04/30/2012 - Housing First: a movement goes mainstream

Last month, over 600 practitioners, policymakers, advocates, and consumers gathered together in New Orleans at an event called the ‘Housing First Partners Conference.’  The 2 ½ day event was the first national conference focused exclusively on the Housing First approach of providing people experiencing chronic homelessness with affordable rental housing linked to services immediately and without treatment preconditions.  Let not the significance of this event be missed.  It marks the moment of Housing First’s acceptance and establishment as the central approach for helping vulnerable men and women experiencing chronic homelessness permanently exit homelessness and regain health, hope, and dignity.  This was Housing First’s “coming out” party, appropriately set on the French Quarter’s famous Bourbon Street.

Think about how far Housing First has come.  Just four years ago, I asked Bill Hobson, Executive Director Seattle’s Downtown Emergency Service Center (DESC) and one of the masterminds behind the Housing First Partners Conference, to fly out to New York City to present to a room full of supportive housing providers about DESC’s work.  In particular, I wanted Bill to share DESC’s experience with the 1811 Eastlake project, a Housing First model that proactively sought out and successfully housed 75 of the most vulnerable and expensive users of emergency health (including crisis alcohol) services in the City of Seattle.  The audience’s questions reflect their reception to this model: “How do you get these people to pay rent?”  “How many run-ins with the police have you had?”  “Isn’t it irresponsible letting people drink themselves to death in your housing?” “What message does this project send to homeless people who’ve worked so hard to achieve sobriety and have earned their housing?”  And this was New York City, often known as one of the most forward-thinking when it comes to homelessness policy and practice.

I need not give a play-by-play of the exchange; anyone who knows Bill Hobson can imagine how he responded to these questions.  What is more interesting is how four years later, many of the same people and organizations who were in that room were now in New Orleans deeply engaged in dialogue and debate about Housing First.  But now the debate wasn’t about whether Housing First is the right approach to ending chronic homelessness, but rather about what are the best approaches within Housing First practice: scattered-site vs. single-site models, adherence to program fidelity vs. promoting innovation, balancing assertive engagement into services with maintaining a low threshold and voluntary approach, and so on.  So it goes, perhaps, with the maturing and mainstreaming of any movement. 

So now that the Housing First movement has gone mainstream, how do we avoid the same fate that has befallen so many other social movements and innovations, where the tendency arises to want to protect and preserve the approaches and practices we’ve worked so hard to establish, even at the expense of the original intent and ideas that led us to those practices in the first place?  Practices become convention, models become institutions, and our efforts lose that original spark of ingenuity and innovation that led to the transformative changes and impacts that inspired the movement.  We no longer challenge ourselves and one another to seek better solutions, or to seek better ways to respond to the expressed needs and interest of the vulnerable and heroic individuals we once saw as our customers. 

How can a movement that has gone mainstream retain the spirit of ingenuity and healthy disregard for convention that led to its birth?  How can we keep our models fresh and dynamic and avoid the complacency that will make our programs, models, and approaches rigid, stale, and unresponsive to the needs of the vulnerable men and women that are our key customers? I leave the Housing First movement with three pieces of advice:

