Why Housing First?

Why do the supporters of Housing First believe that substance abuse should not be a bar to housing?
The Housing First model originated with a psychologist who discovered that people in housing stabilize more often than people not in housing. He discovered this before 1992, and his name is Sam Tsemberis¹.

The Housing First model is really pretty simple:

...provide housing first, and then combine that housing with supportive treatment services in the areas of mental and physical health, substance abuse, education, and employment. Housing is provided in apartments scattered throughout a community. This "scattered site" model fosters a sense of home and self-determination, and it helps speed the reintegration of Pathways clients into the community.²

Pathways to Housing (Tsemberis’ organization) claims a housing retention rate of 85-90%.
Mentally ill and substance-abusing patients adhere to therapy better; tolerate housing better; and are less likely to commit crimes when housed.

Why?

Traditionally, the chronically homeless live in a cycle of surviving on the street, being admitted to hospitals, shelters, or jails and then going back to the street. The stress of surviving each day in this cycle puts a tremendous amount of pressure on the individual’s psychiatric and physical health. “Living in the street,” one Pathways to Housing client said, “It makes you crazy.”³

What’s different about the model, other than “put them in homes”?

The client participates in support services as long as they need them, but participation in a structured program is not a requirement for clients to keep their housing. Clients must only agree to meet with a member of their ACT team five times a month. Multi-disciplinary Assertive Community Treatment teams (ACT) provide clinical, vocational, and health services that are client-driven. These teams are available on-call 24 hours a day, seven days a week.⁴

Not every program that claims to be using “Housing First” really is using “Housing First.” This is a critical distinction. You can see from the above that the Housing First model means having support staff on-call 24/7. It means support is client-driven, not provider-driven.

We know that 88% of those who have housing in the “Housing First” model are likely to keep it. Only 47% of those not in that model are likely to keep it.

We know that the recidivism rate of former criminals is lower (by 71%) among those who are housed⁵. The study was conducted in Vancouver, B.C. Our own data over the last few years show this trend is real; the number of days spent in jail is reduced by 66%⁶ (6 months housed vs 6 months prior to housing).

The South King County pilot project^7,8 showed a reduction in jail bookings (not the same as jail time), and drug and alcohol use was reduced.

Further, we know that Housing First, applied to the mentally ill and substance abusers, is cheaper than leaving them to live on the streets. This is seen in Utah, Florida, Seattle, Vancouver, Los Angeles. The amount saved per person housed depends on many variables, however. A Vancouver study, published in JAMA in 2015⁹, found no difference in quality of life at 2 years, but substantial cost savings ($14k vs $22k, per person).

It is only common sense that the Housing first model could be appropriately applied to the disabled, the elderly, the infirm, and the chronically ill as well as to the mentally ill and to substance abusers. In a sense, the most vulnerable of the most vulnerable truly need the protection of homes. In addition, all of the homeless are experiencing degradation of their health. This is an inevitable result of living in the weather. And, to be honest, most of the homeless would be happy with substandard housing – it’s better than the streets, the tents, the cardboard boxes. They’d gladly accept a large waterproof box with a locking door, if they and they alone had the keys.

Footnotes:

1  http://works.bepress.com/sam_tsemberis/

2  https://pathwaystohousing.org/housing-first-model

3  https://pathwaystohousing.org/housing-first-model/mental-health-homelessness

4  https://pathwaystohousing.org/housing-first-model/mental-health-homelessness

5  http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0072946

6  http://allhomekc.org/wp-content/uploads/2015/09/SA-AG-3-9-16-Meeting-Packet.pdf, p 17.

7  http://www.buildingchanges.org/images/documents/library/2010%20South%20King%20County%20Housing%20First%20Pilot%20Report.pdf

8  http://www.kingcounty.gov/~/media/health/MHSA/documents/SKC_HF_2_yr_outcome_report_8_31_11_final_formatted.ashx?la=en

9  http://jama.jamanetwork.com/article.aspx?articleid=2174029

Statistics about the homeless

In 2013, a report about homelessness was presented to the Bill and Melinda Gates Foundation. You can find a copy of it here. There's a pile of data in that report, and it's very interesting reading. I'm going to summarize some of it, because I understood more after reading it.

Understand, first, though, that these statistics don't necessarily show fault or causation.

They were searching for factors associated with homelessness. They often cite other studies for some interesting related statistics. Generally, I’ve limited statistics to whole numbers in the comparisons (they gave them to 1 decimal point).

5.6% are homeless; 6% of veterans are homeless.

2.8% are homeless again; 2.1% of homeless veterans are homeless again.

41% of homeless men and 83% of homeless women are parents.

30% of homeless report binge drinking in the last 30 days, vs. 16% of non-homeless.

20% of homeless scored 13+ on the Kessler Psychological Distress Scale, vs. 2% of non-homeless.

50% of homeless were unemployed, vs. 11% of non-homeless.

