International Journal of Drug Policy - 2014

Volume 25 Issue 3 May 2014

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558 K.R. Knight et al. / International Journal of Drug Policy 25 (2014) 556–561 unmet. One policy maker outlined the statistics on co-morbidity among the population in San Francisco, underscoring the relation- ship between drug use, place, and social policy in this setting: Of the people in supportive housing in San Francisco, 93% have a major mental illness that we can name. That is very, very high. 80% use cocaine, speed, or heroin every thirty days, or get drunk to the point of unconsciousness. There are no more disabled people in this country. Because of San Francisco's small size and geographic bound- edness, it was expedient to use existing SROs as sites to house the burgeoning urban poor. To date, there are more than 500 SROs in San Francisco, providing homes for approximately 30,000 low income individuals (CCSRO website). These built environ- ments include both larger and smaller building stock, with some SRO hotels housing up to 200 persons and others with only 25–30 rooms. The necessity of using existing SRO housing as sites to accommodate the expanding population of impoverished individ- uals created a trifurcated system. This system has led some women to find housing in older, privately run and managed SROs, some in previously privately owned buildings whose master lease had been purchased by the City of San Francisco, and others to be housed in new buildings built on the demolished cites of older SROs or in other urban spaces. 1 These three types of built environments pre- sented different challenges to women in the management of their mental health. The department of Housing and Urban Health (HUH), the first in the country to formally integrate housing management with public health, was created within the San Francisco Department of Public Health to develop and manage the publically funded older and newer SRO buildings. The HUH discovered through the course of this progressive housing initiative that building new, publically funded SROs is more cost effective and produces better housing and health outcomes for the tenants, than converting exiting privately owned SROs. Even if rental payments could be deferred through welfare or subsidy payment mechanisms, simply placing adults indoors in older SRO buildings was not efficacious if the indoor environment was still chaotic, dangerous, and poorly managed. At the macro-level, the built environment needed to be responsive to "trauma." 2 For a population of tenants with high rates of co-morbid substance use and mental health issues, the built environment – the organization of the physical and social space – was construed as critical to ensuring housing success. One health and housing policy maker compared the different levels of housing stability for tenants in new SRO built environments to those in older SROs, to emphasize the interactive relation between the built environment and trauma: When we look at our success in keeping people housed in our buildings, what we see is that places like the Marque, 3 which has small, dirty rooms, case management, but shared bathrooms. The rate of people staying housed there for two years consec- utively is 30%. That is horrible. The Zenith, a new building, has case management, same as the Marque. But it is beautiful; every room has its own bathroom. 70% of the tenants stay at least 1 The payment structure for rent in these three types of SROs is complex and varies for tenants depending on whether they pay for SRO rooms out of pocket, or through welfare program linked subsidies, of which there are several. Discussion of the complex payment structures is beyond the scope of this paper, but is discussed at length in Knight, KR, Forthcoming with Duke University Press. 2 "Trauma" here is a colloquial (as opposed to clinical) term deployed to refer to the complex array of affective symptoms many chronically-homeless persons, especially women, demonstrate in daily life as a result of historic experiences of abuse and current vulnerabilities. 3 The names of SRO hotels are pseudonyms. Fig. 1. Older SRO room compared to newly built SRO room. two years." The point is the good stuff is the better investment when it comes to supportive housing. The environment mat- ters. I think it is about trauma. People, who have had so much trauma cannot stabilize, cannot stay housed if they still living in a dump. The following pictures draw a comparison between the physi- cal environment deemed to be "trauma-sensitive" and the standard situation in privately owned SRO. The physical layout of a typi- cal SRO is a single, 8 × 10 00 room with shared toilets and showers down the hallway. Newly built SROs were often clean, well-lit, less chaotic, well-managed, and safer. Newer SROs included individual bathrooms and sometimes small kitchens to prepare food. In con- trast, older and privately owned SROs often consisted of a double or single bed, a sink, a small chest of drawers, and a desk. The phys- ical conditions which routinely affected women's mental health in our study included the presence of rats, mice, and bed bugs; graffitied walls and broken furniture; and, non-operating sinks, electricity, door locks, and TV sets. As demonstrated in the photos, the condition and functionality of the physical aspects of the built environment varied a great deal and this variation contributed in positive and negative ways to women's mental health outcomes (Figs. 1–3). Meso and micro-level factors: social relations and behavioral strategies intersect with the built environment to influence mental health The women in our sample had high rates of co-occurring men- tal health and substance use issues and extensive histories of Fig. 2. View of out of window newly built SRO compared to view out of older SRO window.

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