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Breaking free of homelessness

A disproportionate number of the chronically homeless are people with mental illness and substance use disorders. Sam Tsemberis, founder of Pathways to Housing First, argues that it doesn't need to be this way. His program's remarkable success rate-an estimated 85 percent of participants find homes and remain there-makes his case. In the following excerpt from Tsemberis's book Housing First, the author outlines key tenets of his program and how it works.

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Many researchers and program analysts have pointed out that there is potential for ethical problems in the linear residential treatment (LRT) model because there is an element of coercion when housing is offered only as a reward for participation in treatment.1 While such coercion is often justified on therapeutic, pragmatic, and moral grounds, does it lead to greater compliance with treatment? Most mental health experts argue that it does not. In an article summarizing the literature on this subject, Michael Allen concludes that coercion violates the therapeutic alliance, violates ethical principles of mental health practitioners, and "does not work as well as programs that take a ‘housing first' approach." 2

This is why the Pathways to Housing First (PHF) program was developed. We observed that there were a large number of clients who were either unable to gain admission to LRT programs or retain housing once they were admitted. Others--those who had been homeless for years and had psychiatric disabilities that interfered with their thinking and perceptions--never even applied to these treatment-first housing programs.

This subgroup among those who are homeless has been more recently called the "chronically homeless." Some LRT housing providers take the position that the reason these consumers remain homeless is a result of some personal failing or personality characteristic that makes them "treatment resistant" or "hard to house."

From the PHF perspective, the continued presence of the chronically homeless is evidence not of individual failures but of failings inherent in the LRT model of care.

Scattered-Site Housing

I never believed in my wildest dreams I'd find Pathways. They brought me to an apartment in the Bronx. I had such a beautiful apartment-just me-it was something really unbelievable. So I said to myself, ‘I'm gonna be a good citizen, and help people if I can.' [That was] 14 years ago, and I've gotten a lot better, but I can still do better.

-- Pathways to Housing First client

Pathways for Housing First (PHF) rents suitable, affordable, decent apartments from property owners in the community. Apartments are rented at fair market value and meet government housing quality standards. This housing model-known as "scattered site independent housing"-honors clients' preferences such as choosing apartments in neighborhoods with which they are familiar. The PHF program does not own any housing. Instead, either directly or through collaboration with another provider, PHF obtains affordable apartments and provides a rent subsidy on its clients' behalf. (Naturally, some housing and neighborhood choices are restricted by affordability of neighborhoods and units).

The program limits leases to no more than 20 percent of the units in any one building. (The percentage may be higher for suburban or rural clients living in small multi-family units.) This "scattered-site" feature of the housing model helps ensure that people with psychiatric disabilities are not all housed together in one building but are integrated into their communities. In this model, clients don't move into a ready-made unit of a housing program-they move into their own apartments in the neighborhood of their choice. Clients are quick to recognize and appreciate the enormous difference between these two approaches, and they become immediately invested in keeping the apartments and turning them into homes. They also become invested in themselves.

Enormous changes take place when clients move from being homeless to having a place of their own. People place a high value on having their own place and become highly motivated to keep it. Some people spontaneously begin to work on their sobriety and seek treatment as a way of improving their own well being, thereby increasing their chances for successful tenure. This positive outcome is worth emphasizing for PHF, especially given how determined traditional providers are about insisting on sobriety before housing.

Another remarkable outcome of this scattered-site model is its commitment to social inclusion. The other tenants in the building provide a normative context for neighborly behavior that helps PHF clients participate in community living in ways that, for some, had never before been available.

This model also allows rapid start-up and ease of relocation. Because the program's housing component consists of renting apartments available on the open rental market, there is no need for lengthy project planning and construction. PHF clients can quite literally go from being homeless on the streets one day to being housed and thinking about grocery shopping and paying the rent the next day. If clients have a difficult adjustment in their first apartment, they can easily and quickly be relocated to another one while maintaining the continuity and support of their off-site mobile treatment team through the transition.

1. Appelbaum, Paul S. M.D . ; Bonnie, Richard J., LL.B. ; Hyde, Pamela S., J.D. ; Monahan, John, Ph.D. ; Steadman, Henry J., Ph.D. & Swartz, Marvin S., M.D. (2001) Mandated Community Treatment: Beyond Outpatient Commitment. Psychiatric Services (52), 1198-1205
2. Alfred, Allan. (2003). The Past, Present and Future of Mental Health Law: A Therapeutic Jurisprudence Analysis. In Marilyn McMahon (ed.) Therapeutic Jurisprudence, (pp. 24-54) Leichhardt, NSW Australia: Federation Press

Excerpted from Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction. Hazelden, 2010.

 
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