“Housing First” Approach

This entry describes the “housing first” approach in the context of homeless individuals with psychiatric and substance use disorders; however, the philosophy of housing first is applicable to every person and every family that is homeless.

The problem of homelessness entered the purview of the American public in the 1980s with the alarmingly rapid growth in major urban centers of a highly visible population of homeless individuals with drastically elevated rates of mental illness and substance abuse disorders. This growth coincided with and coalesced from several economic changes, such as the removal of federal support for subsidized housing, the increasing scarcity of low-income housing, and a growing disparity of wealth, as well as with social changes such as deinstitutionalization and the crack epidemic. This new mass homelessness revealed what Kim Hopper described in 2003 as “[the formerly] hidden face of poverty ripped from its customary habitat” (Hopper 2003, 176).

Homeless individuals who were most difficult to assist—those afflicted with mental illness and substance use disorders—confounded the psychiatric and [Page 278]social service communities in short order. Even when assisted by social service organizations, these homeless individuals found it much more difficult to gain access to stable housing and to retain it than their less troubled counterparts. The social service organizations seeking to help them came to believe that it was the co-occurring disorders that hindered their progress toward stable housing. Assuming that persons who were diagnosed with mental illness and addictions would be too much of a risk to themselves and the community if they were housed before they overcame these conditions, the overwhelming majority of these organizations attempted to funnel clients into treatment programs to make them “housing ready.” In most of these programs, rigid regulations control consumers' behavior, mandating that in order to become “housing ready” they first become clean and sober, take their psychiatric medications, and obey curfews.

These treatment-first programs seek to resurrect their consumers, releasing each of them like a phoenix into a blue sky of reason, sobriety, and social inclusion. To this illusory end, most housing programs for people who are homeless with psychiatric disabilities and substance use disorders continue to use housing as leverage to induce their compliance with treatment. It is widely believed that only by participating in treatment can a consumer truly become “housing ready.” Thus, housing readiness gained primacy in the lexicon of homeless services and to this day is presented as the sole path of deliverance from homelessness. Yet, as a 2003 survey by the Coalition for the Homeless shows, chronic homelessness among the mentally ill persists. Hard-to-serve consumers are burned out by their efforts to end their homelessness via the mandatory treatment route, which is marred by our collective failure to respond adequately to their needs. For these consumers, the story of the phoenix is a myth. However, there is an effective solution to the problems of this seemingly intransigent population—the Pathways to Housing “housing first” model.