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.
Evictions are a growing problem across the country. In his new book, Evicted: Poverty and Profit in the American City, Matthew Desmond shows that evictions are more common now than they were at the time of the Great Depression. He details the toll that an eviction takes in destabilizing people’s lives beyond just creating difficulties finding housing in the future. In an interview with Desmond on Talk Poverty Radio, they explain that mothers have higher rates of depression two years after an eviction and note that the number of suicides attributed to eviction or foreclosure doubled from 2005 to 2010. Although our participants benefit from the assistance of subsidized housing, they are vulnerable to eviction because they possess few economic resources and might not have recent experience maintaining housing. For too many people, eviction results in homelessness. That is why it’s essential that we practice eviction prevention in Housing First programs.
Eviction prevention is a case management intervention that incorporates planning with participants to prevent lease violations and advocating with the landlord or property manager to allow staff to work with the participant to curb lease violations when they come up. In addition, case managers can negotiate with landlords to allow people to move out without going through a formal eviction as well as rehouse participants when an eviction does occur.
The threat of eviction is typically triggered by a lease violation. Common lease violations we see in Housing First programs include falling behind in rent payments, having excessive visitors, instigating noise complaints, or engaging in illegal activities such as buying and using drugs. Although many of these issues may be related to alcohol or drug use, Housing First programs should focus on behaviors and consequences, as opposed to dwelling on use itself. One Housing First participant explains how staff worked with them to avoid eviction: “Probably six or seven months after I moved in, I relapsed. So, I went through a period of drug addictions…They actually helped me out. I had fallen behind on rent for a few months, so they gave me the opportunity to make up the rent that I hadn’t paid.” Using a Housing First approach increases flexibility and allows us to be creative in helping people maintain housing. These proactive conversations may include budgeting to make sure the rent is paid or strategizing to buy drugs in a safer way. Despite the fact that a person may be using drugs, these harm reduction strategies can help people to avoid displacement and a return to homelessness. If we believe housing is a human right, we must work to keep people housed even when they struggle with meeting the terms of their lease.
Landlords should be our allies in the fight to end homelessness. At the end of the day, landlords want the same thing that our participants want—a safe, stable home. There are benefits for landlords who work with housing programs. One of the greatest advantages for landlords is increased communication and accountability. By working with case managers, landlords have a contact person who can mediate any problems that arise. Case managers can address landlords’ concerns and offer assurance that problematic behaviors will be addressed. At the same time, case managers thoughtfully relay this information to participants and develop their tenancy skills to increase housing stability. If our advocacy falls short and a landlord is set on evicting a client, we may still be able to negotiate with the landlord and offer to move the person out before a formal eviction takes place. By responding quickly, we can maintain our relationship with the landlord and prevent the participant from being burdened by having an eviction on their record.
If people are going to be evicted, the best practice is to get them housed again as quickly as possible. If we don’t plan to continue working with a participant to rehouse them, it reduces the incentive for them to move out prior to a formal eviction. At our annual Harm Reduction in the House Conference a few years ago, Patt Denning said about rehousing people, “It’s the staff’s job to house people. If someone loses housing, you house them again because that’s what you’re paid to do. But, remember this will go a long way to reducing your harm of burnout.” Denning points out that rehousing is better for the participant and provider alike. Eviction hurts. It hurts our participants and it hurts us because we care about them. Eviction prevention provides us with an intervention to avoid this pain.
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.
"...Then things started to change. I started working real close with them, being honest with them."
We want to take a moment to acknowledge the great story that The Indianapolis Star wrote about Penn Place, a first-of-its-kind Housing First program in Indianapolis, IN. This article is an excellent example of how we can be public advocates for our programs and the people that we serve. Penn Place also used this opportunity to ask for donations from the community and received resources to support their participants. Educating our communities about the Housing First Model and its benefits can improve the public support of programs like Penn Place. But, it’s not enough. We have to remember to continue educating the participants in our programs about the Housing First Model as well.
