Housing First and the Homelessness Crisis: What Went Wrong?

    “The homeless crisis interested me,” says Mary Duffy of the time before she herself became homeless in Texas. “I wouldn’t believe this was happening in America, so I did a lot of  research. But you can never do enough research until it happens to you. And there’s just no place for us to go.”

    Duffy, a former trained cook in her 50s, lost her housing after going through cancer treatment and a divorce. She has been on numerous housing waiting lists in Fort Worth, San Antonio and Dallas for three years, and has suffered harrowing experiences in shelters during this time. Many of the programs she has been in are funded to offer an approach called “Housing First,” in which housing is made available without conditions. “I’m still waiting for a Housing First anything to give me a home.”

    Housing First is a well-evidenced, effective model that has gained traction over the past 20 years. So how is it that the homelessness crisis across North America becomes more devastating with each passing month?

     

    The Genesis of Housing First

    Articles like this, or this, or this support the persistent notion that some people are just really, really hard to house, that they are wilfully and persistently, “chronically” homeless. While housing is expensive, as such stories may admit briefly, they suggest that it’s mostly people’s inner troubles that make it impossible for them to acquire or hold onto an apartment.

    Evidence does not support the assertion that drug use is the cause of homelessness. But a severe, escalating lack of affordable housing across North America obviously encompasses the urgent needs of unhoused people who use illicit drugs, or who have substance use disorders or mental health issues.

    How, they asked, can anyone be expected to address such issues when they don’t have a roof over their head?

    Up until the 1990s, the general approach was to imagine people gradually transitioning off the street as they moved through drug treatment or stabilized their mental health. But around that time, some frontline workers and clinicians came to see this framing as backwards. When someone is homeless, they said, what they need first isn’t detox or psychiatry. How, they asked, can anyone be expected to address such issues when they don’t have a roof over their head, a permanent bed, or a door they can lock?

    And so, the Housing First movement was born. It’s often thought to have begun with the Pathways to Housing program in New York City, which in 1992, instead of requiring the traditional period of sobriety following substance use or mental health treatment, began providing housing first, with wraparound services to support people in keeping their new homes. The Homeless Hub’s 2012 report on the evidence supporting Housing First pointed out, though, that Houselink in Toronto was providing non-conditional housing for people discharged from psychiatric facilities as early as 1977.

    Regardless of who came first, the general model of housing without conditions, considered as a human right required before other interventions, has been reproduced, with variations, across the continent and beyond (it is credited with dramatically reducing homelessness in Finland). Housing provided may belong to the organization that offers it; or they may be a broker, helping homeless clients secure places to live throughout a city, subsidizing rent, and providing housing workers to support the newly housed.

     

    Good Intentions Undermined

    As homelessness became increasingly visible in the 2000s, many North American cities and organizations developed housing plans and boldly stated intentions to eliminate homelessness. Many adopted Housing First philosophies as a way to achieve this. Until at least 2018, Housing First was the stated policy of the United States Interagency Council on Homelessness (USICH), which coordinates homeless services across 19 key agencies. USICH did not respond to Filter’s request for comment on its current position.

    Housing First is an evidence-based approach, in that numerous studies show that if implemented correctly, it is an effective way to get homeless people housing and help them to keep it. These include randomized, controlled trials, studies with strict parameters that look at the fates of participants in different cities and different circumstances, and studies that look at the role of harm reduction within the Housing First model.

    So when such a good, proven approach to housing has gained such traction, why has homelessness, both invisible and very visible, increased so dramatically over the past two decades, with an even faster upward trend since COVID-19?

    It’s a question that opponents of the philosophyand of its applicationhave asked. Worryingly, these include Robert Marbut Jr., who in late 2019 was appointed as head of USICH by Donald Trump.

    People who want to see Housing First succeed have every reason to consider why its well-documented successes have not substantially limited the homelessness crisis. “I do think basically people need housing,” said Greg Cook, a longtime housing worker at Sanctuary in Toronto. But despite the rise of Housing First, “what’s actually happened is that you have this massive increase in homelessness in Canada and the US.”

    The Trump administration has begun reforming funding by allowing various requirements for participants to be added to a model that was meant to be unconditional.

