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Life on the Inside

A maverick program has a new deal for street people -- free apartments, no strings attached. So if it?s just a big giveaway, why do conservatives like it so much?

When Andre hears something that strikes him as crazy, he'll lean in, almost uncomfortably close, cock his head to the side, and fix his one good eye on you, bugging it a bit for dramatic effect. Sarah Stanton is getting one of these looks right now, as she and Andre sit side by side on a low brick wall, outside one of Washington, D.C.'s busy soup kitchens. Stanton has just finished telling him that her Pathways program, brand new to the city, offers apartments to homeless people -- right away and with virtually no conditions. After a long silence, Andre grins. "Can you get me a mansion?"

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Stanton laughs. "Oh, today!"

Andre leans back and laughs louder. "Only the best!" he says. "All chrome furniture!"

Stanton is still smiling, but as she pulls a stack of paperwork out of her messenger bag, Andre realizes her offer is real. He turns serious and stares out at the street. He has no job and no income -- he lost his veteran's benefits a while ago and isn't sure how to get them back. He doesn't really remember the last time he lived indoors, unless you count jail.

Stanton asks if he would like to visit her office. He'll need to see a doctor. "A psychiatrist?" Andre asks. She nods; Pathways wants to determine whether Andre has a mental illness serious enough that, left on his own, he would be unlikely to find and keep a home or a regular job. He seems wary. But when she returns to the soup kitchen a week later, he is waiting for her, his possessions packed tight into a small duffel. "So, do I need to act crazy?" he asks, screwing up his face. "It makes you this way, you know?"

"What does?" she asks.

"Living in the street," he says. "It makes you crazy."

Mental illness can make it hard to hold down a job, stick to a budget, and stay in the good graces of a landlord. But homelessness can be part of the cause of psychiatric problems as well as an effect: A life without privacy or shelter can turn even a manageable mental illness into full-blown madness. It is that vicious circle of illness and homelessness that drives the work of Pathways to Housing -- Stanton's employer and, at the moment, perhaps the most radical program for the homeless anywhere in the country.

For years, homeless people had only two options: sleep outside or hope for a space in a shelter. During the 1990s, so-called "permanent supportive housing" introduced a third option: a permanent, private room or apartment in a nonprofit building with psychiatrists, social workers, and nurses on site. Trouble was, these programs tended to be difficult to get into, particularly for the long- term homeless who are often mentally (and physically) ill, addicted to drugs, fearful of shelters, and distrustful of social workers. Supportive housing programs usually involve a long list of preconditions, such as six months or a year in a "transitional" group home, mandatory counseling and medications, a record of responsible behavior, and sobriety.

Pathways, by contrast, sweeps homeless clients into an apartment within two weeks. And it never threatens to take that home away. Although Pathways offers clients medical and psychiatric services, as well as substance-abuse and job counseling, it doesn't require anyone to use them; the group maintains that housing is therapeutic in itself. It should come first, and fast, as the foundation for ongoing treatment. "You're curing the housing problem first," Pathways founder Sam Tsemberis explains. "You cure the person later."

This idea can be jarring to anyone who expects work to come first and reward to follow. But the chronically homeless are seldom able to make that leap. Faced with a bunch of strict conditions for housing, and lots of ways to get kicked out, many assume they will fail, so they reject help. And the costs of these refusals are steep. On any given night, this group occupies half of the nation's emergency shelter beds, even though they make up only about 10 percent of the homeless population. By living, and often dying, on the street they also run up enormous bills for federal and local law enforcement agencies, social service providers, prisons, and hospitals. In 1997, the University of California at San Diego Hospital followed 15 chronically homeless residents for 18 months and tallied 417 emergency room visits between them, at a cost of more than $1 million.

Pathways relies on this fundamental calculation -- that reversing the order of services to put housing first produces much better results with no greater costs. Launched in New York City with a handful of employees in 1992, the program has grown to 85 caseworkers, psychiatrists, and nurses, plus 35 mostly part-time positions held by its clients, and has moved hundreds of mentally ill and homeless New Yorkers into apartments. Today Pathways works with nearly 500 clients -- a small number compared to New York's nearly 40,000 homeless, but considerable for a young organization.

This unorthodox success has made the program a target of criticism from others in the field. A common view is that the chronically mentally ill and homeless aren't "ready" for housing. "The hell I took from my colleagues!" says Alexa Whoriskey, the program's New York director of psychiatry, who came to Pathways through a fellowship at Columbia University. "In the beginning, they laid into me for what poor care this was." Whoriskey's colleagues thought Pathways clients needed hospital beds and constant supervision. Instead, the organization was taking highly unstable people, giving them the keys to an apartment, and leaving them there alone.

Improbably, Pathways has been a favorite of the Bush administration, which has chosen to focus its homelessness efforts on long-term cases and shift aid from shelters to permanent housing. But if the program is so profligate that even some liberals object, why in the world would conservatives be gung-ho about it? Bush homelessness czar Philip Mangano, a crusading Bostonian respected by liberals and conservatives alike, admits Pathways is "a tough political sell." But, he notes, it is also research-driven, cost-conscious, and accountable -- and those are traits that appeal to anyone.

During the 1990s, when the Clinton administration tripled spending on the homeless to about $1 billion a year, most of the new money went to the "continuum of care," a funding initiative based on the idea that although shelters alone would not make homelessness go away, "wraparound services" -- from rehab programs to job training -- might. Despite the surge in funding, the number of homeless people nationwide continued to grow. Even in the booming '90s, according to the Urban Institute, 2.3 million people were homeless at some point in the course of a year. Today, according to the U.S. Department of Health and Human Services, roughly 600,000 people are homeless on any given day, and New York City is facing the largest numbers of homeless people it has seen since 1990.

Pathways has demonstrated that it can shrink those numbers. Between the years 1993 and 1997, research showed that 88 percent of Pathways clients, all of them extreme cases, remained in housing, compared to just 47 percent who went through New York City's treatment system. Another study, funded by the Substance Abuse and Mental Health Services Administration, randomly assigned 225 mentally ill New Yorkers to either Pathways or a traditional program. After 12 months, Pathways clients were homeless 3 percent of the time, compared with 28 percent for those in the city's system.

And the approach costs no more (in fact, probably less) than conventional programs. In a five-year study, Dennis Culhane, a professor at the University of Pennsylvania, showed that New York City could give each of its mentally ill homeless residents their own apartment or room plus access to support services for roughly the same amount the city was already spending on ER care, prison time, shelters, and other services. Culhane found that someone mentally ill and on the streets costs government about $40,500 each year. (Homelessness czar Mangano believes Culhane's accounting is too conservative, because it leaves out the costs of police and court time, care at private hospitals, soup kitchens and other street outreach.) Pathways, on the other hand, spends only about $22,000 a year on each of its clients, and a good portion of that is money already allotted to them through government benefits programs.

Pathways' newfound national prominence, however, has yet to completely erase doubts that it gives away too much, too fast -- or, at the very least, that its success is unique to New York. Which is why founder Tsemberis has set out to prove his program can work elsewhere. By the middle of 2005, Stanton and the rest of Pathways' Washington team plan to move 75 mentally ill homeless into apartments around the city. So far, they've offered apartments to Bob, a fragile, elderly man who has slept in the same grassy stretch along Wisconsin Avenue for most of the last 30 years; to Muriel, a strikingly childlike Lebanese immigrant who lost custody of her kids, and then her home, when the onset of mental illness alienated her husband and her mother; to Michael, who is battling delusions, rage, and HIV; to Dolores, an elderly African American woman who has struggled with drugs. And today, to Andre.

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