Housing First is a harm reduction approach to supportive housing. In the United States and Canada, and increasingly throughout Europe, homeless service providers have adopted Housing First as the guiding framework at the program and community level. Programs readily embraced the idea that we should remove barriers to housing people experiencing homelessness. The low threshold admissions policy gets people into our housing programs, but it is not sufficient. As any housing provider can tell you, the work truly begins after someone gets into housing. Once a participant is housed, participants and case managers alike may find themselves wondering, “What now?”
The critical ingredient of harm reduction-based services can guide the way that we approach participants in Housing First programs and facilitate nonjudgmental conversations with them about the risky behaviors they engage in. However, our team consistently finds that the knowledge and use of harm reduction strategies are missing in many Housing First programs. For example, during the course of one of our Housing First trainings, we met a case manager working for a housing program which identifies as practicing Housing First. When the case manager was asked about harm reduction training and practice in their program, they explained that they house people who are actively using drugs but was unable to articulate harm reduction’s role beyond that.
In an attempt to understand why programs aren’t consistently practicing harm reduction, we conducted a rapid review and document analysis of the open access literature on Housing First from the United States and Canada. The results demonstrated a lack of explicit mention and informed discussion of harm reduction in the majority of the Housing First literature. This may be a contributing factor to the limited education and application of harm reduction in Housing First programs. Read the full open access article, published in the Harm Reduction Journal here: Housing First and harm reduction: a rapid review and document analysis of the US and Canadian open-access literature
We’ve taken a break from blogging the past month to work on our annual conference, Harm Reduction in the House. The conference focuses on how harm reduction can be applied to improve the delivery of housing and other social services. There are a number of nuanced issues that come up for participants in programs using the Housing First Model. This year, conference attendees were able to hone in on areas to use harm reduction including safer substance use practices, sexual health promotion with tools like PrEP, and engagement strategies that promote positive changes like the SODAS Method. The conference hosted several hundred presenters and attendees from around the Midwest including Illinois, Indiana, Wisconsin, Michigan, and Ohio. In this post, we look at some of the reaction and takeaways from the conference.
The theme of this year’s conference was “Growing from Our Roots.” Harm reduction is getting into the mainstream. In recent years, a broader range of programs and providers around the world have embraced harm reduction. Growing from Our Roots is a reminder that harm reduction work began with drug users and people actually engaged in risky behaviors. Their community, respect, and self-determination drive the principles of the harm reduction philosophy in service delivery. They are experts in their own lives and must be included in the work and accompanying advocacy efforts. Daniel Raymond, policy director at the Harm Reduction Coalition, attended the conference and offers additional thoughts on this topic and more in “Holding space for the unredeemed: harm reduction and justice.”
One of the popular sessions at the conference was the “Irreverent: Harm Reduction Youth Work and Radical Ministry” workshop. Rabbi Menachem Cohen and Pastor Alli Baker led a group discussion including youth who are LGBTQ and have experienced homelessness. The conversation explored the experience of homelessness from a young person’s perspective and what providers can do to create safe, welcoming environments. When workers listen nonjudgmentally and remain flexible, they have the power to support youth in getting off the streets and remaining housed. Rev. Kathryn Ray is a member of Clergy for a New Drug Policy and offered her thoughts on this workshop after attending the conference in “Rule Breaking and Radical Love.” She discusses the way that harm reduction can open doors for people and says, “Harm reduction work is gospel work.”
We have to acknowledge that we could not put on this conference without the help of our amazing volunteers. Thanks to everyone who pitched in! Among other duties, we had volunteers live-tweeting the conference. Below are some of the highlights from the day. For a full list of tweets, check out #HousingisHR on Twitter.
Photo credit PrEP4Love.com
The fight against HIV/AIDS advanced tremendously over the last 30 years. Treatments can decrease viral loads to undetectable levels, improving the health of people living with HIV and lowering the chances of transmitting HIV to others. But, with over 40,000 new HIV infections annually in the United States there is more to be done. Additionally, people of color, trans women, and men who are gay or bisexual continue to be disproportionately affected by HIV. In response, the National HIV/AIDS Strategy increasingly promotes HIV prevention efforts.
