The Housing First approach at the heart of the At Home study was created by Dr. Sam Tsemberis in NYC back in the early 90s. He was born in Greece, immigrated to Montreal with his family when he was eight, and later moved to New York for graduate studies. In addition to his many other duties, he is now serving as a consultant to the At Home study. A charismatic and engaging personality, he agreed to speak with me over the phone a few weeks ago and I’ve excerpted a portion of that conversation.
I moved from Montreal to New York to be trained as a clinical psychologist in the late 1970s. A few years later, Reagan became president. He’s often credited as the president who introduced homelessness to the United States. That’s because he was a proponent of “trickle-down economics.” My image of that is of a large horse eating his fill and a few of his oats fall out of his bag to the ground where a bunch of hungry little birds compete for the droppings. It never really worked – not then and not today – the horses remain well fed and do very well and the birds are left hungry with little to eat.
I was doing my clinical internship at Bellevue Hospital in New York when the Reagan administration decided to cut funding for affordable housing. Suddenly things began to change for people who were living on fixed disability incomes. If they had to leave their apartment to go into the hospital for one reason or another – once they recovered and were discharged, they had no way to get back into housing. That’s because simultaneous with these cuts for affordable housing, the real estate boom was gaining momentum. People on fixed incomes who had been able to pay for a small apartment were suddenly priced out of the market. They began to drift, moving in with family members or staying on neighbour’s couches. Eventually they landed on the street.
An intolerable sight
I was walking to work at Bellevue and I was seeing all this unfold at the street level. I would see more and more people on the street with their stuff, sleeping under stairways, begging for food on the sidewalk. And then I started seeing people who had been inpatients at Bellevue – I would see them on the street still in their hospital pyjamas with their belongings in shopping bags.
I applied for a job to work with people who were homeless because it was something that was intolerable for me to see and I thought that maybe I could be of some service to them. I applied to work on a mobile crisis team that would drive around the city to work with people who were mentally ill and homeless to see if they needed treatment. The project was called “Project Help,” and its mission was to prevent homeless people who were mentally ill from dying on the street.
Most of the people we dealt with had neglected their health. For instance, they might have had cellulitis on a foot which was swollen out of its shoe, or a wound long ignored and turning gangrenous and the person might lose their leg. We would bring them to the hospital in the hope that they could be treated and then discharged to some reasonable housing accommodations. And that may have happened in some cases, but all too often we would see the same people back on the street. It became a cycle.
That was the beginning of my awareness that there was something terribly wrong with the system. The same people kept going in and out. A couple of us decided to get together and wrote a grant to the National Institute for Mental Health to try a different approach to homelessness. And this approach was called “psych-rehab” (psychiatric rehabilitation). Essentially, the idea was to shift the decision-making authority from the clinician to the client.
That was a fundamental shift and it opened up a whole new world of possibilities because according to traditional clinical training, you as the well-trained expert know what’s best for your client and your role is to get the client to follow your plan. This new approach – the client-driven approach – changes that equation dramatically. It puts the client in charge of the direction of the treatment and puts the healer in the position of helping to facilitate what the client wants to achieve.
When I was learning about how to implement psych rehab, I was told that even if clients didn’t want to be housed, we had to help them achieve their goal whatever it happened to be. I was taken aback by that because I thought we were going to be housing homeless people with a new approach, but I realized that it was more important to honour the principle of consumer choice and I agreed to give it a try.
Housing First begins
So, we changed the mission of the program from helping people who are homeless with psychiatric disabilities get housing to helping people who are homeless with psychiatric disabilities live successfully in the environment of their choice. It was an important shift because it meant that I was not bringing any hopes or expectations to the table, I was there to learn what people wanted.
It’s a dramatic power shift, it’s a dramatic motivational shift, and given that the approach we had been using wasn’t working, we were prepared to try something new. And in hindsight, it is this shift that has led to spectacularly effective results. What we discovered was that people wanted homes first and treatment later. We discovered that people with mental illness were able to make their own decisions and were much more capable than we thought possible.
I was unable to persuade the hospital system I was working for at the time to start a housing program using this new approach. So, in 1992 I left and started Pathways to Housing, which is a non-profit entity that provides housing for homeless people with mental illness.
Changing the game
Most agencies would select people who weren’t actively using – they didn’t want a tenant who was using crack, for instance. They would select those people they thought were going to make the best tenants. But we decided we were going to do the opposite; we were going to take exactly those people who didn’t meet the criteria of the other programs.
Once we started asking our clients what they really wanted, they began saying to us, “Listen, I don’t want to live in a shelter, I don’t want to live in some kind of congregate housing with other people with mental illness, I just need a place of my own.” So we resolved to house them in independent apartments. These were regular affordable apartments in buildings located throughout the city’s low priced rental neighbourhoods. People went literally overnight from being homeless on the streets to being a new tenant and a member of the community. The whole process ended up normalizing people’s lives. People loved having a place of their own – living in a place that was their home not in a housing program. You could say that, in a way, we ran a focus group – we asked participants what they wanted and then went ahead and constructed the program that the participants described.
People want to get better
Before we started this approach, every other program required people to get treatment and be clean and sober before they got housing. The assumption was housing would be an incentive for people to improve their lives. It doesn’t really work that way. What we found was just the opposite, if you go with what people want – housing – they become highly motivated to improve their lives so they can hold onto the place.
This gets to the fundamentals of human nature: people want to feel good, they want to get better, they want to get off the streets, they want to get a handle on their addictions or symptoms, they want to reconnect with family, and they want to get a job. It’s not like you have to create these incentives – the motivation is there. What you have to do is create the supports that will help people achieve these goals.
A few years ago my mother moved back to the village in Greece where I was born. The guy who lives across the street from her is, I would say, bipolar. He’s manic at times, he’s a big ouzo drinker, and when he’s cycling up he does some very odd things. One summer when I was visiting, he was burning the plastic rain gutters off his house because some uncle had installed them for him and he hates that uncle… He lives very marginally, working seasonally and doing odds and ends of work, but he’s very much a part of that village. When he’s doing something strange people know that he’ll calm down in a few days when he stops binging. When he calms down he returns to the kafenion and is welcomed by the other villagers. He’s woven into the fabric of the place. The cultural values that make that possible, the values of social inclusion, have had a strong influence on me and my work.