Housing First and the Research and Practice Relationship in Advancing a Field

Print Share on LinkedIn More
“BOOK 7 #3” BY HEATHER GOODWIND / WWW.HEATHERGOODWIND

“BOOK 7 #3” BY HEATHER GOODWIND / WWW.HEATHERGOODWIND.COM

 

Editors’ note: Stephen Gaetz, a professor in York University’s faculty of Education, director of the Canadian Observatory on Homelessness and of the Homeless Hub, and president of Raising the Roof, is at the forefront globally of research on homelessness and mobilization of that research to effect change at the level of public policy. His most recent publications are A Safe and Decent Place to Live: Towards a Housing First Framework for Youth and Coming of Age: Reimagining the Response to Youth Homelessness in Canada (both 2014).

Pathways to Housing was formed in 1992 under the principles of the “Housing First” approach, innovated by founder Sam Tsemberis, at the time a professor of psychiatry at New York University, whose work around solving chronic homelessness began in New York in the early nineties and since then has become a model that is replicated globally. The Housing First model is based on a core set of principles: (1) Move people into housing directly from streets and shelters without preconditions of treatment acceptance or compliance; (2) The provider is obligated to bring robust support services to the housing. These services are predicated on assertive engagement, not coercion; (3) Continued tenancy is not dependent on participation in services; (4) Units [are] targeted to most disabled and vulnerable homeless members of the community; (5) Embraces harm-reduction approach to addictions rather than mandating abstinence. At the same time, the provider must be prepared to support resident commitment to recovery; (6) Residents must have leases and tenant protections under the law; (7) Can be implemented as either a project-based or scattered-site model.1

While there are critics who argue that the model rewards bad behavior (housing is provided for addicts without the usual preconditions demanded by other programs, such as, Kick the addiction first, then you get a home) the radically simple approach has, according to advocates, been incredibly effective with those who are most chronically homeless.

This article is from NPQ’s fall 2015 edition, “Making Things Work: Considerations in Nonprofit Strategy.”


Stephen Gaetz calls himself an engaged scholar, which means that he sees himself as an agent for change, having an impact on both policy and practice. Gaetz is well known for his work in Canada on Housing First, the homelessness program that has proven itself to be extraordinarily effective with—predominantly—single homeless men in the United States, Europe, and Canada. His work focuses less on the level of outcomes and more on looking at the processes of applying the model in various communities—or, as he puts it, “How you get from the concepts to the actual implementation, and what happens in between.”

Gaetz has embedded himself in the field, doing a lot of collaborative work with communities, national and regional organizations, and all levels of government. For instance, the Canadian Observatory on Homelessness is currently working with the At Home/Chez Soi team (the world’s largest research project on Housing First) to develop evidence-based assessment tools for communities engaged in the Housing First approach. In an area where private consultants’ products dominate, the goal is to connect researchers with the users of research in the nonprofit sector and in government in order to help provide communities with options that are reliable and evidence based. So, as he summed it up, “like the applied side of the research across Canada. That’s it.”

But that is a lot. Getting an effective program proven, recognized, replicated properly, and then written into policy in such a way that funding becomes available is no small feat. “There were clearly Housing First–like programs in existence before it became a popular concept,” says Gaetz, “but between Pathways in New York and then some work in LA in the ’90s, it started to get traction and a name. The good news is that someone like Sam Tsemberis [the psychiatrist credited with firmly establishing the concept] thinks very conceptually, so the model was not simply a description of the clinical side of the work but—perhaps even more important—laid out the key core principles that underlie the work.”

In addition, the effort to establish an evidence base for the work started early. Gaetz described the attention to research as key to the program, because “the reality is that policy and practice aren’t always driven by evidence. So, Housing First is one of the models I think we can legitimately call a ‘best practice’ now, because over the years the evidence has accumulated across sites and involved different types of research.”

But according to Gaetz, being a good idea that is well proven and has effective spokespeople is not enough. “It also aligned with a number of other things going on in the early part of the turn of the century. You had a convergence of things happening politically that aligned with the model. You had this evidence base for a very significant conceptual paradigm shift in how to respond to homelessness. And you had the ten-year plan idea emerge. These began to be supported by the nonprofit advocacy sector, which had some effective spokespeople—the National Alliance to End Homelessness taking the lead—and then also at the government level through the United States Interagency Council on Homelessness. These thought leaders were successful in conveying to communities and local government that we can and must do things differently.

“And this might sound odd coming from me,” Gaetz continued, “but style is important. Can you grab and keep an audience? It’s funny, but in our sector we always say, Ohhhh, tsk-tsk, too showy! But it’s important, and that is something that I’ve had to learn.”

Presentation is important, says Gaetz, because “even if people hate the present, they tend to hate change more. You have to grab people. So, you have people, you have the idea, you had the conceptual shift that was tied to ten-year plans, you had support within government and outside, you had infrastructure in place to spread the ideas—and then come the funders in force.”

But that certainly was not a time to rest, because that convergence point that advocates long for carries its own set of problems. “I think it’s important to realize that when something becomes well known and popular—when it becomes official policy and something funders want to do—that’s a good thing, but it’s also dangerous, because communities may feel that they need to implement the idea but may do it very poorly because they do not understand or care about the design.”

And, as with every such policy, there are unintended consequences that should be—but often are not—watched closely. Gaetz believes that in the case of Housing First, the consequence of singularly prioritizing chronically homeless people with high-acuity mental health and addiction issues, while a laudable goal, also resulted in not sufficiently attending to the whole array of issues fueling the problem—in other words, prevention. “To me, this selectiveness comes from the politics of scarcity in the United States—you know, we only have this much money—and I think that the consequences of that are very negative, and I’m wary of when we say we have to do this first. And the metaphor that gets used—and gets used up here [in Canada], too—is that it’s like an emergency room: we triage and prioritize people who are close to dying. But you would never, ever build a whole healthcare system around what happens in the emergency room.”