    The drastic rise in visible homelessness in North American cities has been accompanied by less obvious housing insecurity, where people couch-surf, or live in overcrowded rooms or apartments, or in other non-shelter, non-street versions of not having a home. Conservatives and the current White House administration routinely cite only the more visible kindparticularly the “skid rows” or encampments that spread in recent years and have exploded in the pandemic amid shuttered services and people’s attempts to distance—to call for law enforcement crackdowns and criminalization of homelessness, or punitive, prison-style shelters (including actual, repurposed correctional facilities), where housing is a privilege to be earned by compliance with arbitrary rules.

    The Trump administration’s 2019 report The State of Homelessness in America also noted that the administration has begun reforming funding for Housing First programs by allowing various kinds of requirements for participants to be added to a model that was meant to be unconditional. It also called for policing designed to reduce the “tolerability of sleeping on the street.”

    People who have lived on the street for years don’t always find being suddenly allotted an apartment transformative in itself. It might well be in an unfamiliar and inaccessible part of town, away from their social networks and from services for food, income generation, and harm reduction upon which they depend for wellbeing and safety. These factors, and the need for wraparound services to mitigate them, seem obvious, but policymakers express disingenuous confusion at the inability of some poor and serially traumatized people to “hold onto” housing.

     

    Housing First in Practice

    Just because a program is described as operating on a Housing First basis doesn’t mean that it really works that way. One former clinical lead for a major Housing First organization in a US city, who requested anonymity to protect the organization and his current job there, told Filter that newly housed residents may be kicked out for not being a “good fit,” due to behavior such as noise or causing damage.

    “Where else would they be a good fit?” he asked, rhetorically.

    Although Housing First is supposed to house people without judgment or conditions, an underlying expectation of moving to abstinence can result in an unofficial “don’t ask, don’t tell” approach to substance use. Rather than frankly addressing the mitigable risks of overdose, supporting residents with safe spaces to use drugs and harm reduction supplies, some programs leave residents alone until they attract negative attentionand may then lose their housing as a result. The unconditionality frequently doesn’t persist for the six months, eight years or lifetime that may be required.

    “No one would state that but I have seen it in practice many times.”

    “We let people in but eventually [we assume] they’re going to stop [using drugs] because we expect it or because [we assume] housing means they will stop,” said the source. “No one would state that but I have seen it in practice many times.”

    “Clinical challenges when not homeless will persist from when homeless,” Dr. Stefan Kertesz, a Birmingham, Alabama physician who works with homeless veterans through the US Department of Veterans Affairs, told Filter. And yet, he added, we often expect the opposite.

    A major Canadian trial, looking at health and cost outcomes among people housed via Housing First programs compared to “treatment as usual,” found that as well as reducing homelessness and improving health outcomes, these programs also saw people reduce their drug use overall. Still, other randomized controlled trials do not fully show this, Dr. Kertesz said. Certainly there is no basis for assuming that drug usewhether problematic or notwill stop on cue just because you put people in a house. But that shouldn’t be the point.

    Dr. Kertesz added that evidence such as the Canadian trial does not support the assertion that it’s always cheaper to provide supportive housing than for people to remain homeless. But, as a 2016 commentary in the New England Journal of Medicine by Kertesz and others argued, cost savings are also not the point: Housing for everyone is. Housing First is the best way to house people, and not particularly costly,” Dr.  Kertesz said, describing the notion that it’s only worth doing if it saves public money as “a stupid and immoral logic.” 

     

    Punishment Versus Support

    In the US and in the current political climate, the persistence of behaviors, such as drinking alcohol, that are seen as inevitably problematic or representing a substance use disorder or moral failing when poor people exhibit them, has spurred increasingly authoritarian, punitive approaches to both substance use and homelessness.

    In addition to law enforcement crackdowns, these include examples like Robert Marbut Jr.’s previous gig as the founder of the ironically named Haven for Hopea massive, partly open-air “transformational campus” in San Antonio, Texas, initially developed for Hurricane Katrina refugees in 2006, where access to a roof over your sleeping mat among hundreds of others is a privilege that must be earned, via participation in substance use counselling and drug testing, or other programs. Breaking curfew or failing a drug test can put you back in the concrete courtyard.

