In the late 1980s and early ’90s, on both ends of the country, the concept of Housing First was born. In 1988, a Los Angeles social worker named Tanya Tull was convinced that shelters were not the answer. She founded the organization Beyond Shelter, which prioritized housing for families with children and provided support services to help them graduate to self-sufficiency.
A few years later, in 1992, the New York City nonprofit Pathways to Housing, led by Sam Tsemberis, also adopted the concept — and then turned it into a global movement.
Tsemberis was a street outreach worker working with people with mental illness and who were consequently homelessness. Prior to that, he worked at Bellevue Psychiatric Hospital, seeing first-hand the pipeline between mental illness and the streets.
In the ’80s, social service systems used a staircased or linear model, prioritizing behavior measures, such as resolving a person’s mental illness or addiction, as a condition to be considered ready to receive housing. Housing, if made available, was the incentive. Tsemberis saw the failure in this in his work as a clinical psychologist at Bellevue.
“People that I was treating in the inpatient service in Bellevue Psychiatric Hospital in New York City, I would see on the streets on my way home,” Tsemberis said.
Housing First reverses the process, and Tsemberis put it into practice when he created Pathways to Housing. There, staff worked with some of the most historically challenging situations: serving people experiencing homelessness with concurrent psychological and addiction issues.
The figures vary slightly from study to study, but it’s estimated that as many as 1 in 3 people experiencing homelessness in the United States also live with a serious, untreated mental illness.
In a randomized study published by American Psychiatry Publishing, the initial results bore out the logic behind Housing First: Between 1992 and 1997, in its first five years, 88% of the Housing First program’s participants through Pathways remained housed, compared to only 47% in the New York’s residential treatment system.
They were on to something.
Tsemberis formed Pathways Housing First to train more organizations on the Housing First model, conduct research and advocate for the new approach. It would become a standard for the nation.
As the model spread, additional research continued to show better success rates for ending homelessness with Housing First than with the linear model. With its evidence-based credentials, it was heralded by the U.S. Substance Abuse Mental Health Services Administration and praised in research from the National Institutes of Health for its success in ending chronic homelessness among people experiencing severe mental illness.
In 2004, President George W. Bush’s administration adopted it as part of its national policy to end homelessness. And, it has been endorsed by National Alliance to End Homelessness for its proven record in ending homelessness, interrupting substance abuse, encouraging employment and improving overall health.
In addition to heading up Pathways Housing First, Tsemberis is a faculty member in the psychiatry department at Columbia University Medical Center and continues to conduct research and studies on homelessness, mental illness and addiction.
“If we’ve demonstrated anything in the research that Housing First has shown, it is that whether you are on board with harm reduction or giving people second, third or fourth chances or working from a compassionate point of view or not, we know it’s actually very, very effective,” Tsemberis said.
Five Principles of Housing First
In his research published with the American Psychiatry Association, Sam Tsemberis has documented flaws in the linear residential treatment model. Among them is the lack of choice or freedom in treatment or housing.
Housing is often congregate, decided according to clinical status, and people are frequently moved, which causes additional stress. Also, the skills needed for those living situations are not always transferable to other living situations. But the biggest problem is that people who are homeless are denied housing because it is contingent on getting treatment first.
Instead, Tsemberis created a Housing First model based on five principles:
Immediate access to housing with no readiness conditions: Residents meet with support teams, but their housing is not contingent upon clinical status.
Consumer choice and self-determination: Meaningful housing options are provided, which for most people means independent housing, not congregate compounds. A supportive learning environment supports informed choices to increase self-sustainability.
Recovery orientation: Peer support helps an individual work toward self-defined goals and toward long-term recovery rather than just managing crisis after crisis.
Individualized and person-driven support: The approach is flexible to fit each participant’s needs, pace and goals.
Social and community integration: Team members work with the participant, as well as community members and landlords, to help people understand Housing First, break down myths and support integration.
A Wake-Up Call
Housing First has been a philosophy in the halls of housing politics for years, but now the COVID-19 pandemic is making its case among the general public.
“For years, in the Housing First community, we’ve been arguing, give people a place to live right away. It’s safer, it’s saner, it’s more compassionate, it’s healthier, it’s so many things that immediately change,” Tsemberis told Street Roots. “And people are like, ‘No no no, you need to be clean and sober, you have to be more together, you have to demonstrate you can manage this.’ That debate has been going on for a very long time. Suddenly COVID-19 comes along, and everybody is like, ‘What are we doing leaving people on the street? They’re too close together. Let’s get them into a house right away.’ Yes, yes, let’s do that.”
