A reverse approach to homelessness

THE BALTIMORE SUN

NEW YORK - Social workers Vickie Stoyanova and Jerome Marzan have their hands full. Their job on this steamy day in Harlem is to drive a homeless man with mental problems and a crack habit to a hotel where he will stay until they find him a new apartment. He was kicked out of his last place after he turned it into a drug den.

As they drive, their charge announces that he is on the lookout for women eating ice cream cones. "Take me away and make me forget about what happened back there," he says, his brain buzzing with jumbled thoughts. Stoyanova, who calls her client a "really sweet guy," later confirms that the 49-year-old is schizophrenic. "But you probably got that," she says.

In most cities, including Baltimore, Stoyanova's sweet guy would still be living under a freeway ramp. He is a client at Pathways for Housing, a program that sets up mentally ill homeless people in apartment buildings with other New Yorkers rather than hotel-like residential facilities with teams of social workers. The program, unlike virtually any other in the nation, is changing the way many in this country, including those in the Bush administration, think about homelessness.

For decades, housing has been the end reward for months of sane and sober living. But for some homeless people, especially those with mental illness, staying clean and rational for an extended period is impossible. Stoyanova's client roamed the streets for 20 years before she and Marzan started looking out for him. They gave him an apartment despite his drug habit and wild mannerisms and have stuck by him through arrests and relapses. The Sun is not identifying him because of his illness.

At the hotel, Marzan gives advice. "Look, you've got to be really cool around here," he instructs. "Don't lose your keys." The man hasn't stopped talking. His bugged-out eyes take in his new surroundings. Before he enters the hotel, he strikes a dramatic pose and delivers one last monologue, this time about the Indian restaurant across the street. "Oh, yes, they remember me," he yells.

A new model

Stoyanova and Marzan know that the man won't soon stop smoking cocaine or inviting junkies home, but that's not the point. He's off the streets and learning, albeit slowly, to function in a rational world. "We understand that he is not going to stop getting high," Marzan says. "But we can get him to take a bath and make sure he gets his food stamps."

Sam Tsemberis, a psychologist who started the program about a dozen years ago, says the concept of housing the homeless before they receive treatment for drug addiction or mental illness isn't something he thought up. "It's what people told me they wanted," he said, referring to the men and women he met as an outreach worker in New York in the 1980s.

Pathways' harm-reduction model, which stresses protection over everything else, is winning converts. As word of its success has spread - 85 percent of the program's clients remain housed - duplicates are cropping up. Philadelphia, San Francisco and Denver are among a growing list of cities with "housing first" initiatives.

Baltimore could join the list soon. Laura Gillis, who heads the city's homeless services department, has invited Tsemberis to visit the city this month to explain how his program works. Members of her staff will also travel to New York to shadow Pathways staff for a day. Gillis will unveil a pilot program similar to the Pathways model in early July, she said.

The effort here will be small at first, with 20 apartments and a matching number of drug treatment slots, but it could be expanded, said Gillis, who is president of Baltimore Homeless Services Inc., a nonprofit arm of the city Health Department. In keeping with the Pathways model, Gillis' staff will sweep people off the streets and give them apartments. Participants will not be forced to enroll in drug treatment or psychiatric therapy, although the hope is that they will eventually.

The cost of the pilot program will be covered by several city agencies, including the Housing Authority of Baltimore City and Baltimore Substance Abuse Systems Inc. Gillis doesn't expect the cost to be exorbitant. The Pathways program costs $22,500 per person a year. More conventional programs cost $40,000 to $65,000. A bed in a New York state jail costs about $85,000. State hospitals charge $175,000.

'Survival mode'

Pathways serves 400 to 500 people a year and has an annual budget of $12 million. Funding sources include grants from foundations and the government, as well as benefits already available to clients such as housing vouchers and food stamps.

