This is the latest in a series of blogposts about homelessness. This time, I spoke with Sam Tsemberis on the phone from New York, where he started a successful program in 1992 called 'Housing First'. He added to the interview with a few edits by email as well.
MdS: So I’ve been writing about homelessness on my blog for a couple of months now and I came across the Housing First initiative which started in the US but now it seems to be being used by other countries like Finland. Can you give me a little bit of a history about Housing First? Where it started and why?
Well it started in 1992, that’s about 25 years ago. And it started in New York City. At the time, I was working in an outreach program and having a great deal of difficulty because it was near-impossible to find programs to refer people to. I was working with people who were either literally on-the-street homeless or using public spaces and parks or – in the wintertime – transportation terminals, or sometimes drop-in centres for the homeless. So, it was a very particular group among the homeless population but probably the one that the general public think of when they hear the word homeless. However, this group represents only about 20% of the population.
The outreach program was based in Bellevue Psychiatric Hospital – because the people we were particularly interested in were people who were not only homeless, but who also had a psychiatric disability – mental health issues. So, it was people with psychiatric disabilities who happened to be homeless. And that’s the group that we had a hard time engaging because they didn’t really want to go to hospital, and even if they did go to hospital the hospital would hold onto them for a couple of weeks and then discharge them back into homelessness. When we would try to refer them to one of the few existing housing programs, it was impossible to get them accepted because the programs were under the assumption that people who had a history of mental illness need to be seeing a psychiatrist, taking medication, and living in residential settings that were supervised. These programs were under the misconception that the mental illness meant that people were unable to manage housing on their own and really needed to live in supervised settings.
So, the people we were dealing with on the streets were not desirable applicants for the existing housing providers who required psychiatric treatment, sobriety, and program compliance as a precondition for offering housing. The people who were applying wanted housing and they were either unwilling or unable to participate in treatment or attain sobriety. Those were the conditions in which Housing First was started. It was clear we needed a new approach to solve this problem.
MdS: So, you found that you had all these people with secondary problems as well as homelessness and how did you go about approaching … I guess you approached the government for assistance or the city council or something? Who did you get support from in a financial sense?
First we had to design a program that would solve the problem. Then we approached the government for funding. Programs that provide housing and supports are typically funded by the government because they require a long-term funding commitment. In the case of Housing First, we wrote a grant application for something called Supported Housing which provided money for rent and case-management services. And we wrote that grant to the New York State Office of Mental Health. It was like the mental health ministry, I guess you would say. It was a competitive grant and we were fortunate enough to win one. That funding for rent and support services was how we got started.
MdS: So this was back in 1992, is that right?
That’s correct, yes.
MdS: Since then, has the state continued to fund the Housing First initiative?
Well, I mean a lot’s happened since 1992. It wasn’t even called “Housing First” when we started. We called it “the apartment program”. And in some of the grants I wrote it was called “the consumer preference independent living model” because I was trying to be very specific about what the thing was.
Look, what really created the program, the real success of this program, was the idea behind Housing First – initially, I didn’t know it was going to be a success to tell you the truth, but we were willing to take a chance at it – and the idea came from a change in mindset. It wasn’t really a change in housing that created Housing First.
What created Housing First was a shift in approach we took in how to provide housing and services to this group of people. And the shift came because we essentially had to admit that what we were doing in the past wasn’t working. And so we changed our approach and engaged people by asking them for their advice and asking them what they thought we should do to help them address their problems.
So, Housing First is often talked about in terms of a homelessness intervention, or a homelessness ending kind of program, but really the intention was for it to be a systems-changing program but not so much around the homelessness but around the idea of putting people with mental illness in charge of their lives. And once we did that they quickly pointed out that housing and then treatment was really a much better sequence. All we had to do after that was kind of create the program design to make that possible.
MdS: I guess in Australia what normally happens with homelessness is that the federal government pays the money to the state government and the state government supervises the activities of housing providers. So how does that work in the US, or in New York? I guess it’s different in each state, is that right?
Yes, but there is a general pattern between the federal government and the states. There is some money that is provided by the federal government – because they usually collect the highest percentage of taxes – they provide, for example for services for the poor that is paid for by Medicaid; the federal government would pay 50 percent, the state would pay 25 [percent] and the municipality would pay 25 [percent]. That’s the way it goes.
