1.2. The History of Housing First

Housing First was developed by Dr. Sam Tsemberis, at Pathways to Housing in New York, in the early 1990s ((Tsemberis, S.J. (2010) Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction Minneapolis: Hazelden.)). Housing First was originally developed to help people with mental health problems who were living on the streets; many of whom experienced frequent stays in psychiatric hospitals. The target populations entering Housing First later grew to include people making long stays in homelessness shelters and those at risk of homelessness who were discharged from psychiatric hospitals, or released from prison. With some modification to the support services, Housing First services are now also used with families and young people who are homeless in North America.

Before Housing First, permanent housing with support was only offered to homeless people in North America after they had graduated from a series of steps that began with treatment and sobriety. Each step on this ‘staircase’ was designed to prepare someone for living independently in their own home. When all the steps were complete, a formerly homeless person with mental health problems was meant to be ‘housing ready’ because they had been ‘trained’ to live independently. These types of services are sometimes called ‘staircase’, ‘linear residential treatment’ or ‘treatment-led approaches’.

These ‘staircase’ services and the ‘housing readiness’ culture had originally arisen from practice in North American psychiatric hospitals, where individuals with a diagnosis of severe mental illness were initially considered incapable of functioning in all areas of life and needed around-the-clock supervision and support. By the 1980s, North American mental health professionals were raising serious questions about the effectiveness of services based on these assumptions about severe mental illness ((Ridgway, P. and Zipple, A. M. (1990) The paradigm shift in residential services: From the linear continuum to supported housing approaches. Psychosocial Rehabilitation Journal 13, 11-31.)). However, a staircase approach became firmly established as the model for helping homeless people with high needs in North America.

The staircase approach for homeless people had three goals:

• Training people to live in their own homes after being on the streets or in and out of hospitals.
• Making sure someone was receiving treatment and medication for any ongoing mental health problems.
• Making sure someone was not involved in behaviour that might put their health, well-being and housing stability at risk, particularly that they were not making use of drugs and alcohol (sobriety).

During the 1990s, it started to become clear that staircase services for individuals with psychiatric diagnoses, especially those with co-occurring addiction problems, were not always working very effectively ((Ridgway, P. and Zipple , A. M. (1990) The paradigm shift in residential services: From the linear continuum to supported housing approaches Psychosocial Rehabilitation Journal 13, 11-31; Carling, P.J. (1990) Major Mental Illness, Housing, and Supports: The promise of community integration American Psychologist 45, 8, 969-975.)). There were three main problems:

• Service users became ‘stuck’ in staircase services, because they could not always manage to complete all the tasks necessary to move between one step and the next.
• Service users were often evicted from temporary and permanent housing because of strict rules, such as requirements for total abstinence from drugs and alcohol and being required to participate in psychiatric treatment.
• There were worries about whether staircase services were setting unattainable standards in the requirements they placed on people, i.e. service users were expected to behave more correctly than other people; they were required to be a ‘perfect’ citizen, rather than an ordinary citizen.

North American ‘supported housing’ services, developed as an alternative to staircase services, had a different approach. Former psychiatric patients were immediately, or very quickly, given ordinary housing in ordinary communities and received flexible help and treatment from mobile support teams, within a framework where the service user had a lot of choice and control. Support was provided for as long as was needed.

‘Supported housing’ services in North America did not require abstinence from drugs or alcohol, and they did not expect full engagement with treatment as a condition for being housed. Giving former psychiatric patients far more choice about how they lived their lives, while encouraging positive changes and providing help when it was asked for, was found to be more effective than a staircase approach. This supported housing model was the basis for Housing First ((Tsemberis, S. (2010) Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction Minnesota: Hazelden.)).

However, as homelessness began to increase, services for homeless people often continued to use the stairway model, because that was still consistent with the predominant mental health services model in the USA. As most of those who were on the streets – the visibly homeless – were thought to have very high rates of severe mental illness, it seemed reasonable to use the traditional mental health services approach that had often been used by psychiatric hospitals. Most homelessness services therefore followed the staircase model. In Europe too, homelessness services had been designed according to a staircase approach, which saw housing as the end goal rather than as the first step in ending homelessness.

Research on staircase homelessness services reported similar problems to those identified in staircase mental health services ((Sahlin, I. (2005) The Staircase of Transition: Survival through Failure Innovation: The European Journal of Social Science Research, 18(2), 115-136. Sahlin, I. and Busch-Geertsema, V (2005) The Role of Hostels and Temporary Accommodation. http://housingfirstguide. eu/website/wp-content/uploads/2016/03/The-role-of-Hostels-And-Temporary-Accomodation-ejh_vol1_ article3.pdf
Pleace, N. (2008) Effective Services for Substance Misuse and Homelessness in Scotland: Evidence from an International Review Edinburgh: Scottish Government – http://www.gov.scot/Resource/Doc/233172/0063910.pdf)). In particular:

• Homeless people became ‘stuck’, unable to complete the steps that they were expected to follow to be rehoused.
• Staircase services were abandoned by homeless people who did not like or could not follow the strict rules.
• There were concerns about the ethics of some staircase services – particularly a tendency to view homelessness as the result of someone’s character flaws – with homeless people being blamed for causing their own homelessness.
• Staircase services could be harsh environments for homeless people.
• Costs were high, but the effectiveness of staircase services was often limited.

