workers and generates in them a senseof urgency to help. They fear that their failure to act may mean not onlyuntreated mental illness and a poor quality of life for their clients, but pos-sibly their victimization on the streets, untreated physical illness, and evendeath. In addition, the interdisciplinary nature of many homeless outreachteams helps workers to maintain attention to the social problems of homelessindividuals within a dominant mental health framework.

Over time, workers must place their zeal for finding and engaging peoplein the service of transferring them to continuing treatment and rehabilitationservices and into housing. These transitions involve expressive as well asinstrumental factors. Many homeless persons, including those with mentalillness, show a remarkable ability to survive a life on the streets and in sheltersand to develop supportive social networks. Their ability to adapt to homelesslife may prove unhelpful, though, once they are housed and social isolationbecomes a long-term problem for them. In addition to garnering sufficientresources to make a transition from homelessness to stable housing, then,homeless persons need to shed the stigma of homelessness and construct newidentities for themselves as housed persons and community members.

For workers, a relative blurring of staff–client boundaries that comes withtheir work in the community (Cohen and Marcos ; Cohen and Tsemberis; Martin ) and the multiple needs of mentally ill homeless personspoint toward, but generally stop short of, consideration of how or whethertheir clients can attain full membership and citizenship in their communitiesapart from their roles as clients or patients of mental health and other socialservice agencies. Many homeless individuals may find that such programsoffer, in effect, a ticket to a new poverty niche, with substandard housing andsocial isolation in place of emergency shelters and homeless companionsin misery, and second-class or “program” citizenship in place of the non-citizenship of homelessness. Program citizenship may substitute for a loss ofwork and social relationships, but it may also discourage individuals fromreconnecting with family and friends and their own lost or unused main-stream skills. Eventually, as Jacqueline Wiseman observes, public institutionscan become the only source of mainstream social contact in the lives of manymarginal persons (Wiseman ). If programs that work with mentally illhomeless persons may help these individuals to pass from the non-citizenship


status of homelessness to the marginal status of second-class citizenship,only one’s relationship, in both instrumental and expressive terms, to one’scommunity and the larger society can grant the effective status of first-classcitizenship (Rowe ).

Citizenship Theory: Some Relevant Themes

Citizenship is an elastic concept in contemporary social science and polit-ical discourse. Janoski () discusses two important theoretical traditions:T. H. Marshall’s developmental model of legal, political and social rightsthat are balanced with taxes, military and other service obligations to thestate (); and the Tocquevillian/Durkheimian model of solidarity andgeneral exchange, represented in part by civic participation and volunteerism.Janoski distinguishes between substantive citizenship, which concerns the waysin which stigmatized groups gain rights and recognition as citizens, and formalcitizenship, which concerns the ways in which aliens become naturalizedcitizens with attendant rights and obligations. He further distinguishes betweenpassive legal and social rights and obligations conferred upon members ofsociety, and active participation in the rights and obligations of one’s com-munity, including political action and dissent. He notes the simultaneousprocess of expanding citizenship rights through social movements to includegroups that have previously been excluded from participation in civic andpolitical activities, and restricting citizenship through state acts regardinglegal entrance requirements. Citizenship, in Janoski’s view, involves the rela-tionship between the state, which alone can give legal sanction to citizenshipnorms, and the citizen; civil society, in contrast, provides the structures andinstitutions that mediate between citizen and state and the context withinwhich citizenship has meaning. Finally, Janoski describes four types of cit-izenship rights: legal rights or liberties; political rights, including voting andparticipation in the political process; social rights that support citizens’ claimsto economic subsistence; and participation rights, involving individual andgroup rights to participate in private decision making. In each category hebalances citizenship rights with corresponding obligations.

Bellah et al. () frame citizenship in relation to political participation atthree levels: the politics of community, where people reach moral consensusin face-to-face interaction with their neighbors and local communities; thepolitics of interest, which involve conflicts between interest groups with oppos-ing interests, and in which politicians and political parties act as brokersof those interests; and the politics of the nation, where politics is raised tothe level of statesmanship and where local interests, in theory, give way tonational goals and ideals. Bellah and his colleagues argue that an Americanculture of radical individualism favors an autonomous middle-class indi-vidualism that excludes others from full membership in society and fails tocome to terms with the power of large organizations and institutions. Theyargue that we can enhance effective citizenship by strengthening civic associ-ation through voluntary organizations, religious bodies, the family, and otherinstitutions; through social movements in the American tradition of demo-cratic reform that can check the power of government and “administrative


despotism”; and through linking local participation to a national publicdialogue that religious and civic “communities of memory” support andsustain.

Werbner and Yuval-Davis () argue that democratic citizenship isa dynamic and contested concept; a negotiated compromise, shaped bycultural and political elites, between forces of normalization and forces ofdifference. Like Janoski, Werbner and Yuval-Davis note the simultaneousprocess by which the concept of citizenship serves both to open up new arenasof freedom for previously excluded groups and to restrict and structure thatfreedom through legal and procedural limits. They call for a shift in dis-course toward an emphasis on social and cultural difference and the globaldimensions of citizenship.

