Is Your (Housing) Partner Faithful?

Is the Housing First program in your community faithful to the principles of the theory?

This is a more important question than you might realize. After all, Housing First programs  have data going back at least 10 years which shows both incredible cost savings and better personal outcomes for the homeless individuals who participate. Housing First, which is just what it sounds like, emphasizing getting people in apartments rather than routing them through a continuum of care, is a win-win for everyone, but if your community does not stick to the original ideas, it won't experience all the benefits.

It is generally an uphill battle to get any housing program going in a community, and this one is a labor-intensive, fairly expensive model to implement. After all, when you are giving the most compromised people housing, many others will complain. But the most compromised people are the most expensive for the community, and show the greatest improvements once housed. However, I challenge you to explain this to a homeless person who is putting her all into self-sufficiency or a housed person working three jobs in a way that does not make them furious.

What I dimly remember from my statistics class is that good research means that you only change one factor at a time, so that you can prove that what you think is causing a positive change is in fact the thing that creates change. When you are providing real time services in a community to real people, though, it's hard to have a true research trial. In that case, according to the scholarly stuff, "fidelity may be simply defined as 'the adherence of actual treatment delivery to the protocol originally developed.'"

So what is the original protocol? And how do you judge adherence? Here are some research-based questions to ask your community's Housing First provider.

1) Are they working with the most compromised (i.e. the most resource consuming) individuals in the community?

It may be tempting for Housing First providers to choose the people that they think will be most successful. This "creaming" is antithetical to the entire philosophy of Housing First. But it may be seductive to Housing First providers for many reasons. After all, at times it is very hard to imagine how a dually-diagnosed person who is non-compliant with all conventional forms of treatment will succeed in housing. Housing vouchers are valuable resources and providers may feel that they should place people they think will be successful. But part of the way we know this program is working is when ER visits, jail days, hospital days and police calls are reduced. So if you don't have a person who is accumulating all these negative issues, as difficult to work with as they may genuinely be, then you are missing the basic premise of Housing First.

2) Are the choices of participants collaborative?

Too often the only agencies that can afford to implement this type of housing programs are the bigger, better-funded, more established agencies. What are their relationships and communication skills with the street outreach teams, the soup kitchens, the jail outreach workers so that they can be sure that they are finding the most compromised and vulnerable people to house?

3) What is the consumers' level of perceived choice?

This harm reduction-based model does not require sobriety and/or medication compliance. This is a hard thing for many to swallow, as traditional housing programs have generally required a length of sobriety, abstinence from substance while housed, and assumes that participants may not have independent living skills. They generally require that a person acknowledge his mental health diagnosis, at least to the point that he will agree to take psychiatric medications. Research in psychiatric rehabilitation indicates, however, that the most effective place to teach a person the skills required for a particular environment is within that actual setting.

Research can be boring, I know, particularly to those working or living on the front lines of homelessness. You may be telling yourself that you don't have the time or energy to think about these issues with the monumentally sad and difficult challenges that face you each day. I am just trying to hand some ammunition to those of you in the trenches.

Photo credit: Print North East