Housing First: Ending Homelessness, Transforming Systems, and Changing Lives

Deborah K. Padgett, Benjamin F. Henwood, & Sam J. Tsemberis

228 pages, Oxford University Press, 2016

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Few social problems have appeared to be as intractable as contemporary homelessness. Seattle and Los Angeles each recently declared a “state of emergency” after a noticeable escalation of homelessness in the past year. In New York City, a sudden resurgence of street homelessness has prompted almost daily local headlines. Polls show the issue is back atop the public’s agenda. At the same time, news accounts across the United States have heralded certain cities’ and states’ successes in battling homelessness. Houston, New Orleans, Philadelphia, Phoenix, Salt Lake City, and the state of Virginia, for example, each have declared that they have effectively ended homelessness among veterans.

How can we make sense of these competing narratives? Homelessness researchers Deborah Padgett, Benjamin Henwood, and Sam Tsemberis offer an answer. Their new book, Housing First, examines the reasons that the eponymous Housing First movement has succeeded dramatically in battling homelessness when traditional, top-down efforts have failed. In doing so, the book offers broader lessons about the risk that institutions built around addressing social problems may lose sight of their core missions behind the ideologies and vested interests of the professionals involved.

The social services sector has long been plagued by bad service, low professional morale, and a lack of impact. Aware of these complaints, governments tend to give meager funding to social programs, and, tragically, professionals in the sector accept that the down-and-out citizens they serve deserve the second-class services they receive. Service systems are often uninformed by research, tone-deaf to their clients, and utterly lacking in innovation.

Housing First has upended this state of affairs. The movement began in the early 1990s, when staff members at a New York homelessness program led by Sam Tsemberis decided to step back from their work and listen to the people whom they were unsuccessful in getting off the streets. They learned that these people preferred the dignity and autonomy of living on the streets to the subjugation of living in shelters. They preferred the freedom to avoid medication, doctors, and sobriety to the mandated services prescribed by the homeless services system. Most of all, they wanted places to live like everyone else—not in facilities set aside for people like them, with rules and overseers, but in regular apartments, places of their own where they could lock their doors and experience privacy.

This was a radical revelation in the top-down social services sector, where treatment professionals usually assume they know best. Traditionally, the sector’s paternalistic prerequisites for housing have deterred many homeless people: “The climb was too steep, the journey too long, or the difficulty level too high,” the authors write. “Repeatedly trying and failing discouraged many, and they eventually stopped trying, remained homeless, and withdrew into hopelessness.”

Tsemberis and his team, on the other hand, gave their homeless clients exactly what they asked for: regular lodgings in standard apartment buildings, without preconditions for substance-abuse treatment or sobriety, and rental subsidies to make the units affordable. The only condition was that tenants let a team led by a peer mentor check on them once a week. Housing First enlisted newly housed tenants to serve as mentors and as members of the committee overseeing the program.

To people outside the homelessness services sector, the idea that housing is the solution to homelessness may appear obvious. Employing randomized controlled trials to prove it may seem like testing whether food would be an appropriate treatment for starvation. Nevertheless, the performance of the Housing First model in several randomized controlled trials has shocked skeptics: 85 percent to 90 percent of people placed in housing remained housed two years later. Research showed high levels of effectiveness in city after city across North America, Europe, and Australia. Several studies, moreover, found that the intervention’s costs were off-set by reduced use of emergency rooms, jails, hospitals, detox centers, and shelters. The US government has now established Housing First as official policy. At the US Department of Veterans Affairs, it has led to a remarkable decline in homeless veterans.

These victories have forced the established “homelessness industry” to re-examine its own approaches. I have made Housing First required reading in a graduate-level class this semester in the hope that it will encourage students to consider how well-meaning professionals (as they are training to become) must collaborate with the people they serve to create responsive and inclusive social programs.

In its critique of entrenched practices, Housing First perhaps offers less a program model than an anti-model. Its guiding principles are essentially exhortations that providers should treat people who are homeless as they themselves would want to be treated. In this way, Housing First points the way for a new, ground-up approach to alleviating poverty and other forms of disadvantage, with insights that appeal to disruptors, progressives, idealists, pragmatists, and even compassionate conservatives. As communities struggle with a resurgence in homelessness, they can look to this book for guidance.