PrEP (pre-exposure prophylaxis) is a new approach to HIV prevention. PrEP treatment means that someone who is HIV-negative can take a daily pill to reduce their risk of becoming infected with HIV. PrEP does not protect against other sexually transmitted infections or pregnancy. It is intended to be used in combination with other safer sex measures, including condoms. Truvada is the medication currently approved for PrEP treatment by the FDA. The medication must be taken for at least seven days to reach sufficient levels for protection against HIV. PrEP is recommended for anybody at high risk of HIV infection. Primarily, this includes men or transgender women who have sex with men, people who are HIV-negative but have a partner who is HIV-positive, and people who inject drugs.
Research shows people who use PrEP experience a reduction in their risk of HIV infection. Transmission of HIV has been demonstrated to drop by over 90% among people who take PrEP consistently. As explained on the website PrepFacts.org, “If you don’t take PrEP consistently it can’t protect you from HIV, but if you do take it regularly it can offer strong protection.” PrEP is sometimes confused with PEP. PEP stands for post-exposure prophylaxis and can reduce someone’s risk of becoming infected with HIV after they’ve come into contact with it. To be effective, PEP treatment must begin within 72 hours of exposure to HIV and last for a month.
It’s important for housing first providers to be informed about PrEP and PEP and to share information about these treatments with their participants. Housing first providers work with people in marginalized communities who are at a heightened risk of HIV exposure. In addition to the groups previously mentioned, HIV is more prevalent among people who are homeless. Although PrEP is highly effective, one in three health care providers haven’t heard about it. So, it’s up to service providers and other helpers in the community to spread the word about this option.
Even if a health care provider is aware of PrEP, they might be too rushed to fully understand what’s going on with their patient or stigmatize their risky choices. The Housing First Model gives service providers the time needed to get to know someone and find out about potential risks they face. If housing first providers are using a harm reduction approach, they are more likely to get honest information about a participant engaging in unprotected sex or injection drug use. That means that they might be aware of a person’s heightened risk for getting HIV and can bring PrEP to someone’s attention, who may not hear about it otherwise.
Sex feels good. It helps satisfy our need for intimacy and connection. People do it despite the risks of unwanted pregnancy or sexually transmitted infections. As with all harm reduction work, staff's goal is to help people strategize how to get the benefits from a behavior without experiencing the consequences. Creativity is a necessity when service providers are collaboratively building a menu of options to reduce harm in their participants’ lives. But, that creativity can be stifled when staff try to talk about sex and participants respond by saying that they will never use condoms or that they are HIV-positive and sexually active. Don’t be deterred! Just because a person isn’t willing to do something in the safest way possible, doesn’t mean that they won’t consider other strategies that may help. Instead of using fear to motivate decision making, the focus should be on education, options, and empowerment. These values are reflected in many of the public health campaigns promoting PrEP which are more focused on being sexy than scary. Getting comfortable talking about risky sexual behaviors and the pleasure people get from their sex lives positions case managers to introduce options like PrEP to their participants in an appealing way.
Here are some additional resources for learning about PrEP. Check out this website for information on where to find PrEP in your area. PrEP is covered by most insurance providers and Medicaid. For more details about how to get PrEP, including links to available payment assistance programs, go to prep4love.com created by the AIDS Foundation of Chicago. Prepfacts.org was created by the San Francisco AIDS Foundation and includes a detailed list of frequently asked questions. The Well Project focuses on women’s health to address HIV/AIDS and presents a balanced overview of PrEP in the article “PrEP for Women”. On September 23rd the Midwest Harm Reduction Institute will be hosting a presentation on PrEP at the annual Harm Reduction in the House Conference in Chicago. Consider attending the conference or following the hashtag #HousingisHR to keep up with the conference.
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.