And the metaphor, he says, is false, in that it limits the response to homelessness to one priority group, thus excluding much-needed focus on other populations. Housing First has primarily been proven successful with single adult men, “but how do we deal with homelessness among adult women fleeing violence, who are often not necessarily visible because of safety issues but are nonetheless important?,” he asks. “How do we deal with youth who are maybe too young to be considered chronically homeless? It’s hard to be homeless for twenty years when you’re sixteen! So, that kind of thing. What I’m saying is, we need a ‘solutions to homelessness 2.0’ that still keeps Housing First central, that recognizes the importance of prioritizing chronically homeless people—but as one priority—and that also focuses on the needs of other subpopulations and works on addressing the flow of people into homelessness. Because, in a way, we’ve talked ourselves into a trap, I think, by overpromising that if we do ten-year plans—if we simply prioritize chronically homeless people—we will solve homelessness.”

You need to do three things to address homelessness, says Gaetz: “You’ve got to prevent it from happening in the first place, number one. You’re going to need a crisis response (because no matter how good your prevention is, bad things will happen), number two. And, number three, you’ve got to move people out of homelessness with the supports that they need. And for the longest time, we were stuck on that middle part. That’s where investment is, and I would argue it’s still in many ways largely there.”

Asked about the rather phenomenal volume of research associated with Housing First as compared with other approaches and interventions, Gaetz replied that the historical lack of a strong link between research, policy, and practice in the homelessness sector may in part be due to a lack of interest among funders but may also reflect a kind of anti-intellectualism about the role of research in decision making. “When I worked in the sector, there were always people who said, ‘We don’t need research—we know what the problem is, we know what the solution is.’ And I always tell people we’re generally at least partially wrong on all three of those. But maybe the reason that Housing First has been so researched is very directly because it emerged out of a mental health and addictions space, where there are not only substantial funding differences but also an inherent interest in research. If Sam Tsemberis had been a social worker in Idaho doing Housing First, things may not have evolved in the same way—but he’s a researcher. My point is, the intervention emerged out of the mental health sector, not the social work sector, even though there are strong social work components. And again, most of the homelessness work, if up to social workers, would mostly be situated not in that space but in a more social work/charitable model context.”

But some of the research about the model that received the highest profile was on cost savings, meaning the idea that if formerly chronically homeless people were off the street and had resources to pull from, they would pull less from expensive crisis-service budgets. “I think it’s what we would call ‘symbolic’ or ‘strategic’ use of research. For some decision makers, that’s what they want to listen to. And rhetorically, what a brilliant (and true) point to be able to make. Because the ‘something different’ that we are asking you to do may be counterintuitive, but it works. Not only does it work, it saves money.”

Of course, acknowledges Gaetz—understanding the complexity of how in-government cost offsets really work—this doesn’t mean that when you house somebody and they use less of or become less involved with the legal system, or use health services less, the government then reduces its health budget or its corrections budget. But it does mean that those institutions can do different things.

“A lot of people I know will complain that you can’t reduce homelessness to a dollars and cents thing, but my argument is, You know what? In your arsenal of tools, use whatever works and is really good. And the At Home/Chez Soi project in Canada has, I think, done the best work on that whole issue of cost offsets that’s ever been done—the most sophisticated work in terms of service utilization prior to being housed and after. And the evidence is there—particularly for that very complex group of people that were served by Housing First. That’s actually where most of the savings accrue, so it’s been good. It’s been strategic, but that’s a good use of research. And we shouldn’t be afraid of that.”

This style of engaged and formative research is all about creating impact, says Gaetz, and simply writing an article that three people read is not that. “You want policy-makers, you want to help practitioners and the public, and as researchers we’re not trained to do that. You want those people to take on and learn from the research and do something. So, yes, my role is to help figure out what works, for whom it works, how it works—and figure out how to communicate that effectively to the people who need to know.

“But convincing people to pay attention is insufficient. We need to keep testing the model and expanding the view. We need to understand how it works for different subpopulations, because if you’re in education or healthcare, you’d be a fool today not to talk about diversity and the need to make sure your response addresses the needs of different groups of people. Some proponents of Housing First assume that those kinds of issues of difference disappear, and really it’s all about individuals.

“In Canada, the issue would be around Aboriginal people and the history—what we’ve done to that population and thus how we’ve alienated them from service use. How do we make this or another approach work in that context? How do we make it work with families? How do we make it work with young people leaving care? The point is, Housing First is based on solid principles and theoretically should work for anyone. We just need to adapt it to meet the needs of different population groups.”

Gaetz returns again and again to the importance of the principles of Housing First when implementing and researching the model. “Educating people about Housing First is a huge challenge, because you think it’s straightforward: read this document, watch this film by Sam Tsemberis, read this paper, read this report. But in fact, people may or may not do that, and the misunderstandings about what it is, even for those who buy into it, is profound. The principles can bring you back to basics quickly. So that whole piece around fidelity to the model accompanied by necessary technical support is really key to its success. So we have to be mindful of that. I think with any model it’s not enough to have the good idea, it’s not enough to write it down; that won’t ensure good implementation. I think that, as I said earlier, when Tsemberis first declared the core principles, that was a gift. Of course, they can be modified and reshaped, but they are a central reference point. That was very smart, I think, because, as I say, you have to be really careful when funders and policy drive an approach. I like that that happens, but one just has to be careful, because things can go awry.”

Note

  1. Housing First core principles as outlined by DESC in Why Housing First?