In the realm of homeless services, what happened with Housing First over time is that, you know, initially – the first five or six years – we were just figuring out how to run the program. And then we realised, “This thing is working really well, we should expand it, we should tell people about it.” And when we went and explained how the program worked, we had also conducted some research studies – so we had data about its effectiveness – people didn’t really believe us.
Even with all that, other providers thought that we were taking people that were much easier to serve than the ones they were serving or that we had easier access to housing or a bunch of other excuses for not believing us and not changing their ways. They just couldn’t believe that people could go from the streets right into an apartment and with some support manage to have a life in the community like everyone else. So, we continued doing studies to build the evidence for effectiveness.
In 1997, we conducted a randomised control trial with a colleague at New York University. It was a true trial – you know: 225 people, half were randomly assigned to Housing First and half were assigned to the existing treatment and sobriety and then housing programs – and the results were spectacularly successful in support of the Housing First program. About 84 percent of the people that were housed by Housing First got housed much more quickly and also stayed housed. Whereas, in the other group, it took almost three times as long to get housed and less than half of the people [were] housed. I mean, the housing stability rate after two years was something like 40 percent in the traditional model, compared to 84 percent in the Housing First model (I don’t remember the exact number but it was something of that magnitude, it was a huge difference).
And so, when the studies were published in the American Journal of Public Health – you know, peer-reviewed journals, including Psychiatric Services – that changed the conversation about this program. People began, instead of saying, “It wouldn’t work here,” or, “You’re not working with our people,” they would say, “Would you come over and help us figure out how to do it here? How do you fund it? How do you get started? How do you work with landlords? How do you provide the support services?” So, it really was a big, big shift. About 10 after its inception several factors coalesced to create substantial efforts in dissemination in the US.
And soon after that it began to gain interest in other countries, initially Canada and then Europe, especially western and northern nations. Not so much in Australia. There was one program in Sydney called [Platform 70], and the City of Sydney and a group called the Bridge Housing, a property management group, partnered to operate a very good program in Woolloomooloo, actually. And even though they had very good results the city never really jumped on that to duplicate it or to expand it. I’m not sure what happened there. There was another group in Melbourne, the Mental Illness Fellowship of Australia, that also liked the idea and they began a Housing First program called Opening Doors, I believe.
But it seems in Australia there’s a lot of political and policy support for something called Common Ground, which builds large single-site buildings and offers tenancy to the poor and homeless. That seems to be more of a predominant model there, for some reason, even though there’s not a lot of data supporting its effectiveness.
MdS: I’ll have a look into those. Thank you very much. I just wanted to ask another question. When I read your website it appeared to me that what you do is you take people and you put them into apartments in the broader community and then you wrap services around them to make sure that they stay housed. Is that correct?
Totally correct. Remember. this is a program designed to reflect the client’s preferences. Most people want to live in ordinary apartments integrated into the community. They do not want to live in a program. So, tenants live in apartments, pay 30 percent of their disability income towards their rent, meet the terms and conditions of a standard lease, get home visits from support services workers, and manage a life in the community, living like everyone else.
MdS: So, when you say you put them into the community how do you get those apartments, do you have like inclusionary zoning?
You need the grant money for the rent supplement program. Rent is subsidized by government grants. It is like social housing but integrated into the community. The program provides money for the rent subsidy and also pays for the support services. The program rents apartments at the lower end of the real estate market – so you’re basically looking for a cheap, decent, affordable apartment in the neighbourhood that the client would know or find desirable. You ask the client for their preference and you try as best you can to find a place that they would like.
So that’s how we do it. We’re beating the streets and knocking on doors and asking landlords to rent to us. We have the advantage that we can tell landlords that there’s someone to support this tenancy, that rent payment is assured by the agency, that the person renting this apartment is supported by the agency and that if there’s an issue with the tenancy there’s someone to call. That helps landlords feel comfortable renting to the program.
MdS: So, when you approach the landlords they know who’s going to be living in their apartment, right?
