Beyond Crisis:
Imagining a very different life in community for people with SMI
Johanna Ferman, MD, Integrus Health Group
August 2025
Summary
A new framework is put forward providing a roadmap for what life ‘in community’ can look like for people with SMI. It posts the vital nature of three pillars – affordable housing, employment (harnessed to economic development) and quality care – embedded in a grounding community. It maintains that we can achieve vastly improved outcomes if we use a social contract that connects existing resources, while emphasizing the centrality of civic life and the arts in the creation of welcoming space for the most vulnerable. It moves from isolation to vibrant, integrated lives. Hope for real improvement becomes a motivating force.
What we face
A diagnosis of a severe mental illness (SMI)[1] remains a deeply traumatic moment – for individuals and their families alike. Too often, it marks the beginning of a frightening descent into crisis. Criminalization, homelessness, and prolonged instability are not distant risks but common outcomes. Families frequently shoulder the burden alone, keeping loved ones at home despite rising dysfunction or sometimes dangerous behaviors, and with little support.
Seventy years after deinstitutionalization began, we now face a perfect storm:
First, there is a chronic shortage of permanent, affordable housing. From 1980 to 2023, the U.S. homeless population grew from 125,000 to over 700,000. Today, people with SMI comprise 25–33% of that population – which is far above their 6% representation in the general public.[2]
Second, the care system has been hollowed out over decades – particularly in hospital, residential, and rehabilitation services. Legal protections, once designed to prevent abuse, now too often obstruct access to care, especially for the 50% of people with SMI who lack insight into their condition (anosognosia). The result is that these individuals cycle through emergency rooms, jails, and the streets.
Third, national disability policies and labor systems create both financial and structural barriers to meaningful work. The $15,000 annual income cap on SSI means even modest earnings can jeopardize essential benefits like healthcare and housing. This pushes individuals and families to focus on maintaining eligibility, rather than pursuing growth. Beyond income limits, the system fails to account for the relapsing nature of SMI. Many individuals are capable of working during periods of stability but need to pause or reduce involvement when symptoms recur. Yet few employment pathways allow for that kind of flexibility. Instead, work becomes an all-or-nothing gamble, rather than a supported path toward recovery.
Fourth, many people with SMI remain disconnected from the everyday life of others, with stigma compromising friendships, civic roles, and informal social ties in spite of deeply valuable models like Fountain House.
What’s been lacking
Despite islands of excellence, progress has been piecemeal and reactive. We’ve lacked a guiding framework – no blueprint to integrate what we know works.[3] In its absence, we default to crisis response, reinforcing stigma and squandering decades of clinical and programmatic gains. There has been little hope for betterment in such continuing crisis.
How might we think out of the box that is the frightening status quo?
Imagine: An alternative approach
This work offers a vision for what life can be like for people with SMI – a framework designed to adapt to local needs and strengths – and the genius that is ‘on the ground.’
It proposes a series of 7- to 8-year pilot programs across urban, suburban, and rural settings. It suggests an approach that should be rigorously evaluated before informing national policy. Unlike deinstitutionalization 70 years ago, this approach is meant to be tested, refined, and rooted in evidence.
The Design of Imagine: Three Core Pillars Rooted in Community
At the heart of this vision are three interconnected pillars, planted within what we call a grounding community.
What is a grounding community?
Human connection is essential to well-being. For people with SMI, connection – to each other, to meaningful roles, and to broader community life – is especially vital. Such a grounding community deeply reflects a set of values emphasizing the whole person. This means not having SMI (or ANY diagnosis) define the person -- seeing a person with SMI vs SMI becoming the person – yet no more denying the existence of these conditions than denying diabetes, rheumatoid arthritis or congestive heart failure.
Such communities would be characterized by:
A mindset of acceptance and understanding of SMI;
Welcoming spaces for social engagement, using the evidence-based Clubhouse Model that weighs heavily on peers; and
Opportunities to participate in artistic, environmental, or civic endeavors, from music and painting to local governance or community improvement.
What do we mean by “three core pillars?”
The Imagine framework is built on three interdependent pillars:
Permanent, affordable housing
Meaningful activity (paid or unpaid) supported by economic development
Accessible, high-quality behavioral and physical healthcare
While some pieces of this model already exist, the components are rarely designed to work together. Instead, services are siloed, with overlapping case management systems and fragmented communication – resulting in confusion, inefficiency, and missed opportunities.
The goal is not simply to expand services but to align them so that housing, work, and care reinforce one another. The following sections explore each pillar and the relationships that support more effective, coordinated use of resources.
(Details on infrastructure, oversight, and participant selection are in development.)
Pillar 1: Permanent subsidized housing
Permanent, affordable housing is the first structural pillar of the Imagine model. It addresses the most urgent and visible need in communities today, and without it, the other pillars struggle to function effectively. Critically, housing was never addressed during the early waves of deinstitutionalization, and families have long served as the default safety net, often without the resources or support to do so.
