Housing First programs prioritize highly vulnerable people with a serious mental illness who are coming out of extremely stressful circumstances. Considering these factors, it's expected that case managers will encounter some participants who experience psychosis. Psychosis refers to the presence of psychiatric symptoms involving a loss of contact with reality. These symptoms are the defining features of schizophrenia-spectrum disorders. But, these symptoms can be present for other reasons including: a mood disorder (most commonly bipolar disorder but also depression); substance use (e.g. hallucinogens or alcohol withdrawal); a physiological condition (e.g. head injury or migraines): or even just extreme deprivation caused by a lack of sleep, food, or water. Symptoms of psychosis include delusions, hallucinations, disorganized thoughts or behaviors including becoming catatonic, and negative symptoms (decreased motivation, limited emotional expressions, and decreased interest in pleasurable activities or social interaction).
It’s important to distinguish between delusions and hallucinations. Delusions are fixed false beliefs that may include the belief that a person has special powers (grandiose) or that someone is controlling or inserting thoughts into someone’s mind. Sometimes it can be hard to identify whether something is delusional because there may be degrees of truth. For instance, people may experience persecutory delusions (a belief that they are going to be harmed or harassed). In reality, many people we work with regularly encounter harassment and abuse related to their mental illness, lack of money, housing status, race, gender identity, or sexual orientation. Hallucinations are sensory experiences that occur without an external stimulus or outside input. A person may hear, see, smell, taste, or feel something that isn’t actually there. They may appear to be listening and responding to voices without anyone in view talking to them. Visual hallucinations tend to involve scenes with family members or animals (bugs crawling on your arm), seeing shadows, or visual distortion. To get an idea of what it’s like to experience auditory hallucinations check out this video and for an example of what visual distortion can feel like look at motion aftereffect illusions. Imagine how difficult these experiences can make going about your daily life.
Experiencing psychosis can be distressing and even harmful, regardless of the type and cause. Psychosis is associated with an increased risk of depression and suicide, impaired functioning in school or employment, and strained relationships resulting in a loss of supports. Symptoms of psychosis usually begin when people are between the ages of 16-30. Early intervention is important because the duration and severity of a psychotic episode can increase the likelihood of additional episodes and poor outcomes in the future. Coordinated Specialty Care (CSC) is a treatment program specifically developed to support people experiencing their first psychotic episode. CSC providers develop a personalized treatment plans that can incorporate medication, therapy, case management, education or employment, and family support to address a manage psychosis.
Because of the risks associated with psychosis, case managers and other helpers can use a harm reduction approach to support people. As with substance use, the focus should be on reducing the negative consequences of psychosis. Case managers should help participants learn to manage psychotic symptoms in a way that reduces their impact, instead of emphasizing the elimination of symptoms. The presence of psychosis does not have an inevitable result. It does not mean that a person can’t maintain housing and independence. As Sam Tsemberis, CEO and Founder of Pathways to Housing, explained in the @Home documentary segment on Housing First, “People have a functional ability and it’s quite separate from their diagnosis. You can believe that the government is after you or that there are people flying in from outer space and they’re going to take over the planet. And, leaving all that aside, you can still go get a ham and cheese sandwich and some French fries, have a meal, or go shopping.” Understanding that people who experience psychosis can and do successfully stay housed is essential for effectively using the Housing First Model. Below, are some things to keep in mind to support people experiencing psychosis.
people who experience psychosis can and do successfully stay housed...
Begin by assessing for safety. People with psychosis are at an increased risk of suicide. If a case manager thinks a person is at risk of hurting themselves, they should be direct and open about the topic. A case manager should try to figure out if the person has a specific plan, previously attempted suicide, and the likelihood that they will act on their suicidal thoughts. The risk of violence to others is also a possibility. However, it’s important to point out that people with a mental illness are not more likely to commit violent acts. Instead, they are over 10 times more likely to be the victims of violent crime than the general population. If there is a clear threat, consider assisting the participant with hospitalization or safety planning and contracting.