    In Canada, however, managed opioid or alcohol programs are occasionally available in combination with housing for serially traumatized and heavily substance-using individuals. In these very limited, fully wrap-around programs (there is one in Ottawa and a somewhat different version in Vancouver), retention rates are excellent, demonstrating that with safe access to the substance a person is dependent upon, as well as more conventional supports, virtually all health, wellbeing and social integration outcomes can improveand that there is zero need to require abstinence.

    “People have the right to make choices about how they want to live their lives. Harm reduction is not a stepping stone on the pathway to abstinence, necessarily.”

    Likewise, at Healthcare for the Homeless, an organization in Baltimore, Maryland that appears to walk the talk on Housing First, harm reduction is inseparable from that philosophy. “People have the right to make choices about how they want to live their lives,” Lawanda Williams, its director of Housing Services, told Filter. “Harm reduction is not a stepping stone on the pathway to abstinence, necessarily. We really see it as a form of treatment in itself.”

    The result of this commitment, along with a truly coordinated, multidisciplinary service that works closely with landlords and developers to actively deal with issues that can come up in housing people with inadequate income and unaccustomed to permanent housing, is the sort of success that earned Housing First its reputation in the first place.

    It’s important to note the context: Healthcare for the Homeless secures housing for people who have already moved up to the front of a years-long waiting list for subsidies. These subsidies, in the form of vouchers of various kinds, make up the difference between the 30 percent of residents’ income that they are required to contribute and the actual market cost of rent.

    But retention rates, Williams said, are extremely high: around 98-99 percent. For those who qualify for its services, it appears that this Housing First program truly does end homelessness.

     

    Supportive Housing, Or Affordable Housing?

    In mainstream North American discourse, drug use is still often viewed through a moralistic lens—as sinful or as criminal—or through a pathologizing lens, as a “brain disease” or mental disorder which prevents rational decision-making. These ways of thinking condition how substance use is seen in the shelter systems that temporarily accommodate people without permanent housing. They may also shape the way workers or policies treat their homeless clients, distorting what should be a supportive, straightforward path from shelters or programs to permanent homes.

    Shelters in the US typically ban substance use and drug test residents. There may not even be clarity over what constitutes an infraction. Cherrie, who asked that her last name not be used, lived for a year-and-a-half in her car with her pre-teen children and husband. She told Filter that the family was kicked out of their Tacoma, Washington shelter when she tested positive for kratom. She was using the legal herbal painkiller to manage chronic pain from the accident and disability that contributed to her family’s lack of housing in the first place.

    In more conservative states such as Texas, where Mary Duffy is homeless, drug testing—like attendance at religious classes—can be a way of earning privileges in massive, prison-like shelters. These include the Bridge Homeless Recovery Center in Dallas—where a female resident was raped in the bathroom, Duffy said, on the first day she attended—and Haven for Hope, where she didn’t sleep due to gunshots and fear during the two nights she spent there.

    But even in less fundamentalist-Christian contexts, both shelters and the supportive housing they lead to in a Housing First model heavily pathologize homelessness, treating the condition of not having a home as a sort of chronic illness. We see this in programs’ languagethe chronically homeless” or “the very difficult to houseand in the persistent conflation of homelessness, which can both cause and in some cases result from mental illness, with mental illness, disability and addiction in themselves.

    “We keep saying we need more supportive housing. It reinforces that narrative that people are homeless because they are different.”

    Calls to fund Housing First responses to homelessness often focus on supportive housing, resulting in funding for a small number of homes that are expensive due to the supports that come with them, rather than a large number of decent, affordable, accessible ones that might prevent people from acquiring the trauma, addiction or mental illness that ultimately make those supports necessary.

    “We keep saying we need more supportive housing,” said Greg Cook of Toronto’s Sanctuary. “It reinforces that narrative that people are homeless because they are different, because they have mental illness, because they use drugs … It’s a neoliberal narrative that people’s inability to get a job or to get housing is an individual failing. It reinforces the idea that it’s people’s fault they’re in a tent in a park.”

