Deborah Padgett M.P.H - Housing First

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Library of Congress Cataloging-in-Publication Data

Padgett, Deborah.

Housing first : ending homelessness, transforming systems, and changing lives / Deborah K. Padgett, Benjamin F. Henwood, and Sam J. Tsemberis.

pages cm

Includes bibliographical references and index.

ISBN 9780199989805 (alk. paper)

eISBN 9780199989829

1.Homeless personsHousingUnited States.2.Homeless personsServices forUnited States.3.Homeless personsHousing.I.Henwood, Benjamin F.II.Tsemberis, Sam J.III.Title.

HV4505.P23 2016

363.50973dc23

2015014797

Consider the following questions:

How often in the vast landscape of health and human services does a small programmatic innovation become the leading approach in less than 20 years, making waves in a multibillion-dollar service sector?

How often is a fundamental change in social policy attributed to research findings?

How often does a successful evidence-based practice address human rights and consumer choice as central to its philosophy?

How often does an innovative social program obtain endorsements from conservative and left-leaning political leaders?

How often in recent history has an innovative social program originated in the United States and become widely adopted in Canada, Australia, and Europe?

The answers to these questions range from not often to almost never. Yet they all apply to the subject of this book: an approach to ending homelessness known as Housing First. Many ambitious social programs have started small, taken root and flourished, but few have shown positive and robust results from empirical research and subsequent dissemination. As we approach the fourth decade of what was supposed to be a troubling but transitory epidemic, homelessness in America has not gone away. But there are promising signs that it can be ended for many.

In 1992, Housing First was developed as a new program by psychologist Dr. Sam Tsemberis, who founded Pathways to Housing, Inc. Hundreds of nonprofit social services agencies existed in New York and around the United States, offering a range of programs from emergency shelters to transitional housing and permanent housing. Support services ranged from minimal-to-absent (usually in shelters) to comprehensive, for example, help in accessing housing, case management support when housed, as well as job training, mental health treatment, and more. Single adults, mostly men, were the most visible segment of the homeless population and a significant minority had serious mental illnesses such as schizophrenia. It was these men and women whom Tsemberis had tried with middling success to persuade to go to a shelter or a psychiatric hospital. After years of directing New York Citys emergency outreach team for the homeless, Tsemberis was converted to a consumer-driven approach known as psychiatric rehabilitation, and he started taking homeless persons at their word. When they insisted that what they really needed was a place to live, not a shelter or a hospital ward, he searched for a way to make that a reality.

Now jump ahead some 20-odd years. Pathways to Housing is still a small player on the multimillion-dollar homeless services scene in New York City, but the housing first model it spawned has begun to transform homeless services nationally and internationally. What set Pathways on this transformative course was its philosophical premise and programmatic approach: to provide immediate access to housingmost often an independent apartmentand support services to individuals with mental illness living on the streets. This housing first model was in direct opposition to the mainstream approach to homeless services in the United States and most other nations. The mainstream approach, variously known as the continuum of care or staircase model mandated treatment and behavior change as prerequisites to moving toward the longed-for top stepindependent permanent housing.

The problem with the mainstream model was that for many people the climb was too steep, the journey too long, or the difficulty level too high. Repeatedly trying and failing discouraged many, and they eventually stopped trying, remained homeless, and withdrew into hopelessness. The net result: The mainstream model had a steadily growing number of dropouts, and the people it ).

Pathways to Housing honored the desire for choice by moving homeless men and women directly into their own furnished apartment and enveloping them in support services. The consumer choice ethos was further employed by not requiring medication adherence or abstaining from drugs or alcohol to keep ones apartment. This was not an incremental change, a softening of demands. It was a reversal of fortune, something completely different.

Pathways was also groundbreaking in its embrace of rigorous self-evaluation early on. In 1997, the young program became the experimental arm of a four-year randomized trial funded by the Federal governments Substance Abuse and Mental Health Services Administration (SAMHSA).

This complicated and ongoing story of systems change is the subject of this book. To this end, we scoured the literature on HF to ensure full coverage of the topic. We also interviewed a few key implementers of the approach to tap into various perspectives and experiences. Regrettably, we could not interview everyonethe number of people who have made significant contributions in homelessness research, practices, and policies in the past two decades would require a book in and of itself. And another volume would be needed just to interview and credit the many hundreds of people who work quietly under the radar introducing HF programs to their communities.

The three coauthors are uniquely qualified to tell the story of HF through our extensive research on Pathways and the model it spawned. One of us (Tsemberis) is the founder of Pathways to Housing. Another of us (Henwood) has extensive practice and administrative experience in the agency in its New York City and Philadelphia programs and has gone on to become a researcher on HF. Finally, the lead author (Padgett) was initially involved as a Pathways board member, departing the board in 2005 to engage in qualitative research on HF for the next 10 years and counting. For these reasons, we reasonably could be considered biased in favor of housing first. Cognizant of this, we have sought to present opposing viewpoints, to explore criticism of the HF model, and to acknowledge its limitations when and where they exist. We hope the reader agrees that this story is one worth telling and reading about. It is not often that such a story arises.