To meet this need, underutilized real estate – such as vacant schools, office buildings, or houses of worship – should be repurposed for public good. Models for this already exist in the U.S. and internationally.[4] Oversight of these developments should reside in a nonprofit entity or community trust, ensuring local accountability.
Importantly, housing should also support those who care for or contribute to the well-being of people with SMI. This includes behavioral health professionals, artists (who may also engage as art therapists), and caregivers. By offering housing in exchange for their ongoing roles in the community, we reinforce the interdependence between housing and work, and begin to address workforce shortages across all three pillars.
The purpose is not to isolate people with SMI, but to foster a thriving, interwoven community – radically different from the de facto segregation seen today in encampments or in ghettoized sections of many cities.
Still, housing alone is not enough. For the roughly 50% of people with SMI who experience anosognosia – a lack of awareness of their own illness – stable housing by itself may not lead to stability. Some will become distracted and disengaged and may neglect their living space, or fail to pay rent.
Pillar II: Meaningful work and economic opportunity
Work – paid or unpaid – is fundamental to self-worth, purpose, and recovery. This has long been emphasized in the research of William Anthony, Ph.D., and the Boston Center for Psychiatric Rehabilitation. People with SMI, like all of us, must see real opportunities for participation, tailored to their abilities, interests, and changing capacity over time.
Participation should be flexible and graduated. Many individuals experience periods of wellness interspersed with episodes of illness. Employment pathways must reflect this rhythm, allowing for re-entry, pause, and growth without penalty.
Economic models should support this inclusion. Financial tools like ABLE accounts, developed by Michael Morris, allow individuals to earn and save beyond SSI limits without losing vital benefits. These mechanisms must be accessible to all as they stabilize and seek to re-engage in volunteer or paid activity.
Local businesses can commit to hiring people with SMI in exchange for tax benefits. Examples like Thelma’s Kitchen (and Reconciliation Services building of an industrial kitchen to expand into catering) in Kansas City, Rubicon Bakery in California’s East Bay, and urban farming projects in repurposed Detroit buildings already demonstrate how this model can thrive across settings. Vocational training and continuing education should also be available—whether toward a degree, a trade, or personal enrichment.
Outside of traditional work settings, people with SMI bring a range of talents that can be harnessed by the community. Partnerships with local artists, civic groups, or small businesses can open pathways for creative expression, learning, and leadership. Some individuals may become learners; others, teachers. Everyone has something to contribute when inclusion is intentional.
Pillar III: Accessible, quality health and behavioral healthcare
Just like anyone with a serious chronic illness, people with SMI need access to coordinated, continuous care from early diagnosis to rehabilitation delivered as close to home as possible.
Early intervention is key. Coverage must be guaranteed for people in the early stages of illness, with access to intensive, wraparound services. Programs like EPC in Missouri or EDAPT in California demonstrate how early psychosis care can be life-changing when it includes family support, psychotherapy, medication, and navigation services.
To receive care, access could be expanded by locating clinics, private practices, or outreach teams within the neighborhood or nearby, and incentivizing participation through tax benefits. These providers should meet high standards: offering 24/7 access, using evidence-base treatments (including dual-diagnosis care, CBT for psychosis, long-acting injectables, and clozapine), and actively coordinating with housing and employment services.
Not everyone will stabilize in outpatient care. Some will need more intensive supports – including assisted outpatient treatment (AOT), residential treatment, or inpatient hospitalization. These services may be at a distance, but should remain accessible and integrated into the broader care continuum.
A major barrier across all levels is the workforce shortage. We must expand the pipeline of clinicians trained in psychosis treatment – both prescribers and therapists. One promising approach: offering permanent subsidized housing to providers who commit to practicing in community-based SMI care. This not only supports recruitment but also embeds providers in the communities they serve.
Relationship between pillars
A core failure of our current system is that the pillars – housing, work, and healthcare – are rarely designed to work in concert. Services operate in silos. Resources are fragmented but also overlapping and duplicative. The impact of this? Much as a rocket, dismembered and left adrift in space, its parts cannot assure the lift needed for steering to safety. Without a specific set of relationships between the pillars, no matter our funding of one or another, our investments fall short of creating the sustainable outcomes we so long to achieve and we continue to feed chronic disability, disenfranchisement and homelessness.
The Imagine model depends on interdependence. It introduces a social contract – a mutual agreement between residents and the community. This contract is not about surveillance or coercion. It is about shared responsibility. Living in community is not passive. For example:
People with SMI, in exchange for subsidized housing, agree to engage in treatment, care for their living space, and participate in community life. Psychiatric advance directives (currently under evaluation in California) offer one way to preserve autonomy while preparing for periods of instability.
Healthcare providers, coordinators, navigators, artists, and elders may also be eligible for subsidized housing, but commit to play a role in the community – whether by providing care, running programs, or supporting other residents. This builds on models like loan forgiveness programs for providers in underserved areas.
All residents, regardless of role, commit to some form of paid or unpaid work that supports community well-being.