Think about the mindset of a person entering a Housing First program from homelessness. Their days are dictated by survival—wondering where their next meal is coming from, where they can sleep, what dangers might await them if they manage to close their eyes for a few hours. Without a sense of safety, they are under constant stress and it is difficult to focus, think logically, and connect with other people. An opportunity to escape the constant struggle of homelessness is presented and they jump at it! When you’re offered housing, there’s no space to consider the benefits of reduced service requirements and a client-centered approach. That means what we tell someone at intake or orientation about the Housing First Model might not be absorbed. So, we should seek other opportunities to reinforce our approach and why we use it.
There are aspects of the Housing First philosophy that are expressed in our daily work with clients. Any time we collaboratively help someone explore potential solutions to their problems, we highlight the Housing First emphasis on flexibility in services and valuing their perspective. In addition, we should explicitly describe aspects of the Housing First Model or they may go unnoticed. As one Housing First program participant explained, “It was shortly after that in one of our one-on-one sessions where [my case manager] said…’You realize your housing is not contingent on you being abstinent?’ And I hadn’t realized that at that point…Then things started to change. I started working real close with them, being honest with them.” All the flexibility and support in the world doesn’t make a difference if people don’t know it’s there. Even if we explain upfront that abstinence from substance use is not required, our clients are conditioned to assume that service providers have certain expectations. That’s why it’s so important that we revisit the Housing First Model with our participants and discuss the meaning of harm reduction and our commitment to deliver services that they want. Continually educating participants about Housing First can help us develop trusting relationships.
As helpers, our lives can get hectic. It’s easy to get caught up in managing our caseload and the day-to-day needs of our clients. But, it’s important to find opportunities to reinforce the approach to housing used in our programs. The Penn Place article itself is another opportunity to revisit the Housing First Model with our participants. It could be shared with them in a home visit or a community meeting. Finding ways to help participants understand our programs ensures that they get the most out of them. We should engage our participants about Housing First—what it is, what makes it different, and how it can benefit them.
We saw this story the other day about a shooting at a homeless encampment in Seattle. The initial report is that these people were not targeted because they were homeless. But, it serves as a reminder of the extreme risks people are exposed to when experiencing homelessness. As service providers, we know that survival—in the face of violent episodes like this one or complex health problems—is a constant struggle for many of our participants. The average life expectancy for a person who is homeless is 15 years lower than the average American. Housing is a critical determinant of health. For people experiencing homelessness there is a straightforward solution to alleviate their condition and improve their quality of life, provide housing first. An essential element of that approach is a Low Threshold Admission Policy (LTAP).
In my years of doing street outreach I’ve learned firsthand about the realities that people face when they live on the streets or in shelters. People I tried to help have died while waiting for the housing they so desperately needed. One woman died from her chronic health problems just days before she was approved to move into a housing program. I will always remember the pain of knowing how close she was to having a place of her own. Physical health conditions pose the greatest risk of mortality to people who are homeless, as opposed to substance use disorder or mental illness. However, all of these health conditions are exacerbated by the circumstances of homelessness—the lack of sleep, poor nutrition, difficulty maintaining medications, and exposure to the elements.
Random acts of violence and hate crimes targeting people who are homeless are another reality our participants face. One night, a person I worked with came into the shelter bloodied. He explained that he was attacked on his way there by a group of high-school aged kids. Others have told me stories of being woken up in the night by somebody robbing or assaulting them. The shelters can only provide limited protection since they are frequently overcrowded and underfunded.
But, my experience is not unique. We work with an exceptionally vulnerable population—people who are homeless, oftentimes with co-occurring disorders and limited resources. A tragic fact is that we will lose people we care about in doing this work. It’s not a question of if but when. For those of us that work in homeless services, we know that this is the world that our participants are living in and we hope to be a part of changing it.
The life-threatening risks of homelessness create an urgent need for the Housing First Model and its LTAP for supportive housing programs. LTAP means simplifying our intake processes and removing as many barriers to entry as possible in order to expedite the process of getting people off the streets and into housing. It should not be acceptable to deny a person entry to our programs because of ongoing substance use, untreated mental illness, or criminal background. We must open our doors to people and embrace the idea that housing is a human right.