“It’s woken everybody up to the fact that homelessness is a public health issue,” Tsemberis continued. “Not only for people who are experiencing homelessness, but for all of us. And COVID connected that. The same is true every single day before COVID, but now COVID has brought that into focus.”
A Values-Based Approach
Tsemberis’ research and success in ending homelessness has made him the closest thing to a celebrity that there is in the housing policy world.
Pathways to Housing expanded to locations in Washington, D.C.; Philadelphia; Burlington, Vt.; and Atlanta, and Tsemberis serves as the executive director for the Greater Los Angeles VA-UCLA Center of Excellence for Training and Research on Veterans Homelessness and Recovery. He has received honors for his work by the American Psychological Association and was awarded Canada’s Meritorious Service Cross.
Tsemberis sees the shift with the Trump administration, away from housing efforts and toward more punitive measures to criminalize homelessness, as part of the “Make America Great Again” time machine to an earlier, puritanical America — a world grossly disconnected from the causes and solutions surrounding today’s homelessness and housing crisis.
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“That punitive and judgmental approach of requiring people to improve their lives just because they’re poor has always been a terrible and very moralistic and ultimately ineffective approach to working on this,” Tsemberis said. “We’re still blaming people. And there’s something so compelling that we see only those people who are visible, that becomes in the public’s mind, this is what homelessness is about. But that’s actually a very small group. Most people who are homeless are hidden. And so then the public has a very distorted idea of what homelessness is about.”
While Tsemberis’ model has been replicated across the globe, the United States lags behind other countries that have concluded that the solution to many street-level problems starts with a home, Tsemberis said.
“We’re so married to a capitalistic approach, we even talk about people in terms of ‘frequent utilizers’ of social services and what people cost, what homelessness costs, as if people have price tags on them,” Tsemberis said. “And if they’re too expensive to the social programs, then we pay attention to them, but if we can get away with it on the cheap, if you’re just a Walmart-level user of services, we don’t need to pay attention to you because it’s not costing us anything. The whole thing is kind of depraved as a system of thinking about it.”
Tsemberis cites the approach of Scandinavian countries and New Zealand as examples where cities are solving the problem. It’s not all rosy. In recent years, the numbers of homeless people have begun to rise across Europe. In the Netherlands, leaders of the four largest cities have appealed to the central government to create more affordable housing and release more funding for homeless services.
But Finland, for example, which implemented Housing First 12 years ago, has dramatically reduced the number of people experiencing homelessness. Formerly homeless residents have stayed in housing long term, according to press reports, ultimately freeing up other resources and costing the state less per person per year.
“The way that all these countries are doing it is a values-based approach,” Tsemberis said. “They’re not doing the numbers first. They’re saying, look, we’re a society that believes that everyone who lives here needs to have a decent place to live, needs to have health care, needs to have education. These are basic human rights of our social contract. That’s where they start from. And then they figure out how to make that happen with the budgets that they have.”
The U.S. doesn’t have that consensus, Tsemberis said.
“This is why the politics come into it,” he said. “We have a society that says everyone’s on their own. If you just work harder, pull up your bootstraps — the so-called American Dream, which works well for a small number of people, but not for many, and yet it has an incredible staying power, selling power. Everyone wants the American Dream.”
Meanwhile, 8 million Americans have fallen into poverty during the pandemic, the middle class is shrinking, and financially, opportunities around housing, education and basic needs are increasingly out of reach for many people.
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"It’s all about providing the resources. It’s all about income disparity, and it’s about making the decision as a society that we need to help people who can’t manage to participate in the way that most people do. If capitalism had figured out a way that would create affordable housing and still make a profit, we wouldn’t have homelessness,” Tsemberis said.
“Homelessness is just one tiny symptom of a system that’s broken. It’s a symptom of a much bigger problem, and we’re not talking about the bigger problem.”
The Blessing of Being Wrong
For all the success attributed to Tsemberis’ work in housing, one of his greatest joys was realizing how wrong we were — specifically about the capacity of people with mental illnesses to live and thrive on their own, in their own housing, with the right support.
“For centuries, we have been dealing with people with mental illness as if they are incapable, that because you have schizophrenia you have to be in supervised housing 24 hours a day,” he said. “We institutionalized people up until the 1950s in these huge horrible institutions, lifelong.