More or less. It’s not specific. You don’t want to discuss the tenant’s personal information. You say that you’re a program that helps people find housing and you want to make sure the tenancy goes well, so you look after things, and there’s someone to call, and you’ll be assured of the rent and if there’s an issue at all please call us. Like that. It’s not like descriptive of what happened to the person or if they had a history of hospitalisation or anything like that. None of that information is disclosed to the landlord, no.
MdS: I don’t know if you’ve read about it in the newspapers but in Sydney and Melbourne especially we’ve had a big increase in immigration in Australia and so rental and also property prices are going up very sharply. There seems to be in the last five years or so an increase in homelessness as a result of that. But now the state government in NSW is starting to talk to developers to get them to put aside some apartments for – I guess what you’d call – rent-controlled apartments.
Yes. That’s a great idea.
MdS: That’s what is happening here because it’s so expensive now in the big cities.
I think that it is expensive everywhere. If we’re not going to build or set aside – either build exclusively like they do a lot in Europe, they build social housing and you have to qualify for tenancy based on your income, and a very good way to address the affordability crisis in housing - as long as housing remains a for-profit commodity we are subject to market forces. This is pretty much the case in most Western countries – and if we’re not going to build affordable housing we’re going to have increases in homelessness. What we should be doing is operating housing as if it is a basic human right. That is what Housing First does: offers housing as a matter of right not because you are meeting certain treatment or other preconditions.
If more western countries change their approach from housing as product in the marketplace to providing housing as a basic human right, the government would have to assume more responsibility in regulating and providing affordable housing for all its citizens.
I think that this Housing First program – to the extent that it informs that conversation – it’s not a program that is about housing per se, but it’s a housing program model that says by way of the evidence from its research that you don’t have to build group homes and you don’t have to have people supervised 7/24. People want to live in normal housing, integrated settings in the community. It’s more dignified, it’s more effective and it also is much cheaper to the taxpayer to do it this way.
We’ve learned a great deal about people’s capabilities. You know, someone who is surviving homelessness, and the person has a mental illness and addiction problem, but who is also able to figure out where it’s safe to sleep and where to get a meal on the streets of a city, can certainly manage an apartment of their own. So, it informs the kind of housing and the kind of services this particularly vulnerable group of people needs.
MdS: I guess what I’m hearing here is that when you said earlier that there was a shift in your thinking when you were setting up the program, from giving services to asking what services were required, that was a big paradigm shift. Is that right?
That’s correct. And I think, to the extent that Housing First has created a paradigm shift that conceptually is the paradigm shift. What is manifest as the paradigm shift is that you see people with all kinds of clinical problems going into housing. That’s the manifestation but it’s not the shift. The actual shift is that those people are actually in charge of the decision-making in their own lives, possibly for the first time. And also, they’re probably moving into an apartment of their own for the first time, have always wanted one but either that option was not available to them or they were just too poor to be able to afford one.
MdS: I think I’ve got a clearer picture now. What do you think? Is there anything else that you’d like to add to what you’ve already said that might be informative for my readers?
Are your readers the general public?
MdS: Yes.
I don’t know if this makes sense, Matthew, but I think that one of the things that’s occurred to me is that we have done something that is hurting us by allowing homelessness to continue for as long as it has. Especially because we know how to cure it. It’s not like we don’t know how to fix it, we actually know how to end homelessness for everybody. If we can end homelessness for the group of people we’ve been talking about we could end it for everyone. But in particular for this group of people, we know we can end it and we haven’t.
And as long as we don’t end it, I think what we’re doing is in some ways shutting down our own humanity because it takes a certain level of cutting yourself off from your empathy to be able to walk past a homeless person. This is not about the suffering of the person who’s homeless. This is about the rest of the folks who are walking past them, and they are making themselves into smaller, less-feeling human beings in order to tolerate homelessness. And I think that if we really would focus on this and not allow homelessness to be part of the urban landscape, we would all feel a lot better.
MdS: Just one more question? That was for the general reader, but what would you like to say to the government authorities in Australia to make them take Housing First more seriously?
Well I guess I would say that if you wanted a solution to homelessness that was cheaper than shelters and cheaper than emergency rooms and cheaper than arresting people - and not only cheaper but more humane and more effective - then you should consider Housing First as the primary policy for your homelessness interventions.