Don’t argue with psychosis. The nature of delusions is that they are fixed beliefs and unlikely to change based on conflicting evidence. Arguing with people about the validity of their idea will only encourage them to dig in their heels, find faults in your logic, and possibly even refuse to continue working with you. As with all harm reduction work, the quality of the relationship is essential. Case managers should align themselves with their participants and avoid being confrontational. Even casual statements like, “Don’t be silly” or “Get it together” can be dismissive and isolating. Remember that whatever they are experiencing is real to them and genuinely affects them. Help people explore their symptoms and speak in a calm, clear, and concise way. Don’t pretend to hear what the person hears or share in a false belief. Without feeding into a delusional thought, we can still identify with the feelings it creates in a person. For instance, a case manager might say, “It’s really scary to feel like you’re constantly being watched by others. That takes a lot of strength and courage. How do you manage to get through your day despite that?”
Help develop a list of options that can include personal coping strategies and professional support from a psychiatrist, therapist, or case management team. As we mentioned in a previous post, a participant has a right to choose whether or not to take medication. Although medication is considered a go-to response for the treatment of psychotic symptoms, there is some research showing that people may benefit from managing psychosis without medication. A recent study compared people with schizophrenia who were being treated with antipsychotic medications and those who were not. The study showed similar levels of symptoms but higher levels of general functioning among people not taking medication. Although medication may be most effective for some, we should explore strategies beyond medication with all of our participants to help them cope with psychosis. Don’t assume that someone needs medication in order to be successful in housing. At a recent training, one attendee mentioned a participant who was homeless for 25 years prior to being housed in their program, does not take medication, and maintains the cleanest apartment of anyone on their caseload!
Respect people’s right to use drugs. People may use illegal drugs or alcohol to self-medicate the symptoms of psychosis. For example, participants have reported using depressants like alcohol, heroin, or other opioid pain relievers to drown out voices and help them sleep. There might be therapeutic benefits to other substances as well. As researcher and journalist Helen Redmond explains, “Nicotine may even have specific properties that ‘treat’ symptoms of schizophrenia.” Consider the capacity for nicotine to improve mood, memory, and concentration and how that may balance the impact of psychosis. In a harm reduction program, helpers should never remove a helpful coping mechanism before finding substitutes. With substance use or psychosis the course of treatment is the same—to nonjudgmentally help people explore and understand the function, the potential consequences, and the alternative ways to manage it.
Some additional resources for information on psychosis include Mental Health First Aid, the National Alliance on Mental Illness (NAMI), and the Hearing Voices Movement.
As service providers, we can be part of improving the safety of LGBTQ communities by ensuring access to the basic human rights of housing, health care, and necessary supports.
The country is still reeling from the Pulse Nightclub shooting last weekend that left 49 people dead and many others injured. As we mourn the lives that were taken and for those families and communities that will forever be impacted, it is important to remember this tragedy is one event in a long history of violence against a specific community, and to recognize the trauma many of those who identify as Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) face on a daily basis.
People who identify as LGBTQ are disproportionately at-risk of experiencing violence—childhood abuse, sexual assault, intimate partner violence, harassment by law enforcement officers, and hate crimes. This is especially true for people who are trans-identified. In addition, members of this community are disproportionately affected by poverty and more likely to experience homelessness than others in our society.
The risk of violence and homelessness is increased for sub-groups of the LGBTQ community with intersecting vulnerabilities like youth, women, or people of color. Despite being only 5% of the total population, between 20-40% of homeless youth identify as LGBTQ. One recent study from Georgia State University found that over 28% of homeless and runaway youth in the metro-Atlanta area self-identify as LGBTQ. Among the victims of LGBTQ hate crimes resulting in homicide, people of color are disproportionately impacted. This is represented by the fact that the Pulse Nightclub shooting took place on Latin Night.
