‘Housing First’ is an approach to ending homelessness that centers on quickly providing homeless people with housing and then providing additional services as needed. It is an approach first popularized by Sam Tsemberis and Pathways to Housing in New York
in the 1990s
, though there were Housing First-like programs emerging elsewhere, including Canada (HouseLink in Toronto
) prior to this time. The basic underlying principle of Housing First is that people are better able to move forward with their lives if they are first housed. This is as true for homeless people and those with mental health and addictions issues as it is for anyone. According to Pathways to Housing, “The Housing First
model is simple: provide housing first, and then combine that housing with supportive treatment services in the areas of mental and physical health, substance abuse, education, and employment.”
The core principles of Housing First include:
Does Housing First work?
- No housing readiness requirements. Individuals and families are not required to first demonstrate that they are ‘ready’ for housing. This approach runs in contrast to what has been the orthodoxy of ‘treatment first’ for homelessness, which suggested that people who are homeless should be placed in emergency services until they are ‘ready’ for housing (having received access to health care or treatment).
- Choice. Key here is the idea that clients are able to exercise some choice regarding the location and type of housing they receive. As we will see below, choice may be constrained by local availability and affordability.
- Individualized support services. Some people, once housed, will need minimum supports, while other people will need supports for the rest of their lives, ranging from case management to assertive community treatment. A key philosophy of Housing First is that people have access to the supports they need, IF they choose.
- Harm Reduction. Harm reduction aims to reduce the risks and harmful effects associated with substance use and addictive behaviours for the individual, the community and society as a whole, without requiring abstinence. In Housing First, this means that absolute sobriety is not required (though as part of the spectrum of choices, people may choose ‘abstinence only’ housing) and a tenant cannot lose housing because of substance use.
- Social and community integration. Part of the Housing First strategy is to help people become socially integrated into their community and this requires socially supportive engagement and the opportunity to participate in meaningful activities. If people are housed and become or remain socially isolated, the stability of their housing may be undermined.
While ideally all Housing First programs share these critical elements, there is considerable variation in how the model is applied, based on population served, resource availability, and factors related to the local context.
There is a body of research
that convincingly demonstrates Housing First’s general effectiveness
, when compared to ‘treatment first’ approaches. Tsembaris and Eisenberg demonstrated that 90% of people
involved in the Pathways program remained housed five years later. Gulcar et al. likewise demonstrated housing stability
. There is a growing body of research
that reveals that people with mental health and addictions issues do very well with a housing first approach, spend fewer days in hospital and require less expensive interventions.
Having said this, additional research is required to answer the following questions:
- How effectively do Housing First programs demonstrate fidelity to the principles of the model? As Housing First grows in popularity, there are increasing pressures on communities to adopt the Housing First model. In other words, one might adopt Housing First as a policy, but may not be able to effectively implement it in practice. Can we ensure that key principles, including client choice, necessary supports and social integration are upheld?
- What is the relationship between Housing First and the Affordable Housing Supply? Housing First, as a rule, does not add to the affordable housing stock. This raises the question of how to apply Housing First in a tight housing market. Can one in fact house people if there isn’t sufficient housing? And in a tight rental market, will a core principle of Housing First – that of consumer choice – be sacrificed? Finally, does a shift in emphasis to ‘Housing First’ without a concurrent investment in affordable housing merely shift the focus on the problem? That is, for most people who become homeless, the problem is a lack of affordable housing supply (and access) and income, and any effective response must address these issues.
- How are the needs of sub-populations met through Housing First? Does one size fit all? Do young people, who have no experience independent living, require a different model of Housing First, one that includes key elements of transitional housing? Do Aboriginal people, new Canadians and racialized minorities have different needs? Women (concerns for safety) and families (community integration) may also require special considerations. Furthermore, there is some evidence that people with severe addictions may not fare as well in Housing First.
- What is the duration and extent of supports, and who is responsible for funding them? In some cases Housing First programs provide a time limited investment in supports, ranging from one to three years. For those who need ongoing supports, effective models for continued engagement with mainstream services need to be explored.
- Once housed do people have adequate income to meet basic needs on an ongoing basis? In some jurisdictions (Pathways to Housing, New York), there is a stipulation that people who are housed should pay no more than 30% of their income on rent. This is not true of all jurisdictions. Falvo reported that in Toronto, some people housed through Streets to Homes had as little as $100 per month to live on after paying rent. The impact on social integration and nutritional vulnerability is clear.
These and many other questions remain unanswered. There is not yet sufficient research evidence to argue that Housing First is a ‘best practice’. This is because: a) most studies focus on the same project (notably Pathways to Housing), and b) many studies are in fact ‘case studies’ that have not been conducted by an independent external researcher. Currently, the largest research project ever undertaken on Housing First is the At Home/Chez Soi project, which is currently underway. Funded by the Mental Health Commission of Canada, it involves a five city analysis of housing first interventions, and once completed, will be able to address many of these questions.
AUTHOR: Gaetz, Stephen (2012) Homeless Hub.