MdS: So I’ve been writing about homelessness on my blog for a couple of months now and I came across the Housing First initiative which started in the US but now it seems to be being used by other countries like Finland. Can you give me a little bit of a history about Housing First? Where it started and why?
Well it started in 1992, that’s about 25 years ago. And it started in New York City. At the time, I was working in an outreach program and having a great deal of difficulty because it was near-impossible to find programs to refer people to. I was working with people who were either literally on-the-street homeless or using public spaces and parks or – in the wintertime – transportation terminals, or sometimes drop-in centres for the homeless. So, it was a very particular group among the homeless population but probably the one that the general public think of when they hear the word homeless. However, this group represents only about 20% of the population.
The outreach program was based in Bellevue Psychiatric Hospital – because the people we were particularly interested in were people who were not only homeless, but who also had a psychiatric disability – mental health issues. So, it was people with psychiatric disabilities who happened to be homeless. And that’s the group that we had a hard time engaging because they didn’t really want to go to hospital, and even if they did go to hospital the hospital would hold onto them for a couple of weeks and then discharge them back into homelessness. When we would try to refer them to one of the few existing housing programs, it was impossible to get them accepted because the programs were under the assumption that people who had a history of mental illness need to be seeing a psychiatrist, taking medication, and living in residential settings that were supervised. These programs were under the misconception that the mental illness meant that people were unable to manage housing on their own and really needed to live in supervised settings.
So, the people we were dealing with on the streets were not desirable applicants for the existing housing providers who required psychiatric treatment, sobriety, and program compliance as a precondition for offering housing. The people who were applying wanted housing and they were either unwilling or unable to participate in treatment or attain sobriety. Those were the conditions in which Housing First was started. It was clear we needed a new approach to solve this problem.
MdS: So, you found that you had all these people with secondary problems as well as homelessness and how did you go about approaching … I guess you approached the government for assistance or the city council or something? Who did you get support from in a financial sense?
First we had to design a program that would solve the problem. Then we approached the government for funding. Programs that provide housing and supports are typically funded by the government because they require a long-term funding commitment. In the case of Housing First, we wrote a grant application for something called Supported Housing which provided money for rent and case-management services. And we wrote that grant to the New York State Office of Mental Health. It was like the mental health ministry, I guess you would say. It was a competitive grant and we were fortunate enough to win one. That funding for rent and support services was how we got started.
MdS: So this was back in 1992, is that right?
That’s correct, yes.
MdS: Since then, has the state continued to fund the Housing First initiative?
Well, I mean a lot’s happened since 1992. It wasn’t even called “Housing First” when we started. We called it “the apartment program”. And in some of the grants I wrote it was called “the consumer preference independent living model” because I was trying to be very specific about what the thing was.
Look, what really created the program, the real success of this program, was the idea behind Housing First – initially, I didn’t know it was going to be a success to tell you the truth, but we were willing to take a chance at it – and the idea came from a change in mindset. It wasn’t really a change in housing that created Housing First.
What created Housing First was a shift in approach we took in how to provide housing and services to this group of people. And the shift came because we essentially had to admit that what we were doing in the past wasn’t working. And so we changed our approach and engaged people by asking them for their advice and asking them what they thought we should do to help them address their problems.
So, Housing First is often talked about in terms of a homelessness intervention, or a homelessness ending kind of program, but really the intention was for it to be a systems-changing program but not so much around the homelessness but around the idea of putting people with mental illness in charge of their lives. And once we did that they quickly pointed out that housing and then treatment was really a much better sequence. All we had to do after that was kind of create the program design to make that possible.
MdS: I guess in Australia what normally happens with homelessness is that the federal government pays the money to the state government and the state government supervises the activities of housing providers. So how does that work in the US, or in New York? I guess it’s different in each state, is that right?
Yes, but there is a general pattern between the federal government and the states. There is some money that is provided by the federal government – because they usually collect the highest percentage of taxes – they provide, for example for services for the poor that is paid for by Medicaid; the federal government would pay 50 percent, the state would pay 25 [percent] and the municipality would pay 25 [percent]. That’s the way it goes.