The pain of this moment highlights the need for competent services for the LGBTQ community in homeless and allied social services. We have a responsibility to create safety and security for the most vulnerable members in our communities. But, our organizations and programs are often not structured to sufficiently meet the needs of LGBTQ participants. In shelters and service programs, clients are often turned away, unable to express their identity, or not offered appropriate services. As service providers, we can be part of improving the safety of LGBTQ communities by ensuring access to the basic human rights of housing, health care, and necessary supports. Increasingly, there are discussions happening about how agencies and service providers can be more inclusive and supportive of people who identify as LGBTQ. For instance, the National Coalition for the Homeless and the National Gay and Lesbian Task Force teamed up to create Transitioning Our Shelters, a guide for making homeless shelters safe for people who are trans-identified.
This symbol can be used to indicate that your office is a safe(r) space
Improving the ability of service providers to meet the distinct needs of LGBTQ participants begins with education. Staff and participants alike should be continually trained in cultural competency around LGBTQ issues. We should recognize that our words can be harmful. To avoid that, staff can use inclusive language (e.g. partner instead of husband/wife or boyfriend/girlfriend) and differentiate between sexual orientation and gender identity. We should ask people in our programs about their gender identity and allow them to identify this for themselves. Respect is then further reflected by using people’s appropriate pronouns and chosen names. We should not ignore when LGBTQ participants experience harassment from other participants in our programs but instead encourage respect as part of being a good neighbor and community member. We can make our services more welcoming to LGBTQ participants by offering gender-neutral or single-stall bathrooms in our facilities and simply having honest conversations with these participants about what we can do to increase their sense of safety in our programs. We can also partner with LGBTQ organizations for help with questions and additional resources. This is only a sampling of some of the things we can do to make our agencies and programs more inclusive.
In addition, we should hire people in our organizations who identify as LGBTQ. I am a homeless service provider and an ally of the LGBTQ community. But, without the lived experience of homelessness or identifying as LGBTQ, my ability to understand is limited. Hiring people who identify as LGBTQ and formerly homeless reflects a desire to be representative of the communities we serve and provide spaces where they can feel safer.
The LGBTQ community is vulnerable but strong. One example of the community’s resiliency is the Transgender Housing Network. This group maintains a website that is a temporary housing network connecting trans people with safe and supportive places to stay. Similarly, RAD Remedy is a new website linking people who are trans, gender non-conforming, intersex, and queer to safe and respectful healthcare services. These groups are responding to an unjust system that limits the ability of people who are trans to access adequate housing and healthcare. These are true examples of harm reduction—a community of people exposed to risk and responding in a way to make themselves safer. But the LGBTQ community should not have to do this work alone. Service providers should figure out how to join the efforts that this community is already making to gain security. As programs and agencies committed to social justice, we are all allies in the fight for LGBTQ inclusion and protection.
This is the final post in our series on the Critical Ingredients of Housing First. So far, we’ve covered the other essential elements for implementing an effective Housing First program—a low threshold admission policy, reduced service requirements, separation of housing and services, consumer education, and eviction prevention. Our future blog posts will focus on other aspects of working in a housing first program, looking in-depth at harm reduction in service delivery, and other topics relevant to the people involved in Housing First programs.
Harm reduction is a pragmatic approach to risky behaviors. Harm reduction recognizes that most of us regularly engage in activities with the potential to cause harm including sex, driving, sports, and alcohol or other drug use. People get something out of taking risks. Whether it’s a means of feeling good or relieving pain, we do potentially harmful things, and with good reason. Instead of only trying to eliminate these activities, harm reduction connects with people by avoiding judgment about their behaviors, expressing curiosity about both the benefits and costs, providing resources to do it in the safest way possible, and shifting the focus to improving the quality of life for the individual and their community.
Harm reduction recognizes and employs a broad spectrum of strategies to minimize or remove harm. Yes, that includes abstinence! Harm reduction supports any effort to reduce harm that people choose for themselves. Traditionally applied to substance use, the philosophy of harm reduction has been incorporated into social service agencies’ work with their participants around all potentially harmful behaviors. In order to successfully practice Housing First, we need to incorporate a harm reduction approach to service delivery.