Our own concept of citizenship borrows freely from others’ work: it fallsmost closely within what Janoski calls the Tocquevillian/Durkheimian tradi-tion, as exemplified in contemporary scholarship by Bellah and others. LikeYuval-Davis and Werbner, it focuses on the process of opening up citizenshipopportunities for “persons of difference.” Of Janoski’s four types of citizen-ship rights, it is primarily concerned with social and participation rights,although efforts toward securing these rights may well overlap with efforts tosecure legal and political rights.

The case example that follows outlines the way in which an assertive mentalhealth program led to the development of a “citizenship project”—a system-atic, collaborative organizational effort to advance a citizenship and com-munity integration agenda. We caution that our intention is to describe onlyone organizational application of the citizenship framework, not to delineatethe range of governance structures, program initiatives, or other elements thatcan be employed in implementing such projects. In addition, local consortiaor communities might adopt some of the principles and ideas embedded inthe framework without undertaking a specific organizational interventionunder the broad definition of a “citizenship project.”

New Haven Access and Citizens: A Case Example of aCitizenship Project

Jim W., a white male in his mid-s with a history of serious mentalillness and alcoholism, became estranged from his family in his lateteens after a scandal involving himself and a younger cousin. He joinedthe army and received an honorable discharge, then drifted along theEast Coast, supporting himself with odd jobs that he inevitably lost dueto his drinking. After staying briefly with his sister in the New Havenarea, Jim lived under a highway bridge in New Haven, where mentalhealth outreach workers found him and slowly began to build a rela-tionship with him. Although he protested that he deserved no help, theyfinally persuaded him to enter a subsidized apartment. Two weeks aftermoving in, though, Jim told his case manager he wanted to move backunder the bridge. At least there, he said, he had some friends. (Roweet al. )


In New Haven, an assertive mental health outreach team of the local public-funded mental health center was one of eighteen sites for the federalACCESS (Access to Community Care and Effective Services and Supports)project, a nine-state research demonstration designed to test the effectivenessof systems integration strategies for services to mentally ill homeless persons(Randolph ). The New Haven ACCESS project provided a wide rangeof clinical and rehabilitative services, including mental health and substanceabuse treatment and access to income support (entitlements), work andhousing, for mentally ill and dually diagnosed homeless persons who werenot engaged in traditional office-based treatment. Clients were placed in vari-ous forms of housing—from structured residential programs to independentapartments—through use of a client support fund and referral to programsavailable through the local mental health system and area property owners.Once housed, clients generally continued to receive clinical and supportservices from the ACCESS project or from treatment teams at the mentalhealth center’s main clinic.

The New Haven ACCESS project took up the issue of community mem-bership for homeless persons after housing clients like Jim in the case vign-ette above. Jim and others had managed to function on the streets and inshelters for years without help from service providers, only to find that socialmarginality and isolation left them dependent on clinicians and case man-agers for social contact once they entered housing. It became clear to staff thatbeing placed in community housing fell far short of having a stable homeand positive identity as a “housed person” and community member. A dualisolation from their peers in the homeless community and alienation fromthe mainstream community put many individuals at risk of losing their hous-ing or having a poor quality of life while housed.

In response, project leaders convened a group of service providers, con-sumers, and community members and garnered initial support for anorganized approach to the community integration of individuals trying tomake a transition from homelessness into housing. A successful grant pro-posal to a private foundation provided funds to implement and evaluate aproject, called Citizens, under the aegis of a local emergency shelter partici-pating with the ACCESS project. The Citizens Project may be described asa “community coalition” aimed at addressing health and related conditionsthat are “rooted in a larger social, cultural, political and economic fabric” bydrawing on the perspectives, expertise and resources of diverse sectors of thecommunity (Butterfoss et al. : ).

The project’s objectives were to facilitate neighborhood, community, busi-ness and individual support to homeless persons (including those without amental illness or other disability) who were entering housing; to encouragepublic and community support for homeless persons through public aware-ness and education activities; and to facilitate cooperation between commun-ity organizations, homeless or formerly homeless persons (consumers), andsocial service providers in New Haven. While action steps for carrying outproject objectives referred to initiatives such as negotiating agreementswith local businesses to hire homeless individuals and establishing a homelessspeaker’s bureau, these and other initiatives were given as examples of tasks


the project might adopt; project objectives remained broadly framed in orderto allow the emerging leadership group, called a “Community Council,” totake ownership of the project and adopt specific initiatives. The sponsoringagency, with the Community Council’s agreement, hired a project coordinatorwith previous experience working with homeless persons.

Project evaluators used a number of qualitative and quantitative researchmethods, including participant observation (the first-named author supervisedthe project and participated on the Community Council; the second-namedauthor participated on the Community Council); ongoing review and analysisof written material (minutes, planning documents, the project coordinator’smonthly reports and other documents); written and verbal formative evalu-ation reports to the Community Council; interviews with Council members;and “process logs” recording Council and staff activities.

