March 16, 2016

Housing first please

Housing First is an approach to stabilizing homeless people with mental health and/or substance abuse problems. The idea is to get the person into housing in the community, with no strings attached.

Once housed, all kinds of support are made available to the client, but engaging in treatment is not a requirement.

However, savings come into the picture with all the others.

Both in a research study in which Aubry participated in five Canadian cities—Edmonton, Montreal, Vancouver, Winnipeg, and Toronto—and in programs in New York and Europe, housing stability was significantly greater for those in the program than for those in a comparison group.  But don’t call out the victory band just yet.

There is a serious problem with the research in Aubry’s five cities, perhaps in New York and Europe as well. 

In an article published in the Canadian Journal of Psychiatry last November, Aubry and his colleagues note that New York City’s Pathways to Housing program, as part of it supports, “provided rental assistance.” 

In his presentation in February, Aubry indicated that part of the supports for Housing First clientele in the five cities is a top-up of their social assistance checks.  They would end up paying no more than 30% of their income on housing.  It is hardly unusual for housing costs, especially in a city like Toronto, to exceed even half of the monthly social assistance check.  The implication: the research is irremediably flawed.  The comparison group is not topped up.  So it’s back to the drawing board.  The researchers need to top up the comparison group as well.

This is not to suggest that Housing First is a bad idea, simply that the research provided does not establish what it purports to show. 

Does Aubry have better evidence?  Just in wild speculation, perhaps we might find that money makes the difference, that more adequate social assistance leads to less homelessness, even without added services.  It might be a good idea to see.

One objection to Housing First is that one size does not necessarily fit all.  Perhaps it is useful for some and not for others. 

Community integration is a positive objective, but it might not in all cases mean residential integration.  There are other living arrangements that fit some people.  For alcoholics, for instance, there are wet houses, where a person who is actively drinking, can stay.  Alternatively, there are dry houses for people trying to quit.  Some people with mental health problems have found a boarding house approach to be attractive.  In this model, meals are provided, and each resident has his own room with his padlock on the door.

Another consideration relates to the minority of people with mental health issues who are unable to handle their money.  That problem may lead to homelessness when it is time to pay the rent.  Some form of trusteeship would serve to enhance residential stability in such cases.

In the journal article, the authors begin with reference to the deinstitutionalization experience in the 1970’s. 

Mental hospital beds were closed and the mentally ill were tossed out.  At the time, the pledge was that the money for the beds would be reinvested in services in the community.  That was a promise never kept, and the mentally ill ended up on the street, in jail, and in hostels. 

We need to be certain that a Housing First approach does not end up being another money-saving effort that leaves people worse off.  We need to be certain that the services continue and even expand.

At the forum, those in attendance were also privileged to hear about an Irish experience with Housing First.  Dr. Ronni Greenwood, a psychologist at the University of Limerick, described her experience with such a program in Dublin.  As background, she spoke of an April 11, 2011 census of homelessness in Ireland.  There were 3,808 people who were homeless, 1,509 in Dublin.  Of those, 64 were living rough (e.g., on the street, in fields, in the woods, etc.), 59 in Dublin.

 The program began with four units.

Housing First faced other difficulties. 

The usual model provides the client with a choice of housing.  Here there was no choice.  While the goal was to promote permanence, there were evictions, and the problem was exacerbated by the fact that the landlord was a member of her committee.  As in Canada, rent was topped up.  Treatment was encouraged but not required.  Greenwood also complained about a lack of adequate 24/7 services and a shortage of nurses. 

It was even difficult to find clients willing to participate.