    Many people who have lived on the streets or in often-violent shelters for years may well require ongoing mental health supports or substance use disorder treatment. But it is just as false to assume that homeless people are damaged or ill as it is to assume that drug use caused them to become homeless.

    “I need housing, affordable to me even if I have no income, and nothing else,” Homeless New Yorker, the pseudonym of a man who blogs about his experiences in the Big Apple, told Filter. “As to that, silence. I resent the assumption that I’m homeless because something is wrong with me, and the failure to take proper care of people like myself.”

     

    Getting to the Top of the List

    The lack of spaces available means that only the most “serious” cases may have a chance at housing. Without living literally on the street or fitting into a particular category of needs, a person without a home may not be able to qualify for increasingly limited programs. In the US, the fact that federal funding for homelessness services flows to different states based on unreliable, volunteer-conducted tallies of people actually in the streets at a given point in time doesn’t help.

    The criteria for gaining access to a space may be mysterious or arbitrary, sparking rumors of favoritism, corruption or the need to demonstrate trauma in order to be allotted a home.

    “Right now, it’s really upsetting the way you have to perform disability to get into housing options,” Philadelphia housing and drug-user rights advocate Sterling Johnson told Filter. “Housing First is not a solution. It’s a program that medicalizes you, that says you need this sort of support … it does not create freedom. They don’t need a program that controls their money. You do not need somebody babysitting you all your life. It’s not about throwing them off a cliff, either … Housing should be cheaper.”

    “There’s an awful lot of corruption. We depend on those people for everything.”

    Scarcity of housing options and lack of transparency about how people make it to the front of the years-long line can breed dangerous power dynamics. “There’s an awful lot of corruption,” said Mary Duffy. “I know a few women who’ve got into housing because they’ve slept with whoever. I know of men who’ve got into housing because they know where to get the right drugs … We depend on these people [housing workers or shelter operators] for everything.”

    Duffy, who spoke to me from a friend’s house where she was staying for a few days of respite, feared that by the following week she would be forced to stay, once again, at Haven for Hope.

    Cherise Myers, who has been homeless in various parts of California since her husband walked out in 2016, told Filter that she, like Duffy, has been in programs that purport to lead to housing almost constantly. Supposed “housing pipeline” shelters have often exposed her to horrific living conditions and abuse, forcing her to move from place to place, and at one point to leave the shelters to live in a tent. What they have not done is provided her with a home.

    “As far as permanent housing with a fresh new start, that does not happen,” she said. “Once in a blue moon. No one I know has housing yet. Not one person does. Costa Mesa says no money. My friends in Santa Ana. Not one person has received housing.”

    But Cherrie in Washington’s story has taken a happier turn, thanks to sheer luck in finally coming upon a sympathetic housing worker after many bad past interactions with caseworkers. “While we were camping, I tried over and over again to get the bravery to call this different caseworker,” she said. “I didn’t want the other worker to retaliate or this worker to treat me the way the other one did. I knew that they got their rapid rehousing funding in July [of 2019], and here it is August and I can’t figure out how to talk to her.”

    After more than a year’s wait, her family was approved for Rapid Rehousing, a program that includes rent subsidy to get started in a decent apartment, works closely with the landlord and supports her family with their employment and wellbeing goals.

    Moving up on the long waiting list for the program or for an associated shelter requires high scores on a questionnaire. “Questions would include: Chronic homelessness? Past drug abuse? Current drug abuse?” Cherrie recalled. “Has anyone experienced domestic violence? Illness? Education? I don’t even recall all of the questions, and I have been through the process at least four times.”

    Cherrie’s now-teenaged children are still struggling as they readjust to being housed, she said. In some ways, they miss the closeness the family felt when living in their car, which the family chose to do following traumatizing shelter experiences. But stability and genuine support should allow them to get on with their lives now. This is exactly what a good Housing First program excels at providing.

     

    Why Isn’t Housing a Collective Good?

    There is nothing especially disordered or unusual about the different homeless or formerly homeless people I interviewed for this article. Various betrayals, bits of bad luck, relationship break-ups and medical diagnoses resulted in the initial loss of housing. But a sheer lack of affordable housing was the fundamental cause in every case.

