Opinion: ‘Housing First’ does not mean housing only

In an Oct. 22 opinion piece in the Colorado Sun, a Denver resident argued that a “rehabilitation first” approach involving temporary housing and required rehab is the best way to solve homelessness. But that’s not what the research evidence shows.

Rather, the approach of providing housing first and then intensive support and treatment services has been proven again and again to lead to the best results—both for people experiencing homelessness and for the communities where they live.

Results from our study of a Denver supportive housing program show the far-reaching benefits of the Housing First approach. Our long-term, rigorous evaluation of the Denver Supportive Housing Social Impact Bond Initiative found that after three years in the program, 77% of participants remained in stable housing and experienced a 40% reduction in shelter visits, a 40% reduction in arrests, a 30% reduction in jail stays, a 40% reduction in emergency department visits, and a 155% increase in office-based visits for a psychiatric diagnosis. About half of the total per-person cost of the program was covered by avoiding costs associated with, for example, jail and emergency department costs.

Housing First is built on the idea that safe, affordable, and permanent housing must be available before someone can work on other challenges they may face, like mental health or substance use disorders.

But Housing First doesn’t mean housing only. Supportive housing programs offer people access to clinical treatment, harm-reduction, case management and other services to help them address their challenges and find stability in their lives.

The idea of addressing homelessness through required services or rehabilitation isn’t new. In fact, the Housing First model grew out of frustration with the failed “rehabilitation first” approach favored during the 1980s and 1990s.

Dr. Sam Tsemberis, originator of the Housing First model, has shared how clinical treatment repeatedly failed people experiencing homelessness by blaming them for their own challenges and denying them the “simple dignities of life”—such as a private bedroom and bathroom—that are a crucial foundation for recovery. Instead, rehabilitation first approaches expected people to be sober and compliant with multiple program requirements before they could be “deserving” of housing. As a result, many people fell short of these requirements and remained homeless.

A large body of evidence shows that the rehabilitation first approach doesn’t work. Unlike the outcomes Denver has seen with Housing First, Tsemberis’ research showed that rehabilitation first programs had housing stability rates of just 20-25% and came at a much greater cost to public budgets.

In addition, the Family Options Study found that families offered transitional housing—which includes temporary, service-intensive housing—were just as likely to experience homelessness or housing instability three years after the program as similar families who were not offered any specific program. In contrast, families offered a long-term housing subsidy were less than half as likely to experience homelessness or housing instability three years later.

The evidence is clear: while programs that prioritize permanent housing may not have a 100% success rate, they have a significantly higher success rate than any other solutions that have been proposed to end homelessness.

The problem isn’t that Housing First doesn’t work; the problem is that our country has never committed to investing what it would take to end homelessness — there’s not enough housing and there’s not enough access to treatment and other supportive services. Without large-scale investment in these evidence-based solutions, people will continue to lack access to the housing and services they need, and, left with no other options, they’ll be forced to live on the street.

We can do better than the growing unsheltered homelessness that is so prevalent on Denver streets and around the country. Imagine if those unhoused people you see on the street were living in homes and getting help with their addiction and mental health challenges. Imagine if the reductions in jail stays and emergency department visits seen in the supportive housing program were realized at full scale. What would Denver look like then?

Sarah Gillespie, of Washington, D.C., is the associate vice president for Metropolitan Housing and Communities Policy at the Urban Institute and lead researcher on the Denver Supportive Housing Social Impact Bond Initiative evaluation.