  1. Keep our “outsider’s” view.  Remember that Housing First began as an “outsiders” movement, as a reaction to the established paradigm that viewed the solution to chronic homelessness as treatment-first, housing-later and assumed people with behavioral health issues could never maintain their own housing.  It was with the outsider’s view that more than 25 years ago, two Franciscan friars gave birth to the supportive housing movement by delivering services to people with mental illnesses and substance use issues in SROs on the Upper West Side of Manhattan.  Twenty years ago, it was with an outsider’s view that CSH’s founder, Julie Sandorf, stumbled upon these buildings and many others, decided that the nation needed an intermediary called CSH to bring this thing called “supportive housing” to scale and in every community where people with chronic health conditions experienced homelessness.  It was as an outsider that Pathways to Housing’s founder Dr. Sam Tsemberis decided that he no longer wanted to offer psychiatric treatment to people living on the streets with psychiatric disabilities, but instead offer them what they really wanted: an apartment.  And it was certainly with an outsider’s view that Bill Hobson and DESC decided to rehabiltate and develop buildings like the Morrison, the Lyon Building, Evans House, and 1811 Eastlake to give permanent homes to the most vulnerable people and highest utilizers of public services in Seattle.  As the newly christened “insiders” of a movement, we need to somehow remember to keep that “outsiders” lens.  Or as Jonah Lehrer says in his book Imagine: How Creativity Works, “We need to leave behind the safety of our expertise.”
  2. Stay true to our customers, not our models. Keeping the Housing First movement fresh and alive means recognizing that at its core, Housing First is not a model or a program at all.  Despite our bickering and nitpicking about housing configurations, approaches to case management, and all the acronyms and terms we invent, Housing First is first and foremost about being truly attentive and respectful of what people experiencing homelessness need and want.  It means being active and mindful listeners to our customers.  And what have our customers told us time and time again?  They want a home, a community of support, and the chance to live a self-determined and unconstrained life.  Housing—true housing—without strings or conditions, save for the typical responsibilities and obligations that come with tenancy.  And once they can use their own key to open the door to their own apartment, perhaps they’d like to reconnect with estranged family members, or take care of long-neglected medical conditions, or get a job.  Or achieve some other aspiration.  Or maybe just relax for the first time in decades.  Most of all, they want the chance to decide for themselves what dignity and independence means to themselves without institutions, programs, clinicians, judges, or anyone else deciding for them.
    Recognizing this, the challenge before us comes down to how we navigate and work through fragmented systems, categorical and “siloed” funding, complex and often competing government regulations to give vulnerable men and women the chance (and safety and stability) to decide for themselves.  To do so, we may need to develop certain housing configurations, explicate case management models, create new terms and acronyms, and yes, even develop fidelity toolkits, but all of this are just means to an end.  But we must not let the means get in the way of or become more important than our end. 
  3. Explore new frontiers. Remaining responsive to our customers may also mean venturing into new frontiers, seeking new ways to reach and offer affordable housing to those who are most vulnerable and for whom housing is least attainable. In the Housing First movement’s early days, reaching the most vulnerable simply meant not screening out people based on their presenting conditions like psychiatric disabilities, substance use, or lack of motivation to change and reducing their barriers to housing.  We then realized that reaching the most vulnerable meant we needed to prioritize for housing individuals who’ve been homeless the longest, and reaching into shelters and the streets to actively recruit individuals for housing.  Now we’re learning that the most vulnerable people experiencing homelessness—those with the most severe chronic health conditions and barriers to housing—may be those who may not be thought of as homeless at all: individuals who experience homelessness as a revolving door between institutions and crisis service settings like jails, prisons, hospitals, and treatment programs.  The new frontier for Housing First is to reach into those mainstream public services and offer supportive housing to individuals known to many but well-served by none and have those mainstream agencies make Housing First a routine part of their systems of response. In other words, “meeting people where they’re at” now becomes “finding and reaching people wherever and in whatever settings they’re at.”
    In New Orleans, I was thrilled to hear that these new frontiers were already being explored.  Communities like Seattle/King County (WA), Hennepin County (MN), and San Diego are implementing systems that use data to identify and outreach to individuals who were the most expensive users of jails and hospitals and prioritize them for supportive housing.  Sherriff’s departments and corrections systems, hospitals and Medicaid Departments, and even managed care companies are stepping up to contribute their resources to help pay for supportive housing. These efforts show that the mainstreamining of the Housing First movement can go even further, becoming integral parts of mainstream systems and using mainstream public resources and funding.

As the new “insiders,” we should celebrate how far we’ve come in convincing communities that housing is the key to success and the platform for health, hope and dignity for people experiencing chronic homelessness.  But let’s also remember that our work is far from finished.  We have years of philosophical baggage and misguided practice to overcome and many more communities to enlist.  Moreover, there still remain so many vulnerable men and women stuck on the tragic cycle of homelessness, institutionalization, declining health status, and victimization. There remain many more doors to be opened.  Long live Housing First.


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