    By attributing lack of a house to individual differences, we blame people for structural and societal problems. In the process, we deflect attention from the true causes of homelessness—legislation and policy that, during the same time-frame in which Housing First has developed, have turned housing into a profit-making asset. And in so doing, we overlook the correct “treatment” for homelessness.

    Despite years of a sharply accelerating affordable housing crisis in Toronto, it took COVID-19 for the city to begin offering up vacant hotel rooms in order to reduce shelter numbers and allow for physical distancingand in an attempt to get rid of the too-visible-to-ignore encampments that have multiplied as people seek to escape overcrowded shelters.

    Actually, it didn’t take COVID-19. Rather, it took a lawsuit (and, it seems, may take another one). And that’s just for temporary housing. And yet, according to the City’s latest housing blueprint, HousingTO: 2020-2030 Action Plan:

    A Housing First approach has been a core component of Toronto’s service system for over 10 years. The commitment to Housing First focuses on helping people to find permanent housing as quickly as possible, with the supports they need to maintain it. 

    Michael Eschbach has lived in shelters in Toronto—including the one where he contracted COVID-19 after publicly decrying crowded conditions to no avail—for years. Now released from quarantine in the hotel where COVID-19-positive residents were isolated, he continues to live in a hotel near the airport.

    “Soon I learned about the gravy train. How homelessness is an industry.”

    Eschbach has a housing worker, who has so far been unable to find him a home. Like his peers south of the border, he noted the apparent importance of tallies of homeless people in securing scarce funding, and the apparent lack of interest in what ultimately happens to him as he lives a surreal life in a lonely hotel, far from downtown city services or anything like a community.

    “The housing worker just needed statistics, but didn’t care about the people,” he told Filter. “Soon I learned about the gravy train. How homelessness is an industry. Employing many to fill their pockets but not doing anything to help the homeless.”

    Unlike most of the US, New York City has a “right to shelter” law that guarantees a bedhowever inadequateto everyone who needs one. This has resulted in the city expensively renting hotel rooms that operate with the same strict, paternalistic rules as shelters to accommodate shelter overfloweven though permanent, unrestricted housing would be cheaper to build and maintain.

    Surely it is time for municipalities and regions to think bigger. So long as multilateral agreements and local legislation privilege developer and investor profits in housingover the rights of people to afford to live on a full-time minimum wage salary or on disability, or the rights of people to continue to live in the neighbourhoods in which they grew upHousing First can’t possibly operate as it is intended to.

    A true right to housing, as Housing First has it, is a right that is not dependent on how wealthy or “deserving” you are.

    That’s why housing and anti-poverty advocates increasingly find themselves supporting people living in encampments who reject shelters as inadequate or dangerous, creating community land trusts, or calling for expropriation of vacant properties before they can be sold to developers.

    As pandemic-related unemployment threatens to usher in the greatest wave of evictions and new homelessness North America has ever seen, perhaps it is time to consider a legally protected, or even constitutional, right to housing, and to begin tough work at each level—from city or county by-laws to international agreements on investment—to dismantle the rules that have made housing a game for wealthy speculators rather than a basic need.

    A true right to housing, as Housing First has it, is a right that is not dependent on how wealthy or “deserving” you are, on how much you pray, or on what substances are in your body. It’s a right to a home, period—not a cot or a mat on the floor, with maybe a roof for good behavior. A home.

     


     

    This article is the third in a three-part series of reports by Carlyn Zwarenstein about homelessness and its intersections with drug policy. The first of the series was “The Mischaracterized Relationship Between Drug Use and Homelessness.” The second was “The Pandemic Accelerates the Rise⁠—and Criminalization⁠—of Tent Cities.”

     

    Photograph by Ponderosa Templeton via Wikimedia Commons/Creative Commons 4.0

    • Carlyn Zwarenstein

      Carlyn is a freelance journalist based in Toronto. She writes about pain, struggle, injustice, drugs, exile, suffering—and how to make it better. Her work has appeared in publications including the Washington Post, the Guardian, the Globe and Mail and many others. Her memoir, Opium Eater: The New Confessions, was a Globe and Mail Best 100 book of 2016. An expanded version, incorporating journalism about substance use, pain, harm reduction and what people need to be well, will be published in 2021.

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