The process log evaluation strategy was adapted from previous evaluationresearch with community organizations at the University of Kansas and theUniversity of South Carolina (Francisco et al. ). We chose this strategynot only to measure organizational development and activity over time, butas a tool for providing ongoing feedback to Council members and staffand for actively involving members in identifying important themes andquestions. All Council members and staff were asked to complete weekly logson their Citizens-related contracts and activities. The data were coded undervarious categories, including internal and external contacts; type of activity(e.g. informational presentation on the project or sustained activity withcommunity partners); specific initiative (e.g. book project, job project, etc.);affiliation of person or group contacted; and others. Categories were plottedby graphs at key points and over time in order to demonstrate both cumulat-ive and comparative results. Evaluators presented formative evaluation dataat Community Council meetings in order to help participants monitor theproject’s development and focus its planning efforts (Kloos et al. ).

Evaluators began with two working hypotheses. First, there would be atendency for social service organizations to dominate the development andgovernance of the project. Thus, participants would need to make concertedefforts to shift the relative locus of power from social service organizations tocommunity members and homeless persons. Second, there would be tension,and potential conflict, between the long-term “macro-goal” of helping to estab-lish a more welcoming social and economic environment for homeless personsin general, and the short-term “micro-goal” of implementing initiatives thatwould produce clear benefits to currently homeless persons. Furthermore,this tension would, in part, reflect the interests of representatives of eachof three sectors—consumers, social service providers, and (non-homeless,non-service provider) community, business, and government members andrepresentatives (“community members” for the remainder of this article).

Regarding the first hypothesis, project founders recognized that housingthe program within a social service agency rather than a community organ-ization such as a council of churches or voluntary association, might delaythe process of gaining community involvement and support and build in atendency for the project to “act like” a traditional social service program—one with staff-directed interventions aimed at reducing symptoms or stabilizing


individuals and maintaining them in the community. They decided, though,that the advantages of sponsorship by an organization that already workedwith homeless persons outweighed the advantages of sponsorship by a non-provider organization that could facilitate community involvement but had lessknowledge of, or credibility with, the homeless population, service providers,or the general public.

Evaluation results bore out the hypothesis of initial social service domin-ance. During the first six months of program operation, for example, morethan three-quarters of all program contacts that staff and Community Councilmembers made, including meetings and working sessions, informationalmeetings and formal presentations, and brief contacts in person or over thephone, were with social service agency staff. Over the next year, however, con-tacts with social service providers steadily decreased in comparison to thosewith non-social-service representatives (consumers and community members)until, during the sixth quarter, they represented fewer than per cent ofthe total. In contrast, “community member” contacts grew from per centin the first quarter to per cent in the sixth and last quarter of process logdata collection.

A troubling aspect of the project’s development, however, was its relativefailure to develop an active and broad-based Community Council to facil-itate community involvement and support. Organizers’ initial hopes thatthe New Haven community as a whole would adopt the project or its goalsproved unrealistic. After two years of operation, regular membership haddwindled to a core group of four. In addition, day-to-day program operationand oversight resembled that of a traditional small social service program:the project coordinator, the principal investigator, and the sponsoring agency’sexecutive director made many decisions on project initiatives and gave progressreports to the Community Council. At the start of the third year of operation,however, the project embarked on an initiative to strengthen the Commun-ity Council and consider co-sponsorship by a community organization suchas a council of churches or a business association.

Regarding the second hypothesis—that there would be tension betweenthe process of community building and community acceptance of home-less persons and the development of specific projects to help currently home-less persons—the relative proportion of planning to implementation activitiesduring the first year also reflected a process orientation. The majority ofplanning activities—those undertaken to prepare for later implementationof programs to help individual homeless persons—were internal, and totalplanning contacts—consensus building activities leading to specific programs—far outdistanced those that involved sustained work with external partnerstoward implementing those programs. As predicted, differences of interestand perspective between the consumer, service provider, and communitysectors influenced the project’s early development. Differences included asocial service administrator’s complaint that the Community Council wasignoring the community integration efforts that some service providers madeboth with and on behalf of their clients; consumers’ and consumer advocates’perception, reflected in their dwindling attendance over time, that the projectmoved too slowly in implementing initiatives to help currently homeless


persons; and a business executive’s view that social service providers andevaluators were “academic gasbags”—all talk and no action. Some of thesecritiques influenced changes in the project’s development: The agencyadministrators’ criticism of the project’s divisiveness influenced a relativeshift in emphasis from that of facilitating community members’ involvementin assisting homeless persons, to that of building bridges between communitymembers, consumers and social service providers; advocates and consumerswere influential in the project’s eventual championing of consumer employ-ment; and the business executive became a key player in initiating contactswith area businesses and neighborhood councils for a jobs project.