“And now, the very same people and the same diagnosis, when you give them the opportunity and the support to live independently in the community on their own, can actually manage that just fine. That, to me, is the most exciting thing: We discovered we’d been wrong about the capabilities of people with mental illness or with serious addiction, that they can manage much, much more when they are included in the decision-making of the kinds of housing and services that they need. The whole point of Housing First is that it’s person centered; it’s client driven. … We’ve all had it kind of warped about what capabilities people have. And, to me, happily, we’ve proven that’s not the way it is. People need a decent, affordable place to live, with supports, and they can do very, very well.”
A 2015 study, co-authored by Tsemberis and published in the Canadian Journal of Psychiatry, found that people with severe mental illness and who were homeless who received Housing First “achieved superior housing outcomes and showed more rapid improvements in community functioning and quality of life than those receiving treatment as usual.” And numerous studies have shown a cost savings in community expenses — court costs and health care, for example — by giving people stable, permanent housing.
For a good example of how well Housing First works, look to the VA Supportive Housing program, or VASH, Tsemberis said.
In 2009, the Department of Veterans Affairs reported the number U.S. veterans experiencing homelessness nationwide at 107,000. This population had high rates of serious mental illness, with an estimated 70% living with substance abuse problems and approximately half of them being involved with the criminal justice system.
In 2010, the Obama administration’s Opening Doors initiative led to a massive infusion of funds to functionally end homelessness among veterans, amplifying intergovernmental cooperation with the VASH program — a partnership between the Department of Urban Development and the VA — that paired a permanent housing subsidy with case management. It targeted the most vulnerable veterans, including those with mental and physical health issues and substance abuse disorders, and put more money into securing housing. By 2019, the number of veterans who were homeless in the national Point in Time count was cut in half, down to 37,000, with 83,684 VASH housing vouchers in use.
The VA declared the VASH program the most effective tool for ending veterans’ homelessness.
“They put together 70,000 vouchers and provided the (VA) with case management services to take care of people, and they basically created a huge Housing First initiative for veterans who qualified, who were chronically homeless and honorably discharged. And there’s been more than 70 cities across the country now that have ended veterans’ homelessness,” Tsemberis said.
Those communities include Multnomah County, which in 2016 was the first local region on the West Coast to be certified for driving veteran homelessness down to “functional zero,” meaning more veterans were working toward becoming housed on any given day than falling into homelessness. In 2018, the Joint Office of Homeless Services reported housing 560 homeless veterans in permanent supportive housing.
Still, the 2019 Point in Time count tallied 474 veterans as homeless in Multnomah County, a slight increase over the previous count conducted in 2017. Despite the success of the housing initiative, hundreds of veterans still become homeless each year, the report stated.
“We often think about homelessness as a fixed number,” Tsemberis said. “It’s not. It’s a river. And the river has more people flowing into it now than being taken out of it. So every time we do the count, we’re just looking at that one point in the river. And it’s a flow. And we count half a million people this year, the same number last year. It may be the same number, but it’s definitely not the same people, because many people have moved out, but even more people have fallen in.”
Political Will
George Floyd’s death at the hands of police officers mobilized the Black Lives Matter movement to stand up to police brutality and systemic racism. Floyd’s death ignited the fire within and launched a cultural exploration that has begun to chip away at oppressive institutions.
Tsemberis wants to see that happen around homelessness.
“Political will is an informed public,” Tsemberis said. “We’re not really going to change anything until more people know about the things we’re talking about right now. I think that if we had a public that knew that homelessness is about structural factors — like the conversation we’re having about George Floyd. We’re looking at structural racism that began hundreds of years ago and why it persists in the role of police in our society and the role of discrimination in our society against people of color. We’re having a conversation about the structural problems that lead to the brutality of the police, especially against minority communities that has been going on since the beginning.
“We need to get to that kind of conversation and understanding about the structural factors that contribute to homelessness to create public awareness that will then create that political will so that when you have a candidate that seems to understand what the solution is — rather than a yearning to go back to shelters — we have a shot at changing things.”
On a more personal level, Tsemberis believes the pandemic has given people a glimpse behind the curtain at what homelessness does to a person, that feeling of being treated like you have the plague.
“Walking around all day wearing a mask and treating everybody around me like they have the virus, I thought to myself, this is exactly what people don’t appreciate about being homeless, because homeless people are treated that way every single day,” he said. “We avoid looking at them. We treat them like they are toxic or ill. We cross the street to avoid them. We walk on the far side of the sidewalk. We certainly don’t make eye contact. It’s a way that people have figured out how to cope with seeing so many people on the street. They don’t know what to do so they shut it down.
“This pandemic gives everyone the opportunity (to know) what it feels like, when everyone is walking past you and not looking at you, like you don’t exist, or you exist but you might be toxic. That’s what it’s like to be homeless every single day.”