First Things First. The Housing First and Harm Reduction models in services for the homeless

Poverty and homelessness are receiving an increased amount of national attention lately as people finally realize that their stereotypes of what these issues “look like” are far off track. With the economy continuing to slide, more and more individuals and families are losing their jobs, their housing, their health, and their comfort. We are finally beginning to understand that anybody can find themselves in dire straits. But now what? What are the solutions? The United States homeless population was 636,017 in 2011. Social service providers across the nation offer food, clothing, job readiness training, crisis intervention, and a multitude of other options; however, it is impossible to take steps forward without having stability in housing.

Housing First  is a principle that considers housing a basic human right. One cannot attempt to tackle the complexities of mental disorders, substance use, and traumas when one is trying to figure out where s/he will sleep that night. Survival mode is simply that— surviving another day. Formatted job resumes and clean socks are a flash in the pan. Instead of herding individuals and families experiencing homelessness through the temporary and exhausting paths of emergency shelters and transitional housing, housing first places people directly from the streets into housing. There is no requirement to prove that you are ready to move on to the next level of being “less homeless.”

Permanent Supportive Housing (PSH)  outshines other models in developing sustainable opportunities for those affected by homelessness to rebuild their lives. PSH provides units and wrap-around supportive services without an artificial expiration date. Some may need less intensive services to get back on their feet and move to fair market rental housing; others may live in PSH their entire lives. These programs require that the resident have a documented disability, since PSH works to reach the most vulnerable populations in the homeless world. Residents usually pay 30% of their income for rent, which makes this not only affordable housing but a viable option for those who are on a fixed income (such as SSI or SSDI). The majority of the remaining expenses are subsidized through federal grants. It might be surprising that the George W. Bush  Administration provided a push to create federal policies that would end chronic homelessness over the course of ten years. The United States Integrated Council on Homelessness  and the Substance Abuse and Mental Health Services Administration  declared the Housing First philosophy as a “best practice” in eliminating homelessness in a proactive manner. I agree, and so do many others who work with this population.

Housing First has a low threshold for participation and observes the principles of the Harm Reduction  model. Harm Reduction is an approach that helps consumers to reduce the harm associated with risky activities by incorporating practical techniques and strategies. A participant identifies goals and desired outcomes while working with a case manager to explore ways to achieve these goals. It’s exactly what it sounds like: reducing harm. While it is most often associated with substance use (such as needle exchange programs), Harm Reduction encompasses a wide range of behaviors. Sex can be dangerous, which is why we use condoms and get tested for sexually transmitted infections. Driving can be dangerous, which is why we wear seatbelts and obey speed limits. When we don’t, there are consequences. Harm Reduction is not for or against behaviors— it simply acknowledges their presence and effects in society.

Harm Reduction housing has a very low threshold for participation. While many conventional shelters or housing have rigid intake processes focused on “screening out” residents, Harm Reduction and Housing First emphasize easier, direct access to resources. This switch from program-centric to peoplecentric means that agencies must challenge established rules and regulations that may have seemed inflexible. For example, many “dry” shelters (particularly faith-based) require sobriety upon entry. Some even go as far as to issue a breathalyzer at the front door. Harm Reduction seeks to understand the thought process and action steps needed to actually change a behavior.1  Sure, you’ve thought about quitting smoking to be healthier, but there is a reason that you bought another pack on your way to the train stop. While abstinence may be desirable, it is not a requirement. Relapse is a common, if not expected, occurrence. Besides, even if someone has been drinking earlier in the evening, why assume that this person will be disruptive to the program? It is a lazy practice and discriminates against those who arguably need services the most—who don’t fit into the nicely wrapped package of “easiest to deal with.” When this model is applied to supportive housing, it creates an environment where we can truly focus on individual progress. Workers and participants are seen as equals in partnership, which is a shift in traditional power dichotomies in the field. Of course, who could know your own life better than yourself? You know what is realistic. You know what has worked in the past. You know what triggers particular behaviors. A case manager is there to provide support, guidance, and overall encouragement. It is important to note that s/ he must take a nonjudgmental stance and celebrate small steps. This relationship cultivates self-efficacy and ultimately self-sufficiency— defining success not only in the individual, but also in the program. Outcomes can be measured in various ways. Housing retention is a major factor. The goal is to keep people housed, not to find ways to throw people out. It is a system of eviction prevention. There are services for counseling, financial management, and other engagement efforts to work through vulnerabilities. This creates progress toward stability, especially compared to the inconsistency and unpredictability of the streets. In addition, PSH is costeffective. For every 100 chronically homeless people (disabled individuals who have been continuously homeless for over one year or with at least four episodes of homelessness in the past three years) housed with intensive case management, almost $1 million is saved in public funds annually. This is money rescued from medical, health, legal, housing, and social service units. Emergency room visits, mental health clinics, residential detox, emergency shelter operations, and fees from the social justice system are more expensive than constructing, staffing and operating permanent supportive housing.