In the realm of homeless services, what happened with Housing First over time is that, you know, initially – the first five or six years – we were just figuring out how to run the program. And then we realised, “This thing is working really well, we should expand it, we should tell people about it.” And when we went and explained how the program worked, we had also conducted some research studies – so we had data about its effectiveness – people didn’t really believe us.
Even with all that, other providers thought that we were taking people that were much easier to serve than the ones they were serving or that we had easier access to housing or a bunch of other excuses for not believing us and not changing their ways. They just couldn’t believe that people could go from the streets right into an apartment and with some support manage to have a life in the community like everyone else. So, we continued doing studies to build the evidence for effectiveness.
In 1997, we conducted a randomised control trial with a colleague at New York University. It was a true trial – you know: 225 people, half were randomly assigned to Housing First and half were assigned to the existing treatment and sobriety and then housing programs – and the results were spectacularly successful in support of the Housing First program. About 84 percent of the people that were housed by Housing First got housed much more quickly and also stayed housed. Whereas, in the other group, it took almost three times as long to get housed and less than half of the people [were] housed. I mean, the housing stability rate after two years was something like 40 percent in the traditional model, compared to 84 percent in the Housing First model (I don’t remember the exact number but it was something of that magnitude, it was a huge difference).
And so, when the studies were published in the American Journal of Public Health – you know, peer-reviewed journals, including Psychiatric Services – that changed the conversation about this program. People began, instead of saying, “It wouldn’t work here,” or, “You’re not working with our people,” they would say, “Would you come over and help us figure out how to do it here? How do you fund it? How do you get started? How do you work with landlords? How do you provide the support services?” So, it really was a big, big shift. About 10 after its inception several factors coalesced to create substantial efforts in dissemination in the US.
And soon after that it began to gain interest in other countries, initially Canada and then Europe, especially western and northern nations. Not so much in Australia. There was one program in Sydney called [Platform 70], and the City of Sydney and a group called the Bridge Housing, a property management group, partnered to operate a very good program in Woolloomooloo, actually. And even though they had very good results the city never really jumped on that to duplicate it or to expand it. I’m not sure what happened there. There was another group in Melbourne, the Mental Illness Fellowship of Australia, that also liked the idea and they began a Housing First program called Opening Doors, I believe.
But it seems in Australia there’s a lot of political and policy support for something called Common Ground, which builds large single-site buildings and offers tenancy to the poor and homeless. That seems to be more of a predominant model there, for some reason, even though there’s not a lot of data supporting its effectiveness.
MdS: I’ll have a look into those. Thank you very much. I just wanted to ask another question. When I read your website it appeared to me that what you do is you take people and you put them into apartments in the broader community and then you wrap services around them to make sure that they stay housed. Is that correct?
Totally correct. Remember. this is a program designed to reflect the client’s preferences. Most people want to live in ordinary apartments integrated into the community. They do not want to live in a program. So, tenants live in apartments, pay 30 percent of their disability income towards their rent, meet the terms and conditions of a standard lease, get home visits from support services workers, and manage a life in the community, living like everyone else.
MdS: So, when you say you put them into the community how do you get those apartments, do you have like inclusionary zoning?
You need the grant money for the rent supplement program. Rent is subsidized by government grants. It is like social housing but integrated into the community. The program provides money for the rent subsidy and also pays for the support services. The program rents apartments at the lower end of the real estate market – so you’re basically looking for a cheap, decent, affordable apartment in the neighbourhood that the client would know or find desirable. You ask the client for their preference and you try as best you can to find a place that they would like.
So that’s how we do it. We’re beating the streets and knocking on doors and asking landlords to rent to us. We have the advantage that we can tell landlords that there’s someone to support this tenancy, that rent payment is assured by the agency, that the person renting this apartment is supported by the agency and that if there’s an issue with the tenancy there’s someone to call. That helps landlords feel comfortable renting to the program.
MdS: So, when you approach the landlords they know who’s going to be living in their apartment, right?