The relative proportion of internal and external contacts, heavily weightedtoward the former during the first two quarters, was reversed in favor of thelatter starting in the third quarter, as participants began to spend more timeon concrete initiatives. The project published a book written by homelesspersons, with the goals of empowering homeless individuals and educatingthe public about homelessness. A jobs project for homeless persons, focusedon facilitating improved “intercultural communication” between employeesand their employers in conjunction with existing job readiness and place-ment programs, grew out of a collaboration between social service providersand the business district within which the project was located, with fundingfrom the state department of labor. A proposed “housing readiness” projectto prepare homeless persons to deal with the practical and emotional stressesand responsibilities of independent living, elicited support from local landlords.A leadership project, designed to train homeless persons to participate onboards and action groups for programs that serve homeless persons, promisednew ways to involve homeless persons in the project and increase their “cit-izenship options.” Of the four projects, the book has been published (Mattisonet al. ), the jobs project has secured partial funding and is seeking addi-tional support, the housing project is on hold pending available funding, andthe leadership project is funded and preparing for implementation.

Discussion and Recommendations

If work in the homeless person’s environment, an appreciation of the contextof severe poverty and lack of mainstream opportunities, and involvementwith individuals’ transitions from homelessness to housing prompts outreachworkers’ concern about their clients’ relationship to the larger communityand society, that concern represents a perspective and inclination and doesnot automatically lead to action. When action does occur, it can range frominformal contacts with landlords on behalf of individual clients to formalcollaborations with community organizations geared toward the needs of allhomeless persons.

We view the citizenship framework as adding another element to currentdevelopments within community-based mental health theory and practice.Below, we discuss the framework’s potential contributions at overlappingindividual (the homeless person), organizational (social service programsand their funding sources), and societal ( local communities and the publicat large) levels of analysis (Rappaport ), including recommendations for


applying the citizenship framework to mental health policy and practice andsome caveats regarding its limitations.

Individual level of analysis

The citizenship framework is influenced by, and can be strategically framedin relation to, other consumer- or person-centered developments within mentalhealth and rehabilitation practice, including social integration (Carling ,); consumer empowerment (Chamberlin ; Frese and Davis ;Reidy ) and employment (Van Tosh ; Fisk et al. ), supportedhousing (Brown et al. ; Cohen and Somers ; Carling , ,; Deegan ), and the concept of recovery from, rather than merecontainment of, mental illness, and normalization within society (Davidsonand Strauss ; Spaniol et al. ; Wolfensberger and Tullman ). Therecovery and consumer movements in particular, with roots in the disabilityand self-help movements and their emphasis on a relative shift away fromservice providers’ treatment and rehabilitation goals and toward consumers’goals and aspirations (Chamberlin , ; Richardson ; Deegan; Frese and Davis ), can provide guidance for citizenship initiatives—those geared toward community acceptance and integration of homeless per-sons with mental illness who are re-entering housing. All of these approachesshare the view that individuals with mental illness are whole persons withnormative goals and expectations who can and should be full-fledged mem-bers of their communities.

In general, attempts to operationalize these approaches have relied heavilyupon clinicians and other service providers and have not drawn on the non-social service community. The citizenship approach can build on their con-tributions while adding a more community-oriented and social-contextualperspective and providing a conceptual framework for collaborations betweenservice providers, consumers and community members.

Organizational and systemic level of analysis

The ideal of full citizenship implicitly draws upon what Goldman andMorrissey have called a “fourth cycle” approach to mental health reform,in which the social problems of poor, chronically mentally ill persons aredefined as social welfare issues to be addressed by a wide range of treatment,housing and rehabilitation services (Goldman and Morrissey ). At thelevel of organization of services, the citizenship concept can be seen asa logical extension of the concept of “systems integration” of services formentally ill homeless persons (Randolph ), in the sense that the formerproposes moving outside of social and mental health systems to include thenon-provider community: While innovative organizational practices may pointtoward a concern for homeless persons within their larger environment,social service providers and organizations have difficulty moving outsideof their organizational boundaries to develop partnerships with communitymembers and organizations. The citizenship framework can supply a com-munity perspective and rationale for such partnerships.


Societal and social policy level of analysis

Use of a citizenship framework at the level of public opinion and socialpolicy can draw on the status of citizenship as a positive social value and itsassociation with other commonly held values, including personal rights, re-sponsibilities, and roles as a member of society, access to material resources,and recognition for one’s contribution to society. These values have histor-ical and cultural capital, and their use by and for homeless persons withmental illness (and other homeless persons) may help these individuals enterinto the fabric of community living. Homeless persons’ ability to survive inthe most difficult circumstances, for example, if seen and understood by thegeneral public, can demonstrate the way in which these individuals exem-plify American values of independence and self-reliance. The citizenshipframework, then, can encourage efforts to build on the strengths of homelesspersons and their potential to be assets to their communities (Kretzmannand McKnight ).