This post was written by our research partner Dennis Watson, MA, PhD
Center for Health Policy
Indiana University Richard M. Fairbanks School of Public Health, Indianapolis
*Reprinted from Indianapolis Recovery Coach Newsletter
The U.S. Department of Housing and Urban Development’s (HUD) annual homeless census counted 4,694 adults experiencing homelessness in Indiana this past year. Of these individuals, 596 were chronically homeless (meaning they have a diagnosed disability and have experienced continuous homelessness for at least one year or have been homeless at least 3 times in the past 4 years), 933 had a chronic substance use issue, and a significant number of those individuals with substance use issues are likely experiencing a co-occurring mental health problem. A treatment first mentality (requiring individuals to address substance abuse and mental health issues before accessing necessary services) among providers is a significant barrier to needed services many individuals experiencing homelessness face. However, new trends in homeless services drawing upon the principles of harm reduction are resulting in improved outcomes for this population.
Individuals experiencing homelessness often have difficulty meeting demands of programs requiring abstinence or participation in substance use services because they are not ready to give up their substance use. In many cases, this is because behaviors providers see as negative are providing some sort of benefit to the person in light of all of the adversity they experience on the streets. In cases where individuals do obtain abstinence for the purpose of accessing services, relapse often follows because their end goal was the service (which has been obtained) and not sobriety itself. Harm reduction is a more practical avenue for working with members of vulnerable populations who have experienced significant levels of trauma, as well as individuals who are simply not ready to choose sobriety. While many individuals see harm reduction and abstinence-focused approaches such as Alcoholics Anonymous as being in opposition to each other, harm reduction is actually highly accepting of abstinence as a goal as long as it is the individual’s choice. As such, the successful harm reduction practitioner will help guide an individual toward ever safer behaviors, but will never force abstinence on her/him.
Perhaps the best example of the positive effect of harm reduction services within the homeless population is the Housing First model of permanent supportive housing. The Housing First approach was developed in the early 1990s to address discrepancies between abstinence-only housing services and the realities of individuals experiencing chronic homelessness. As such, it places minimal demands on clients related to substance use and service engagement. Since its development, Housing First programs have been associated with a number of positive outcomes when compared to abstinence-only programs such as higher perceived choice in services among residents, increased access and higher use of behavioral health services, fewer emergency room visits for detox purposes, and reduced involvement in criminal activity. It is because of these and similar outcomes that Housing First is considered an evidence-based practice by the U.S. Department of Housing and Urban Development and the U.S. Substance Abuse and Mental Health Administration.
While harm reduction is only one “ingredient” of Housing First programming, it is one of the most critical to its success. While there are many concerns that harm reduction leads to enabling, it is not an “anything goes model”. Clinicians who employ harm reduction appropriately do not protect their consumers from the natural consequences of their actions, but rather work with them to understand how their behaviors led to those consequences in the first place. (Natural consequences refers to consequences faced by the majority of society, not consequences resulting from arbitrary program rules more often faced by those living in poverty.) In my research, I have seen how harm reduction leads to improved relationships between Housing First staff and residents, which is essential for facilitating positive change. This is because residents are more likely to discuss their substance use openly and seek help related to it when necessary because they do not have to fear being thrown out of their apartments. It is these kinds of open and honest discussions that tools like motivational interviewing and the transtheoretical/stages of change model (tools most substance abuse professionals utilize) hinge on for their success.
If you are interested in learning more about harm reduction and Housing First, I am happy to share copies of my research reports (email@example.com), or you can access helpful information from the following organizations:
This week we suspend our normal blogging topics to pay tribute to a great Housing First champion that we lost last week. Paula Goering was the research lead for Canada’s At Home/Chez Soi pilot project of the Mental Health Commission of Canada, testing Housing First on a national scale. This project, which resulted in over 100 published articles detailing their important findings, convinced the Canadian government to implement Housing First nationwide. It has also provided those of us in the US and other countries with a wealth of research evidence on which to make our own case and inform our practice of Housing First.
We had the pleasure of finally meeting Paula at the most recent Housing First Partners Conference in LA in March. This was quite an honor, and intimidating, as we have read many of her articles and been greatly inspired by her work. We shared a panel on Housing First Fidelity measurement and were both challenged and inspired by Paula’s astute wisdom and commitment to the Housing First model.
We encourage you to take some time to peruse Paula’s significant contributions to the literature on Housing First. Her wisdom and dedication to the Housing First model will not quickly be forgotten.
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.