Building on the supported housing model, Housing First, as developed by Dr. Sam Tsemberis in New York, was focused on homeless people with a severe mental illness ((Tsemberis, S. (2010) ‘Housing First: Ending Homelessness, Promoting Recovery and Reducing Costs’ in I. Gould Ellen and B. O’Flaherty (eds) How to House the Homeless Russell Sage Foundation: New York.)). Housing was provided ‘first’ rather than, as in the staircase model, ‘last’. Housing First offered rapid access to a settled home in the community, combined with mobile support services that visited people in their own homes. There was no requirement to stop drinking or using drugs and no requirement to accept treatment in return for housing. Housing was not removed from someone if their drug or alcohol use did not stop, or if they refused to comply with treatment. If a person’s behaviour or support needs resulted in a loss of housing, Housing First would help them find another place to live and then continue to support them for as long as was needed.

Rather than being required to accept treatment or complete a series of ‘steps’ to access housing, someone in a Housing First service leaps over the steps and goes straight into housing. Mobile support is then provided to help Housing First service users to sustain their housing and promote their health and well-being and social integration, within a framework that gives service users a high degree of choice and control (Figure 1).

In the late 1990s, pioneering American social research by Dennis P. Culhane and colleagues showed there was a small group of people with very high needs, who made long-term and repeated use of homelessness services, yet whose homelessness was never resolved((Kuhn, R. and D.P. Culhane. “Applying Cluster Analysis to Test a Typology of Homelessness by Pattern of Shelter Utilization: Results from the Analysis of Administrative Data” Departmental Papers (SPP) (1998). Available at: http://works.bepress. com/dennis_culhane/3)). Staircase services were found not to be performing well in ending this long-term (“chronic” and “episodic”) homelessness((Pleace, N. (2008) Effective Services for Substance Misuse and Homelessness in Scotland: Evidence from an International Review Edinburgh: Scottish Government – http://www.gov.scot/Resource/Doc/233172/0063910.pdf)), which was being found to be very damaging to the health and well-being of the people experiencing it((Culhane, D.P, Metraux, S., Byrne, T., Stino, M. and Bainbridge, J.”The Aging of Contemporary Homelessness” Contexts, in press (2013). Available at: http://works.bepress.com/dennis_culhane/119)). Housing First, which research showed had been successful in New York, could, in contrast, end long-term homelessness at a much higher rate than staircase services((Tsemberis, S. (2010) ‘Housing First: Ending Homelessness, Promoting Recovery and Reducing Costs’ in I. Gould Ellen and B. O’Flaherty (eds) How to House the Homeless Russell Sage Foundation: New York; Padgett, D.K.; Heywood, B.F. and Tsemberis, S.J. (2015) Housing First: Ending Homelessness, Transforming Systems and Changing Lives Oxford: Oxford University Press.)). The systematic use of comparative research, demonstrating Housing First in comparison with other homelessness services, encouraged wider use of Housing First throughout the USA and attracted attention from the Federal government.

Importantly, there was also an economic case for Housing First. This case centred on the relatively high cost of frequent hospitalisation and incarceration associated with long-term homelessness, i.e. long-term homeless people often made frequent use of emergency medical services, had high rates of contact with mental health services and could often have contact with the criminal justice system. As they did not resolve long-term homelessness in many cases, staircase programmes started to be seen as not cost-efficient, especially because the staircase services themselves were also relatively expensive.

Research was showing that Housing First could potentially deliver significantly better results, for a lower level of spending, than staircase services((http://www.york.ac.uk/media/chp/documents/2008/substancemisuse.pdf)). Comparatively, Housing First cost significantly less than other services. Figures from Pathways to Housing show programme costs of $57 per night, compared to $77 for a place in a shelter (approximately €52 compared €70, 2012 figures)((Source: https://pathwaystohousing.org/housing-first-model)). In London, in 2013, one Housing First service was found to cost approximately £9,600 (€13,500) per person per year (excluding rent). This was compared to between £1,000 per year more for a shelter, or nearly £8,000 more for a place in a high-intensity staircase service (excluding rent). This represented an annual saving approximately equivalent to between €1,400 and €11,250 (2013 figures)((Pleace, N. and Bretherton, J. (2013) Camden Housing First: A ‘Housing First’ Experiment in London York: University of York https://www.york.ac.uk/media/chp/documents/2013/Camden%20Housing%20First%20Final%20Report%20NM2.pdf)).

It was also seen that by ending homelessness among people with very high support needs, Housing First could potentially save money for other services, such as psychiatric services, emergency medical services and the criminal justice system. This was because homeless people with very high support needs, if they were housed with the proper support, would not encounter these services as often as when they were homeless and could stop using them altogether((Culhane, D.P. (2008) The Cost of Homelessness: A Perspective from the United States European Journal of Homelessness 2.1, 97-114 – http://housingfirstguide.eu/website/wp-content/uploads/2016/03/The-cost-of-Homelessness-Aperspective-from-the-United-States.pdf Pleace, N.; Baptista, I..; Benjaminsen, L. and Busch-Geertsema, V.. (2013) The Costs of Homelessness in Europe: An Assessment of the Current Evidence Base Brussels: FEANTSA http://housingfirstguide.eu/website/wp-content/ uploads/2016/03/feantsa-studies_03_web-Cost-of-Homelessness.pdf)). Homeless people with high support needs could now be offered Housing First, which, as well as being very likely to end their homelessness, could be more cost effective than alternative homelessness services((Pleace, N. and Bretherton, J. (2013) The Case for Housing First in the European Union: A Critical Evaluation of Concerns about Effectiveness European Journal of Homelessness, 7(2), 21-41 vid supra)).