The US Department of Housing and Urban Development (HUD) has,since , emphasized citizen participation in policy review and prioritysetting for local decision making on the use of HUD resources (HUD ).Since , HUD regulations have also required local governments thatapply for HUD funding to submit a Consolidated Plan that includes anassessment of, and response to, homelessness, and a local “Continuum ofCare” process as a prerequisite for applying for other HUD funding forhomelessness programs. Community participation in decision making forfederal funds, however, while an important step, falls short of a sustained andsystematic community response to homelessness. In addition, the involvementin decision making of community members who are not social-service pro-viders can be quite limited. Service providers who work with homeless personsconstitute a subcommunity most likely to be aware of HUD requirementsand to have the collective power and expertise to shape a Continuum ofCare’s plans and recommendations with little input from community mem-bers. The citizenship framework emphasizes the need to involve communitymembers and institutions in local planning to address the prevention of andexit from homelessness as part of a rational approach to community building.

Summary and recommendations

The citizenship framework can be a valuable construct because it helps us toconceptualize a gap in our current policy and programmatic approaches—the community integration of homeless persons with mental illness and theroles of community members and institutions in responding to homelessness—and encourages partnerships between consumers, service providers, and com-munity members and institutions to address a problem that affects all membersof the community.

The citizenship framework adds a social level to person-centered andempowerment approaches and can encourage a shift in the orientation andefforts of service providers and funding organizations. Social service organiza-tions might include the citizenship framework in their quality improvement


goals and establish work groups, with consumer and community represen-tation and oversight, to recommend citizenship- or community-integrationinitiatives. HUD, as the federal agency most actively pursuing citizen andcommunity participation, might take a step beyond its current Continuum ofCare process by giving extra points in grant reviews to communities thatinclude citizenship-oriented principles and action steps in their ConsolidatedPlans. Other local, state and federal agencies and policy makers, as well asprivate grant-making organizations, might consider such approaches in theirrequests for proposals and in developing new program initiatives.

The citizenship framework can also encourage mental health and othersocial service organizations and those that fund them to collaborate withcommunity organizations and civic associations in order both to support theformer’s work and to extend the range of opportunities available to theirclients. Such collaborations may widen the range of service and resourceoptions from which individuals can choose in their transition from homeless-ness to housing. They may also serve as “mediating structures” between theindividual and society-at-large (Berger and Neuhaus ) and help individualsto make contact with other such structures—churches, civic groups, neighbor-hood associations and others—that already exist in the community.

At the societal level, prevailing public discourse has focused on how toprovide funding for service programs and to limit the unpleasant experiencesof other community members (through loitering laws, for example). A citizen-ship framework can help to re-focus public discourse about homelessnessand mental illness and homeless persons’ potential contributions to society. Itcan help community members and organizations to re-conceptualize theirrelationship to homeless persons, leading to a greater emphasis on helpingthese individuals find a valued niche in society. Such a re-conceptualizationmay have a positive impact on public discourse, problem definition, and theresponses of community members, institutions, and policy makers to home-lessness as a social issue. Local planners and citizens groups could approachhomelessness as part of larger community-building efforts focused on the useof existing community assets and institutions to create new resources tostrengthen community life (Kretzmann and McKnight ). Civic, serviceand religious organizations that encourage volunteer commitments from theirmembers could undertake citizenship-related efforts, including partnershipswith landlords, local businesses, and government to develop affordable housingand living-wage jobs, thus creating structures for sustained personal involve-ment in addressing the problem of homelessness.

Local efforts could take the form of systematic, collaborative organizationalefforts to advance a citizenship agenda, which we call “citizenship projects.”Such efforts may offer a more sustained and effective use of communityresources than traditional isolated or sporadic direct efforts such as servingdinners at emergency shelters, donating clothing, or the like. Governancemay vary along a continuum from ad hoc groups, to subgroups of an exis-ting organizational board, to governing boards of separate, incorporatedorganizations. Our experience with one citizenship project suggests that organ-izers must pay attention to several interrelated themes and complementarystrategies:


• Leadership and representation. Those who initiate citizenship projects onbehalf of homeless persons with mental illness (or homeless persons ingeneral) must seek some degree of representative balance between mentalhealth and other social service providers, consumers and communityrepresentatives, and must address potential difficulties associated with theparticipation of each. Mental health professionals and organizations, evenwhen involved in partnerships with non-mental health professionals,are accustomed to shaping those efforts. They must learn, through theexperience of participating on community councils or community coali-tions, to step back when necessary and cede part of their power. Con-sumers may become involved with citizenship projects at critical points intheir own transition from homelessness and look to these projects forindividual assistance that they are not able to provide in the early stages.Training in board and action group membership and involvement ofconsumers who are stably housed can help to support the consumersector’s participation. Community participants may, like others, becomedisillusioned when the process of building links between the three sectorsdelays responses to pressing issues such as housing and employment.Education and training on homelessness and behavioral health problems,and involving those individuals as co-facilitators for specific programs,can help to make them more knowledgeable and effective advocates forchange.

