A Housing First approach
Reprinted from "Housing" issue of Visions Journal, 2013, 8 (1), pp. 26-27
Most of us have a sense that many homeless people live with mental health challenges. It is also common knowledge that many street-involved people use drugs, perhaps in an attempt to cope with a mental illness or with the challenges of being without a home. Mental illness, drug use and homelessness are intermingled in a complex and muddled “chicken or the egg” relationship that is difficult to fully understand and explain.
One thing that is well understood, however, is that homelessness worsens mental illness and increases the harms of substance use by placing individuals in unsafe environments. People who are homeless are at greater risk of poor health and early death.1-4 They are often feared and stigmatized, and because of this, have a more difficult time accessing services that could help them. It is easy to see how having a safe and stable home can go a long way in helping people improve their health.
What is Housing First?
Until recently, the conventional approach to housing people who struggle with drug use has been to insist that they seek treatment for their drug use and demonstrate that they are “housing ready.” They were expected to be sober, stable and display basic living skills before they were placed in more permanent housing that they could call home.
People who relapsed into drug use faced the loss of their housing. After several so-called failures (relapses), they were deemed “hard to house.” Demoralized, they would give up or fall through the cracks and end up back on the street.
If a person with mental illness is otherwise being a good tenant, it would seem unfair to evict them for displaying behaviour related to that mental illness. So why would we evict a person struggling with substance use because they are using substances? That would be like a physician refusing to treat a person with diabetes because their insulin is not under control.
Fortunately, many housing services providers have come to the realization that the old approach isn’t working. They are using a new approach to housing, called Housing First, which was pioneered in New York City in the early 1990s.5-6
A Housing First approach sees housing as a fundamental human right that shouldn’t be denied to anyone, regardless of their mental health and/or substance use challenges. This approach strives to place people who are homeless, or at risk of homelessness, into a variety of secure housing options based on their individual and family circumstances and needs. The idea is that once people are housed, they can then be assisted to deal with their substance use and other challenges—at their own pace, if they choose to, and when they are ready. They are not required to be sober, to have mastered life skills or to accept treatment and other interventions and programs they may not be ready for. A team will work with them to assess which supports and services they may need.
Housing First programs have been shown to work to keep people with severe mental illness in stable homes, contribute to better health, reduce alcohol use, and reduce costs related to emergency room visits, police services and social services.5-14
Housing First is also showing promise in successfully assisting people with substance use challenges to maintain housing.
So how does Housing First work for people who use substances?
Harm reduction is a big part of Housing First. This approach recognizes that some people use drugs and assists them in reducing the harms related to drug use. These harms can be related to health, as in the transmission of diseases like hepatitis C or HIV, or overdoses. Other harms include stigma and discrimination, which lead to people being excluded from society. By meeting people “where they are at,” and treating them with dignity and compassion, service providers can assist them in finding solutions that work to improve and maintain both their health and their housing.
Many cities in Canada have adopted a Housing First approach as part of their plans to end homelessness, though are just beginning to clarify what this means in practice.
For Housing First to work, harm reduction measures have to be integrated into housing programs. So how do we integrate harm reduction measures into housing programs, and what do these measures look like?
A few of us at the Centre for Addictions Research of BC at the University of Victoria—Dr. Bernie Pauly, Dan Reist and myself—along with consultant Chuck Shactman, put our heads together to start answering these questions. We wrote a report for the Greater Victoria Coalition to End Homelessness (www.victoriahomelessness.ca). Our suggested approach involves the following four dimensions.
People with lived experience of mental illness, homelessness and substance use need to be involved in every aspect of developing and implementing policies and programs that affect them. We as a society can learn from people’s experiences, start breaking the stigma, and share power in decision-making with people who have historically been excluded from these decisions. Ideally, this approach will identify and result in a variety of specific programs and services that address the different needs of people from different backgrounds and life circumstances.
An adequate supply of affordable housing appropriate to a variety of needs has to be available. People need access to options such as permanent low-cost housing, rental subsidies, rent controls, co-operative housing, and public or social housing. Some housing can be offered in private market rental units, with normal occupancy agreements and rental subsidies, if needed. Some housing can be provided where support and harm reduction services are provided onsite. Additional supports by interdisciplinary teams, as well as harm reduction services, would be available in their community. The key consideration here is to give people the choice as to the type of housing that best suits them and the right to participate, or not participate, in any harm reduction, treatment or support services. The other aspect is that there has to be affordable housing that can accommodate the needs of a range of substance use. Some aggregate housing could be abstinence based for those who choose to abstain and don’t want to be in an environment where there is active drug use. This is part of the continuum of housing options that should be made available.
On-demand harm reduction services and supports must be provided, either onsite or in the community, for people who use drugs. These supports include access to safer drug use equipment and information (e.g., needle exchange, crack kits, supervised injection services), safe disposal of used equipment, managed alcohol programs, and treatment services when people ask for them. Use of these services is not a condition to maintain housing.
Communities have to build this approach into their existing housing system and organizational infrastructure. They would need to train staff on Housing First and harm reduction. They would need to provide public education on the Housing First approach. They would need to develop organizational policies related to harm reduction and substance use in the context of housing services. They would also need to develop information systems to monitor whether homelessness is being addressed through these Housing First initiatives. And communities need to work together in the spirit of caring for the most marginalized.
If you would like more details about this approach, see the Housing and Harm Reduction: A Policy Framework for Greater Victoria report at www.carbc.ca.
About the author
Lynne is a PhD candidate in the Social Dimensions of Health Program, Centre for Addictions Research of BC, at the University of Victoria. She is a National Programs Consultant with the Canadian AIDS Society and chairs the Canadian Drug Policy Coalition
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- Mental Health Commission of Canada. (2012). At Home/Chez Soi interm report. Retrieved from www.mentalhealthcommission.ca/SiteCollectionDocuments/AtHome-ChezSoi/AtHome_InterimReport_ENG.pdf
- Tsemberis, S., Kent, D. et al. (2012). Housing stability and recovery among chronically homeless persons with co-occurring disorders in Washington, DC. American Journal of Public Health, 102(1), 13-16.
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- Collins, S. E., Malone, D. K. et al. (2012). Project-based Housing First for chronically homeless individuals with alcohol problems: within-subjects analyses of 2-year alcohol trajectories. American Journal of Public Health, 102(3), 511-519.