More or less. It’s not specific. You don’t want to discuss the tenant’s personal information. You say that you’re a program that helps people find housing and you want to make sure the tenancy goes well, so you look after things, and there’s someone to call, and you’ll be assured of the rent and if there’s an issue at all please call us. Like that. It’s not like descriptive of what happened to the person or if they had a history of hospitalisation or anything like that. None of that information is disclosed to the landlord, no.
MdS: I don’t know if you’ve read about it in the newspapers but in Sydney and Melbourne especially we’ve had a big increase in immigration in Australia and so rental and also property prices are going up very sharply. There seems to be in the last five years or so an increase in homelessness as a result of that. But now the state government in NSW is starting to talk to developers to get them to put aside some apartments for – I guess what you’d call – rent-controlled apartments.
Yes. That’s a great idea.
MdS: That’s what is happening here because it’s so expensive now in the big cities.
I think that it is expensive everywhere. If we’re not going to build or set aside – either build exclusively like they do a lot in Europe, they build social housing and you have to qualify for tenancy based on your income, and a very good way to address the affordability crisis in housing - as long as housing remains a for-profit commodity we are subject to market forces. This is pretty much the case in most Western countries – and if we’re not going to build affordable housing we’re going to have increases in homelessness. What we should be doing is operating housing as if it is a basic human right. That is what Housing First does: offers housing as a matter of right not because you are meeting certain treatment or other preconditions.
If more western countries change their approach from housing as product in the marketplace to providing housing as a basic human right, the government would have to assume more responsibility in regulating and providing affordable housing for all its citizens.
I think that this Housing First program – to the extent that it informs that conversation – it’s not a program that is about housing per se, but it’s a housing program model that says by way of the evidence from its research that you don’t have to build group homes and you don’t have to have people supervised 7/24. People want to live in normal housing, integrated settings in the community. It’s more dignified, it’s more effective and it also is much cheaper to the taxpayer to do it this way.
We’ve learned a great deal about people’s capabilities. You know, someone who is surviving homelessness, and the person has a mental illness and addiction problem, but who is also able to figure out where it’s safe to sleep and where to get a meal on the streets of a city, can certainly manage an apartment of their own. So, it informs the kind of housing and the kind of services this particularly vulnerable group of people needs.
MdS: I guess what I’m hearing here is that when you said earlier that there was a shift in your thinking when you were setting up the program, from giving services to asking what services were required, that was a big paradigm shift. Is that right?
That’s correct. And I think, to the extent that Housing First has created a paradigm shift that conceptually is the paradigm shift. What is manifest as the paradigm shift is that you see people with all kinds of clinical problems going into housing. That’s the manifestation but it’s not the shift. The actual shift is that those people are actually in charge of the decision-making in their own lives, possibly for the first time. And also, they’re probably moving into an apartment of their own for the first time, have always wanted one but either that option was not available to them or they were just too poor to be able to afford one.
MdS: I think I’ve got a clearer picture now. What do you think? Is there anything else that you’d like to add to what you’ve already said that might be informative for my readers?
Are your readers the general public?
MdS: Yes.
I don’t know if this makes sense, Matthew, but I think that one of the things that’s occurred to me is that we have done something that is hurting us by allowing homelessness to continue for as long as it has. Especially because we know how to cure it. It’s not like we don’t know how to fix it, we actually know how to end homelessness for everybody. If we can end homelessness for the group of people we’ve been talking about we could end it for everyone. But in particular for this group of people, we know we can end it and we haven’t.
And as long as we don’t end it, I think what we’re doing is in some ways shutting down our own humanity because it takes a certain level of cutting yourself off from your empathy to be able to walk past a homeless person. This is not about the suffering of the person who’s homeless. This is about the rest of the folks who are walking past them, and they are making themselves into smaller, less-feeling human beings in order to tolerate homelessness. And I think that if we really would focus on this and not allow homelessness to be part of the urban landscape, we would all feel a lot better.
MdS: Just one more question? That was for the general reader, but what would you like to say to the government authorities in Australia to make them take Housing First more seriously?
Well I guess I would say that if you wanted a solution to homelessness that was cheaper than shelters and cheaper than emergency rooms and cheaper than arresting people - and not only cheaper but more humane and more effective - then you should consider Housing First as the primary policy for your homelessness interventions.
No comments:
Post a Comment