• Adapting to local conditions. The development of citizenship projects willvary with local constraints and opportunities. Citizenship projects mayalso vary, in their founding or over time, along a spectrum from advocacyto break down all community barriers, at one end, to accommodationto community concerns, at the other. Successful projects are likely to bethose in which representatives of traditional sectors (the director of a localbusiness district, for example) become advocates themselves, going againstthe grain of traditional practice or opinion while retaining the credentialsto champion the case for change to their peers.

• Community building and tangible products. Projects organized around the cit-izenship theme, with the long-term goal of linking the practical resourceneeds of housing and income to valued roles and community member-ship for individuals, run the risk of foundering in vagueness. Our ownexperience is that projects using citizenship or community integration asa central theme should be closely tied at their inception to one or moreof the tangible building blocks—particularly living-wage jobs or incomesupport and affordable housing—without which citizenship may be amurky ideal that is difficult to put into practice. This process might bedescribed as that of integrating a “power-based” model of communitydevelopment, emphasizing a broad-based approach to systemic change,and a “project-based” model, emphasizing the provision of specific services(Callahan et al. ). It also recognizes the need to balance achievementof specific short-term goals and outcomes in order to maintain the interestof all participants and the project’s credibility, with long-term benefitsrelated to the larger social and economic context in which homeless-ness exists (Allensworth and Patton ; Boissevain ; Brown ;


Butterfoss et al. ; Croan and Lees ; Hord ; Linney andWandersman ; Stevenson et al. ).

Limitations of a citizenship framework

The framework outlined here has significant limitations and can be thebearer of unintended consequences. The concept of connecting mentally illhomeless persons to their communities may imply that these communitiesare economically stable and have both the resources and the inclination towelcome another economically impoverished subgroup. In fact, the local“community” will include impoverished subcommunities and neighborhoodswhich are the most likely sites for housing formerly homeless individualsand, arguably, the least able to absorb a new subgroup of the disadvantaged.In addition, some would argue that in today’s issue-oriented, internet-connected society, gaining a sense of belonging within one’s local, physicalcommunity no longer carries the same “citizenship advantages” it did inanother era (Uchitelle ).

There are other potential problems with the framework. The very attrac-tiveness, for all parties, of an appeal to widely held but ill-defined notions ofcitizenship, community, and community membership, may impede prac-tical efforts to facilitate community integration for mentally ill homelesspersons. Attention to citizenship can be placed in the service of a highlyindividualistic interpretation of what makes for a good citizen, with a focuson bootstrap-pulling at the expense of outside help or with disregard for thecompromising effects of mental illness, substance abuse, and serious healthproblems for many homeless persons. In addition, a focus on citizenship asan affective value can mask the need for resources such as jobs and housing.Finally, the notion of drawing on community support and the private resourcesof citizens and voluntary groups can be used as an excuse to minimize theneed for government resources and turn the problem over to the privatesector.

Advocates and sympathetic policy makers must avoid setting up an either-or stance of community building versus governmental intrusion by support-ing both local partnerships and continued government involvement in theissues of affordable housing, jobs and income supports, and assistance forindividuals with special needs. Community researchers can participate ateach and all levels of analysis, helping to refine the meaning of citizenshipand community integration through action research. Researchers can con-duct both in-depth and comparative studies of local communities to betterunderstand their varying capacities to facilitate the community integrationof homeless persons. It is likely, for example, that many natural associationsare already taking place between formerly homeless individuals and theirneighborhoods and communities without the help of planners and policymakers. Knowledge of local capacity and activity can help planners, advoc-ates and homeless persons, and community members to implement moreeffective local and regional approaches. Homeless persons, service providers,and community members should not only be the subjects of such efforts butresearch partners, helping to frame appropriate questions and methods.


Conclusion

The multiple needs associated with homelessness and mental illness and thedifficulty of developing systematic and coherent public policies invite us toconsider alternative approaches, including community-based partnershipsbetween service providers, advocates, homeless persons, and the larger com-munity that may lead to progress on the goals of community integration ofhomeless persons beyond what mental health and other service programscan accomplish on their own. A citizenship framework offers the potential tolink individuals’ needs for stable housing and adequate resources to theirneeds for membership and belonging in their communities and in society atlarge, and, perhaps, to give community members new ways to respond tohomelessness. It adds a social component to our individualistic approachto treating and rehabilitating homeless persons with mental illness, and em-phasizes access to the rights, roles, and responsibilities of full membershipin society. Efforts built around this framework pose difficulties in definition,design, and implementation. With systematic and sustained effort, though,and with incentives that recognize the self-interests of different sectors, theconcept of citizenship that we have outlined here may contribute to a gradualculture shift in which the question “After housing, what?” figures more pro-minently in our response to contemporary homelessness.

Acknowledgements

The authors’ work on this paper was made possible, in part, through theirparticipation in the New Haven site of the national ACCESS initiative spon-sored by the federal Center for Mental Health Services of the SubstanceAbuse and Mental Health Services Administration, and by a grant from theMelville Charitable Trust.

References

Allensworth, D., and Patton, W. (), Organizational independence and intra-organizational structure, American Sociological Review, : –.