Chicago conducted an extensive four-year study to research the benefits of housing those who are homeless with problems other than mental illness, such as those with chronic illnesses. Over-populated West Side agencies were seeing repeated setbacks in behaviors and personal health due to the lack of stable housing. This sparked conversations among service providers about the problems of traditional methods and standards in service delivery. The Chicago Housing for Health Partnership (CHHP)  was an extensive project that examined 407 individuals diagnosed with heart problems, liver difficulties, and/or HIV/AIDS2 . CHHP worked with local hospitals and social service agencies to track those participating in the research program. After eighteen months, 60% of participants in housing saw health improvements— particularly HIV/AIDS patients. These outcomes, combined with the cost savings of supportive housing versus emergency services, were presented nationally as a new way to view homelessness in America.

Several social service agencies, housing organizations, landlords, and foundations practice Housing First and Harm Reduction in Chicago. Heartland Alliance’s Midwest Harm Reduction Institute  provides an opportunity for community providers to seek advice and share experiences with peers practicing (or interested in practicing) Harm Reduction in a monthly roundtable setting and annual conference. My participation with this group allowed me to become more firmly grounded in this practice and to more eloquently advocate for Housing First and Harm Reduction with agencies, local government, individuals, and my communities. I’ve learned that we must speak the language of the audience we are working to convince. Economic evidence is most convincing to those who work in government or in procuring funding for these programs. Evidence of resident progress and housing stability is most convincing to those who provide direct services to individuals in Housing First and Harm Reduction programs. Both are equally important in understanding the complex landscape of homelessness.

Deborah’s Place , a large organization providing housing and services for women experiencing homelessness, practices Housing First and Harm Reduction in buildings in Garfield Park , Lakeview, and Old Town . Staff members are trained to appropriately handle situations, such as procedures for finding alcohol in bed spaces or communicating with an aggressive individual. There are eventual consequences to repeated disruptions (such as establishing curfews), but Deborah’s Place staff collaborate with residents to understand the function of disruptive behavior and to better serve their more intensive needs. I have worked as a substitute program staff member on weekends at Deborah’s Place’s Teresa’s Interim Housing Program  for over a year and continue to deepen my practice in these philosophies.

But you have all of these drug addicts, alcoholics, prostitutes and heathens living under one roof! How can these attitudes of Housing First and Harm Reduction possibly be successful? You are just fostering rancid behaviors and letting them live for next to nothing! How is this actually helping solve homelessness in Chicago?

 

The chorus of disapproval is common every time I talk about what I do for a living (and what I would support even if I were not in the field). Before jumping to the thought that tax dollars are supporting drug dens, I ask you to think big. Bigger than your own personal life experience. It would be easier to set benchmarks and expectations if we were all given the same advantages in life. Sometimes we choose our situation, other times we are a victim of circumstance; however, you cannot possibly deny that some people need more help than others—especially in the third largest (and one of the most segregated and violent) cities in America. Don’t over simplify. It is a solution. And it is working. ◊

 

1. James O. Prochaska and Carlo C. DiClemente, “Transtheoretical therapy: Toward a more integrative model of change,” Psychotherapy: Theory, Research & Practice, Vol 19 (1982): 276-288.

2. Joe Barrett, “Homeless Study Looks at ‘Housing First,’” Wall Street Journal, March 6, 2008, www. aidschicago.org/pdf/2008/home_wall_street_ journal.pdf.