A recent census counted nearly 3,000 homeless people in Baltimore. However, most social services workers estimate that there are many more than that. They argue that there are thousands more who are doubling up with family and friends because they can't afford a place on their own. These people, they say, should also be counted as homeless because they have no permanent address and often wind up in shelters when money is short or relations strained. New York, by comparison, has a homeless population of about 38,000.

Gillis said the housing-first model makes sense, although it bucks the traditional model that uses housing as a reward after months or years of counseling, drug addiction treatment and medical attention. "How can we expect people to get their lives together when they are spending their days moving from shelter to shelter?" Gillis said. "Humans don't get a lot done when they're in survival mode."

Tsemberis says that once people get settled in their new apartment - Pathways provides $1,200 to set up house - people want to clean up. "They are suddenly motivated to stop drinking and stop using drugs because for the first time they have something and they want to keep it," he said. Landlords who work with Pathways don't mind having mentally unstable people living in their buildings as long as the rent checks arrive on time, and Tsemberis makes sure they do.

Days at Pathway's East Harlem office start at 9 a.m. when a team of social workers, a psychiatrist and nurse practitioner discuss their "customer" roster. The group is all business, calling out information in rapid-fire mode. "She'll be here today for that Medicaid paperwork." "We don't know if he made his podiatry appointment or not." "He's got a court date this morning. Does he know about that?" "He's going through his money like you wouldn't believe."

'I want to be sober'

Outreach workers meet with participants about six times a month but otherwise leave them alone. On this balmy morning, Darlene Lee, a Pathways service coordinator, meets with a sad-eyed man named Ali at the apartment he shares with his wife and two young children. Inside the apartment, Ali offers his guests seats on two dark-green sofas. The room is not particularly clean, but there is evidence of domestic order: An ironing board is set up in the center of the room, and an aerosol can of peach-scented air freshener is visible in the kitchen. Ali, 43, who asked that his full name not be used, doesn't work but says he'd like to.

"I would like to get a job, but I feel I can't because I drink beer," he explains. "I want to be sober."

A few minutes later, Ali tells Lee that he uses some of his weekly allowance to buy beer. (Participants hand over their benefit checks to Pathways and pay one-third of their rent.) Still, she doesn't lecture. That's not the Pathways way. Sobriety is not a condition of housing.

"It's so hypocritical," Tsemberis said when asked about Ali's beer drinking. "If we said everyone who wanted housing had to be clean and sober, do you know how many homeless people there would be in this country?"

A tough sell

But in Baltimore - where many service providers rely on a housing readiness model that forces homeless people to get treatment before they get housing - that philosophy might be difficult to accept at first, said Kevin Lindamood, a spokesman for the advocacy group Health Care for the Homeless in Baltimore. "This city is hard-wired for housing readiness," he said. "I think the housing-first concept will be controversial."

Lindamood however, is a believer. A couple of years back, he met a homeless man with a long history of police run-ins and emergency room visits. After Lindamood placed the man in a private room at a local boarding house, things changed. "When we looked at his record for the year that he'd been housed, we found he'd been to the emergency room once - and that was because one of our nurses sent him," Lindamood said. "He'd been arrested once, and that was for arguing with an officer who was about to arrest his friend."

Gillis is eager to get started. She hopes to learn from the pilot program and use the information to create a 10-year plan to end homelessness in Baltimore. Many cities are fashioning similar plans in an effort to access millions of federal dollars set aside by the Bush administration, which has launched a crusade to end homelessness among the disabled, including the mentally ill. The president has embraced the housing-first model as part of that initiative.

Tsemberis - a man of compassion -wants more. "There's very little funding for the homeless, which is very frustrating," he said. "With cancer research, there's always funding. If we had the funding [for housing] we could solve the problem, but there's just not enough political will." And that's the part that Tsemberis can't figure out.

After all, who is Ali? Who is the woman wrapped in a blanket under the Jones Falls Expressway? Tsemberis answers those questions with another. "Are they not someone's son or daughter?"

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