Bellah, R. N., Madsen, R., Sullivan, W. M., Swidler, A., and Tipton, S. M. (),Habits of the Heart: Individualism and Commitment in American Life (updated edn), Berkeley:University of California Press.

Berger, P. L., and Neuhaus, R. J. (), To Empower People: The Role of Mediating Struc-tures in Public Policy, Washington, DC: American Enterprise Institute for Public Policy.

Brickner, P. W. (), Medical concerns of homeless persons. In R. H. Lamb,L. L. Bachrach, and F. I. Kass (eds), Treating the Homeless Mentally Ill: A Report of theTask Force on the Homeless Mentally Ill, Washington, DC: American Psychiatric Asso-ciation, pp. –.

Brown, M. A., Ridgway, P., Anthony, W., and Rogers, E. S. (), Comparison ofoutcomes for clients seeking and assigned to supported housing services, Hospitaland Community Psychiatry , : –.

Boissevain, J. (), Friends of Friends, Oxford: Basil Blackwell.Brown, C. (), The Art of Coalition Building: A Guide for Community Leaders, New York:

American Jewish Committee.


Butterfoss, F. D., Goodman, R. M., and Wandersman, A. (), Community coali-tions for prevention and health promotion, Health Education Research, , : –.

Callahan, S., Mayer, N., Palmer, K., and Ferlazzo, L. (), Rowing the boat withtwo oars, NFG Reports, , : , .

Carling, P. J. (), Major mental illness, housing, and supports: the promise ofcommunity integration, American Psychologist, , : –.

Carling, P. J. (), Housing and supports for persons with mental illness: emerging ap-proaches to research and practice, Hospital and Community Psychiatry, , : –.

Carling, P. J. (), Return to Community: Building Support Systems for People with PsychiatricDisabilities, New York: Guilford Press.

Chafetz, L. (), Why clinicians distance themselves from the homeless mentally ill.In R. H. Lamb, L. L. Bachrach, and F. I. Kass, eds, Treating the Homeless MentallyIll: A Report of the Task Force on the Homeless Mentally Ill, Washington, DC: AmericanPsychiatric Association, pp. –.

Chamberlin, J. (), On our Own: Patient Controlled Alternatives to the Mental HealthSystem, New York: McGraw-Hill.

Chamberlin, J. (), Speaking for ourselves: an overview of the ex-psychiatricinmates’ movement, Psychosocial Rehabilitation Journal, : –.

Cohen, M. D., and Somers, S. (), Supported housing: insights from the RobertWood Johnson Foundation Program on Chronic Mental Illness, Psychosocial Rehab-ilitation Journal, , : –.

Cohen, N. L., and Marcos, L. R. (), Outreach intervention models for thehomeless mentally ill. In R. H. Lamb, L. L. Bachrach, and F. I. Kass, eds, Treatingthe Homeless Mentally Ill: A Report of the Task Force on the Homeless Mentally Ill, Washing-ton DC: American Psychiatric Association, pp. –.

Cohen, N. L., and Tsemberis, S. (), Emergency psychiatric interventions on thestreet, New Directions for Mental Health Services, , winter: –.

Croan, G., and Lees, J. (), Building Effective Coalitions: Some Planning Considerations,Arlington, VA: Westinghouse National Issues Center.

Davidson, L., and Strauss, J. S. (), Sense of self in recovery from mental illness,British Journal of Medical Psychology, : –.

Deegan, P. E. (), The independent living movement and people with psychiatric dis-abilities: taking back control of our lives, Psychosocial Rehabilitation Journal, : –.

Dennis, D. L., and Monahan, J. (), Introduction. In D. L. Dennis and J. Monahan,eds, Coercion and Aggressive Community Treatment: A New Frontier in Mental Health Law,New York: Plenum Press, pp. –.

Fisk, D., Rowe, M., Brooks, R., and Gildersleeve, D. (), Integrating consumerstaff into a homeless outreach project: critical issues and strategies, Psychiatric Re-habilitation Journal, , : –.

Francisco, V. T., Paine, A. L., and Fawcett, S. B. (), A methodology for monitoringand evaluating community health coalitions, Health Education Research, : –.

Frese, F., and Davis, W. W. (), The consumer-survivor movement, recovery, andconsumer professionals, Professional Psychology: Research and Practice, : –.

Goldman, H. H., and Morrissey, J. P. (), The alchemy of mental health policy:homelessness and the fourth cycle of reform, American Journal of Public Health, , :–.

Hord, S. (), A synthesis of research on organizational collaboration, EducationalLeadership, February: –.

HUD (Department of Housing and Urban Development) (), HUD Challenge:Special Issue on Citizen Participation, Washington, DC: HUD.

Interagency Council on the Homeless (), Reaching Out: A Guide for Service Providers,Washington, DC.


Janoski, T. (), Citizenship and Civil Society: A Framework of Rights and Obligations inLiberal, Traditional, and Social Democratic Regimes, Cambridge: Cambridge UniversityPress.