As we discussed in an earlier blog post, the Housing First model is based on the principle that housing is a human right. That means that we should not only provide housing resources to people who are practicing abstinence from drugs and alcohol. If every person who uses these substances were homeless, there would be millions more people living on the streets and in shelters. While the issues participants face can create challenges in maintaining housing, they are not insurmountable nor are they grounds to deny a basic human right. Harm reduction providers protect the right to housing by focusing on the consequences of drug use (e.g. nonpayment of rent or excessive visitors) and not just use itself.
Blocking access to housing programs based on drug use alienates the most vulnerable members of our communities experiencing homelessness. As a study on the Collaborative Initiative to Help End Chronic Homelessness highlights, nearly 3 out of 4 people experiencing chronic homelessness have a substance use disorder. People who are homeless and have a substance use disorder must be offered the same options and rights as other people who are homeless. If Housing First is to succeed, substance use can no longer be a barrier to accessing housing. Homelessness does not cure addiction; stability, connection, and unconditional support do.
Homelessness does not cure addiction;
Housing is a powerful motivator to get a person’s foot in the door and link them to a case manager or community-based support team. The harm reduction approach is what keeps them engaged. In Housing First programs, participants have a reduced level of fear about losing their housing, which improves the quality of their relationships with staff. One Housing First participant explained: “I mean that’s scary when your housing is tied to your ability to remain abstinent. I mean you live kind of in a constant fear…It’s not conducive to remaining sober with that kind of pressure and it’s not conducive to remaining housed…It’s a huge relief when you realize your housing is not tied to your ability to remain abstinent.” Establishing a relationship where it’s safe to speak openly about drug use is difficult. Our participants have been conditioned to avoid the topic since it typically leads to doors being closed on them. By allowing participants to be honest, harm reduction can help participants go beyond all-or-nothing thinking and look for ways to mitigate potential problems associated with their drug use.
Harm reduction embraces the belief that participants are experts in their own lives. They are best equipped to define the problems they face, as well as their goals and strategies to overcome them. Harm reduction workers support participants by ensuring they are informed about the potential harms of risky activities and how to improve their safety. Harm reduction strategies in housing include meeting a person’s most basic needs—eating well, getting regular sleep, and paying rent first to maintain the security of housing. Simply attending to these needs can offset some of the greatest harms caused by drug use or other risky behaviors. While we can’t guarantee that people will always make the safest choice, harm reduction ensures that they are making informed decisions about the risks they take and accepts their right to choose for themselves.
Ultimately, Housing First is a harm reduction approach to housing. It creates access to resources for participants without requiring that they meet predetermined outcomes, engages collaboratively with them about their concerns, and respects the choices that they make. As one Housing First staff member said, “Harm reduction and Housing First are working hand-in-hand. You can’t have one without the other, you just can’t.” Housing First gives us an opportunity to reach the most vulnerable people experiencing homelessness and help them secure the supports they want and need. By fostering trusting, therapeutic relationships harm reduction helps people recognize and make use of opportunities for positive change. It shifts our focus away from completely eliminating risky behaviors and onto the person's well-being.
The Housing First Model shifts how housing resources are distributed. One critical change, which is closely connected to the Low Threshold Admissions Policy, is the reduced service requirements in Housing First programs. In traditional programs, access to housing was earned through measures of housing readiness like abstaining from drugs and alcohol, getting a job, or engaging in regular medical care. In a Housing First program with reduced service requirements, people are not expected to jump through hoops to prove they are worthy of housing. There is no mandate to attend peer support groups, group therapy, inpatient treatment, psychiatry appointments, or other services. The options are offered and explored, but the decision to participate is left up to the participant. Service requirements in the strongest Housing First programs are limited to regular contact with a case manager. That case manager engages with the participant about issues they face and increases contact with them when they first move in and again later if they are struggling to maintain housing.
One fear of providers shifting to the Housing First approach is that people will not take care of themselves if they aren’t forced to do it. An early study of Pathways to Housing disproved this notion. The study compared a group of people who were homeless and entered two housing programs—one based on participation in substance use treatment and requiring abstinence (Control group) and the other using Housing First (Experimental group). Although a greater number of people in the Control group engaged in treatment (after all, they were required to do it in order to access housing), there were no significant differences in the rates of substance use or mental health symptoms between the two groups. The Housing First participants obtained housing faster and reported greater levels of perceived choice and autonomy.
