This past week, the Bush administration reported a most welcome 30 percent drop in the number of chronically homeless people living in the nation's streets and shelters. According to a front page article in The New York Times, it attributed "much of the decline to the 'housing first' strategy that has been promoted by the Bush administration and Congress, and increasingly adopted across the country."
What neither the Times nor the Bush administration reported is that the "housing first" strategy being adopted was originated, informed, and guided by a New York City based organization, Pathways to Housing, which pioneered this approach 15 years ago, and has been successfully implementing it ever since. The Bush administration has relied heavily on Pathways, whose program, until 4 years ago, was the only "housing first" program in the nation.
By taking those homeless people that cities traditionally do not deem "housing ready"--they are still using drugs, they are not taking their meds, et cetera--and by giving them their own apartments, and then wrapping social, psychological, and medical services around them, Pathways has proven more successful at stably housing these people than the city has at housing those it deems "housing ready." 88 percent of Pathways' clients have remained stably housed for two or more years, while the city's housing retention rate for similar periods is below 50 percent. Add to this the fact that all the people Pathways finds housing for have, or have had, along with homelessness, co-occuring conditions of mental illness, and one can only marvel at, and be humble before, the program's mission, and its successes.
And one reason for its success, according to its director, Sam Tsemberis, is that the program is "client driven"--i.e., Pathways takes its cues from the expressed needs and desires of the homeless people it serves. (Cf. William Osler's advice to his fellow physicians at Johns Hopkins: "If you listen to the patient, the patient will give you the diagnosis.")
When, during its first dozen years, communities inquired about the Pathways "housing first" program, resistance was widespread. How can you let those people into housing if they've been drug users, or are still using drugs--or if they're schizophrenic? What if they stop taking their meds? The answer, according to Dr. Tsemberis, is that Pathways serves clients because they fall off the wagon.
"That's what addiction means. We anticipate that people will relapse--it's part of the recovery process, and the advantage of this harm-reduction approach is that people are not evicted and homeless again simply because they've relapsed. They remain housed, and so can continue to work on curing their addiction or improving their mental health. What we do, that is, is to separate housing from treatment--thus, if you relapse, you're still housed. There's treatment for addiction and for mental illness--and there's housing for homelessness."
That the Pathways "housing first" model is also less costly than shelters or traditional supportive housing models has now made it attractive to the Bush administration, and to many communities. The Pathways model, however, is based not on economics, or on ridding the streets of "undesireables," but on the belief that housing is not something that must be "earned" by "good behavior," but is a fundamental right. For how can anyone have a decent life without first having a home?
Jay Neugeboren is the author of 17 books, including Imagining Robert: My Brother, Madness, and Survival, and Transforming Madness: New Lives for People Living with Mental Illness.. He serves on the boards of several mental health organizations, including the New York City-Metro chapter of NAMI (National Alliance on Mental Illness), Pathways to Housing, and the Columbia University Center for the Study of the Prevention of Homelessness. His most recent book, 1940, a novel, was published in April, 2008.