Kloos, B., Benedict, P., TwoBears, L., and Rowe, M. (), Citizens Process Log Evalu-ation: Documenting the Creation of a Community-based Organization, New Haven, CT:Consultation Center.

Koegel, P. (), Through a different lens: an anthropological perspective on thehomeless mentally ill, Culture, Medicine and Psychiatry, : –.

Kretzmann, J. P., and McKnight, J. L. (), Building Communities from the Inside Out: APath Toward Finding and Mobilizing a Community’s Assets, Chicago: ACTA Publications.

Lamb, R. H., Bachrach, L. L., Goldfinger, S. M., and Kass, F. I. (), Summary andrecommendations. In R. H. Lamb, L. L. Bachrach, and F. I. Kass, eds, Treating theHomeless Mentally Ill: A Report of the Task Force on the Homeless Mentally Ill, Washington,DC: American Psychiatric Association, pp. –.

Linney, J. A., and Wandersman, A. (), Prevention Plus III: Assessing Alcohol and OtherDrug Prevention Programs at the School and Community Level: A Four Step Guide to UsefulProgram Assessment, Rockville, MD: Office of Substance Abuse Prevention.

Marshall, T. H. (), Class, Citizenship and Social Development, Chicago: University ofChicago Press.

Martin, M. (), The homeless mentally ill and community-based care: changing amindset, Community Mental Health Journal, , : –.

Mattison, A., Benedict, P., and TwoBears, L. (), As I Sat on the Green: Living Withouta Home in New Haven, New Haven CT: Citizens Project/Columbus House.

McKnight, J. L. (), Regenerating community, Social Policy, Winter: –, .Morse, G. A., Calsyn, R. J., Miller, J., Rosenberg, P., West, L., and Gilliland, J.

(), Outreach to homeless mentally ill people: conceptual and clinical consid-erations, Community Mental Health Journal, , : –.

Randolph, F. (), Improving service systems through systems integration: theACCESS program, American Rehabilitation, : –.

Rappaport, J. (), Community Psychology: Values, Research, and Action, San Francisco:Holt, Rinehart and Winston.

Reidy, D. (), Shattering illusions of difference, Resources : –.Richardson, M. (), The impact of the Americans with Disabilities Act on em-

ployment opportunity for people with disabilities, Annual Review of Public Health, :–.

Ridgway, P. (), The Voice of Consumers in Mental Health Systems: A Call for Change,Washington, DC: National Institute of Mental Health.

Rowe, M. (), Crossing the Border: Encounters between Homeless People and OutreachWorkers, Berkeley: University of California Press.

Rowe, M., Hoge, M. A., Fisk, D. (), The bright yellow sneakers: a case exampleof assertive outreach with mentally ill homeless persons, Continuum: Development inAmbulatory Health Care, , , Winter: –.

Segal, S. T., Baumohl, J., and Johnson, E. (), Falling through the cracks: mentaldisorder and social margin in a young vagrant population, Social Problems, , :–.

Spaniol, L., Koehler, M., Hutchinson, D. (), The Recovery Workbook: Practical Cop-ing and Empowerment Strategies for People with Psychiatric Disabilities, Boston: Center forPsychiatric Rehabilitation.

Stevenson, W., Pearce, J., and Porter, L. (), The concept of coalition in organ-ization theory and research, Academy of Management Review, : –.

Susser, E., Goldfinger, S. M., and White, A. (), Some clinical approaches to thehomeless mentally ill, Community Mental Health Journal, , : –.


Swayze, F. V. (), Clinical case management with the homeless mentally ill. InR. H. Lamb, L. L. Bachrach, and F. I. Kass, eds, Treating the Homeless Mentally Ill:A Report of the Task Force on the Homeless Mentally Ill, Washington, DC: AmericanPsychiatric Association, pp. –.

Uchitelle, L. (), Lonely bowlers, unite: mend the social fabric, New York Times, May: B-, B-.

Vaccaro, J. V., Liberman, R. P., Friedlob, S., and Dempsay, S. (), Challengeand opportunity: rehabilitating the homeless mentally ill. In R. H. Lamb, L. L.Bachrach, and F. I. Kass, eds, Treating the Homeless Mentally Ill: A Report of the TaskForce on the Homeless Mentally Ill, Washington, DC: American Psychiatric Association,pp. –.

Van Tosh, L. (), Working for a Change: Employment of Consumers/Survivors in the Designand Provision of Services for Persons who are Homeless and Mentally Disabled, Rockville,MD: Center for Mental Health Services.

Werbner, P., and Yuval-Davis, N. (), Women and the new discourse of citizenship.In N. Yuval-Davis and P. Werbner, eds, Women, Citizenship and Difference, New York:Zed Books, pp. –.

Wiseman, J. P. (), Stations of the Lost: The Treatment of Skid-Row Alcoholics, EnglewoodCliffs, NJ: Prentice-Hall.

Wolfensberger, W., and Tullman, S. (), A brief outline of the principle of normal-ization. Rehabilitation Psychology, : –.

Homelessness, Mental Illness and Citizenship

Documents