Research shows that choice matters in recovery. As one study explains, “providing people with more choices predicts better outcomes for people with severe mental illness.” Stigma around mental health and addiction fuels a false notion that people living with these conditions lack the ability to make rational choices. Housing First disproves that assertion and emphasizes consumer choice at every turn—from housing selection to service participation. Participants are not burdened with benchmarks to meet in order to access or maintain their housing. Instead, housing maintenance is based on meeting the terms of their lease like everybody else. Their participation in services is based on their own choice. As one Housing First staff member explained, “It actually puts a lot of responsibility on the consumer.”
In our trainings on motivational interviewing, we often reference a quotation from Blaise Pascal, who said, “People are generally better persuaded by the reasons they themselves have discovered than by those which have come in to the mind of others.” Just as people are more inspired by their own reasons, Housing First believes people are more committed to goals and solutions they develop for themselves. While we may be able to force someone to make a change for a short time in order to get into a housing program, that isn’t the recipe for creating lasting change. We trust that people are motivated to improve their own lives and best equipped to decide how to do it. Housing creates stability which enables people’s pursuit of positive change. People don’t change because we want them to; change happens when people are ready and find the solutions that work best for them.
As discussed in an earlier blog post, the Housing First model is based on the principle that housing is a human right. If that’s true, it means that we shouldn’t create conditions that limit access to housing. As much as we want to support individuals in pursuing their goals by engaging in additional services, it should not be mandated in a Housing First program. When people feel like they are respected and their perspective is valued, they are more likely to pursue other supportive services. Housing First encourages access and choice to promote positive change.
As service providers, we are advocates for our participants. We relish the opportunity to stand up for the people who have been ignored or pushed down by our system. Through our support, we promote their ability to access housing, public benefits, or other community resources. But, we can find ourselves in a bind when we’re forced to serve a dual role—advocate and rule-enforcer. This is the position that many service providers end up in at single-site housing programs. In these programs, the service agency typically manages a property, acting as a landlord or property manager to its tenants, and provides case management to them at the same time.
Ideally, Housing First programs will separate housing and case management roles. This is easier in programs that use a scattered-site approach, housing participants in buildings with independent landlords throughout the community and providing case managers for them. One case manager in a single-site program articulates this by saying, “The difference is if I worked at scattered-site, if there was an issue it would be the landlord going to the participant or the case worker, saying, ‘This is the problem that I’m having’ and it’s up to us to advocate for them, instead of me working both roles.” When we end up working both roles, it discourages our participants and residents from feeling safe enough to approach staff when they’re struggling. Think about it, if you were having trouble making rent payments or having problems in your apartment, the last person you’d want to talk about it with is your landlord. Instead, you might hope that they just don’t notice you.
This is a major pitfall of some Housing First programs. Housing First is not a “don’t ask, don’t tell” approach to housing services. We will fall short in our efforts to assist them if we aren’t aware of the problems our participants are having and engaging with them about it. We want our participants to feel safe approaching us and talking through their difficulties related to keeping their housing. The more open they are about that, the better equipped we are to assist them with strategizing and avoiding serious consequences like eviction. We can’t expect our participants to feel comfortable approaching us when they see us as the key holder to their apartment. Case managers should be tasked with helping participants with avoiding lease violations, managing them when they happen, and advocating with property managers on their behalf. In the event of an eviction, the scattered-site model also provides greater flexibility to keep the person engaged in services and work to rehouse them.
This doesn’t mean that scattered-site is the only effective way to house our participants. There are benefits to other models like single-site, communal living, and recovery housing that include having a community of peer support on hand. Housing agencies that use single-site can still separate housing and case management by designating specific staff to handle those issues. There are also ways that the Housing First approach can be used in these models by paying attention to other aspects of the model. For example, those programs might still incorporate a Low Threshold Admissions Policy or provide flexibility in the services people use. But, setting up our programs so that case managers aren’t required to also serve as overseer of a property encourages participants to open up and share honestly about themselves.