Building a new substance use disorder (SUD) facility can significantly improve a community’s access to much-needed behavioral health care. However, stigma and misconceptions can lead to significant local backlash. 

For SUD providers, neighborhood pushback can lead to lengthy, expensive legal and regulatory processes. Restrictive zoning policies paired with a lack of community support can prevent a facility from opening its doors.

Educating local agencies, playing “insider baseball” and seeking wise counsel can all help providers overcome a community’s reluctance.

Still, there are no guarantees for providers looking to break into new markets.

Much of a community’s negative reaction to a new behavioral health facility can be attributed to stigma, Andrew Sfreddo, head of behavioral healthcare at health care real estate advisory firm Blueprint, told Addiction Treatment Business. 

“Even though the stigma of behavioral health care has been lifted a lot even over the past five years, there’s still a sense of, ‘That’s fine, but maybe on the other side of town,’” Sfreddo said. “That is something that we deal with on a day-to-day basis, trying to get approval, talking with lobbyists and local attorneys to see if there’s a path for behavioral health care to fill the need within that local area.”

Chicago-based Blueprint is a real estate brokerage firm specializing in senior housing and health care. Sfreddo said the firm is dealing with community pushback on several transactions.

Communities can take issue with all types of behavioral health facilities, experts told ATB. The facilities that are most likely to draw ire are those that provide care to adults and those that provide treatment for SUDs or serious mental illnesses (SMIs).

Facility size and location can also impact a community’s response to a new behavioral health facility, Nathaniel ‘Tani’ Weiner, health care M&A lawyer and co-chair of Polsinelli Law Firm’s behavioral health group, told ATB.

“Facilities in residential neighborhoods draw concerns ranging from NIMBY (Not In My Backyard) anti-development sentiment and concerns about increased traffic and parking needs, to perceptions that behavioral health facilities may decrease property values and/or contribute to health and safety issues,” Weiner said. “Facilities in commercial areas can draw some of those same concerns, and in both settings, we see outdated and prejudicial attitudes about behavioral health treatment, and fear and misunderstanding as unfortunately contributing causes.”

Zoning

Community backlash usually arises once the development becomes public knowledge, a timeline that is often determined by whether a facility requires a zoning variance, Weiner said.

According to a Blueprint analysis of 50 behavioral health care facilities, approximately 19% to 20% are zoned by-right. Locations with by-right zoning qualify for construction without discretionary approval. The other approximately 80% of facilities require varying degrees of applications, public hearings and comment periods before being allowed to open their doors.

Facilities requiring zoning variances, use permits or construction permits often draw community opposition during the application or hearing process, Weiner said, which usually occurs before construction or facility openings.

By-right facilities that fit into existing zoning, have zoning exceptions, or require minimal construction are likely to draw potential community opposition at later points, including during grand openings or even later.

However, legal protections are in place to discourage discrimination. The Fair Housing Act, enacted in 1968, is a “protective shield” for behavioral health residential facilities, Matt Pettinelli, founder and CEO of CapGrow Partners, told ATB. 

“That doesn’t mean that there are no communities that ignore the law and are determined to fight that the law is wrong, or that in their particular situation that the law does not apply,” Pettinelli said. “They [more] often lose that argument in the court system than not.”

Chicago-based CapGrow is a real estate investment firm that acquires and leases properties to behavioral health providers.

The Fair Housing Act is implied even in zoning laws, Pettinelli said. But just because a behavioral health provider is protected legally doesn’t mean it is always worth it to go through the lengthy, complicated process to win the argument against negative public sentiment.

Providers may instead choose to simply open a facility in another, more welcoming neighborhood.

But shifting facility locations means that inhospitable neighborhoods are less likely to get access to an SUD facility. This can limit, delay and prevent treatment for some people in need, Pettinelli said.

Mitigation techniques

Responding to community backlash or zoning struggles can be an uphill battle. Still, strategies exist for behavioral health providers looking to open new facilities.

Simply sending in applications to appeal decisions or challenge zoning without connecting with the community can be a “recipe for disaster,” Sfreddo said.

“Let’s sit down, break bread and have a meeting with the township, the mayor, the fire department, the police department, about what we are trying to create, the patient that we’re trying to serve and how we essentially govern ourselves,” he said. “It just comes back down to education. … You need to make sure you get community support on your side. That’s critical. It’s tough to win without that.”

Teamwork among providers can also help bring a new behavioral health facility to a community in need, Pettinelli said. However, not all providers are willing to share information with a competitor. Sharing information about a less-than-favorable experience may also be a risk for a provider already operating in a specific location if word spreads.

Despite the risks, playing “inside baseball” can be key to spreading access to behavioral health.

Legal advice can also help providers understand variations in local land use laws, state regulations and state and federal disability protection laws, according to Weiner. Due diligence is required to understand the nature and scope of what will be needed to open a new facility.

While these techniques seem simple, the reality is far more complicated and no one-size-fits-all approach exists.

“There is not a key to unlocking this door,” Pettinelli said. “It sometimes takes five different tries. Sometimes it’s not possible. … What you’re trying to do is hope that through communication and education, people are receptive and willing to learn and change. But sometimes they’re not willing to learn to change.”