20% of homeless have no high school diploma, vs 6% of non-homeless.

41% of homeless have been incarcerated, vs 4% of non-homeless.

31% of homeless have fair or poor health, vs 13% of non-homeless.

Many homeless people have experienced an Adverse Childhood Event (ACE), and they've experienced more of them.

An ACE is defined as one or more of the following:

1. Mental Illness in Household – Did you live with anyone who was depressed, mentally ill, or suicidal?
2. Substance Abuse in Household – Did you live with anyone who was a problem drinker or alcoholic? Did you live with anyone who used illegal street drugs or who abused prescription medications?
3. Incarcerated Household Member – Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility?
4. Parental Separation or Divorce – Were your parents separated or divorced?
5. Parents Physically Aggressive Toward Each Other – How often did your parents or adults in your home ever slap, hit, kick, punch or beat each other up? (once or more versus never)
6. Parents Physically Aggressive Toward You – Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking.
7. Emotional Abuse – How often did a parent or adult in your home ever swear at you, insult you, or put you down? (once or more versus never)
8. Sexual Abuse – How often did anyone at least 5 years older than you or an adult ever touch you sexually? (once or more versus never) How often did anyone at least 5 years older than you or an adult try to make you touch them sexually? (once or more versus never) How often did anyone at least 5 years older than you or an adult force you to have sex? (once or more versus never)

Indeed, for each of these experienced, a person is 40% more likely to become homeless. The average score for the homeless was 3.97; for non-homeless, 1.58. One-third of those with a score of 8 (the max) are homeless.

Here are some of the statistics (read the paper for the rest of them!):

58% of homeless have divorced/separated parents, vs 27% of non-homeless;

29% of homeless had an incarcerated household member, vs 6% of non-homeless;

52% of homeless have been struck or hit by parents (not counting spanking), vs 18% of non-homeless;

70% of homeless were emotionally abused by parents, vs 31% of non-homeless.

The numbers do tend to overwhelm somewhat, but step back and look at the patterns.

Causation?

Well, no. We can't show that with this data.

While it's true that 1/3 of those who scored 8 on the ACE are homeless, it's also true that 2/3 are not.

While it's true that 58% of homeless have divorced/separated parents, 42% do not.

What we do see are risk factors.

Just as smoking one cigarette may cause lung cancer, beating your children once may cause them to be homeless as adults.

Caveats

The report was created for the Bill and Melinda Gates Foundation, which has a long history of working to change some the behaviors this report indicates are associated with homelessness. I doubt the data is biased (after all, it's pure data). The choice of questions and topics may have been. 

And when you read the report, you will understand they did some "weighting" with their statistics, and I'm not sure I understand why. The raw data is not all presented, and does not seem to be easily available. I'm planning on asking for their tabulated survey data, stripped of identifying information.

There are questions they did not ask. Use of drugs, use of tobacco, experience with landlords, number of employers, length of last employment, time of last employment, and a few others. This seems to me to indicate a lack of understanding. However, the data they did acquire seems to be reasonable. I'm not sure I trust some of it, and I suspect a bias in the methodology. But it's a study, and the data is useful.

Again, about the One Night Count

The One Night Count found 4,505 people living outside in King County. 2,942 of those were in Seattle proper.

In Seattle, that's only a 4.5% increase. Some news stories make much of this, like this one from Capitol Hill Seattle Blog. What they're thinking, of course, is that the rate of increase is slowing in the city.

They couldn't be more wrong.

This year, you see, because of the shootings, we did not count areas we normally count. Parts of "the jungle," in particular, were not counted -- because of the recent shootings in that area.

Had we counted those areas, I'm sure the numbers would have been much closer to 5,000 for King County, and likely closer to 3,200 for Seattle proper.

One Night Count, King County: 4,505

 4,505 homeless outside in King County

Photo from wikimedia commons, of people sleeping in Steinbrueck Park
(I added the number). Original photo by Joe Mabel, 2011.

That's how many we counted outside last night.
It's a preliminary number, but it shouldn't change very much.
4,505 is enough to populate a good-sized town. The town I grew up in numbered 330; the nearest larger town was 2500.
There is only one way to solve homelessness. It's really simple.

Homes are the answer to homelessness.

Not everyone agrees with me about that. Most politicians want complicated solutions, technological solutions, psychological solutions. But the fact of the matter is that without housing, those will likely not help.

Employment, for example. A number of homeless are employed. Perhaps 30-35% of them, nationwide. Most of those jobs are menial jobs. Dirty, nasty jobs. The wages are lousy, the working conditions poor. Long hours of drudgery. Here in Seattle, many homeless work for various temporary firms after sporting events and concerts, cleaning up the stadiums.

And what of those who are only really suited for office work? Whether disabled, or simply not suited to menial jobs or manual labor? When you're homeless, you carry your stuff on your back, or it gets stolen. There is nowhere to store it -- with some exceptions (which I'll get to in a minute). When you walk into an interview with a backpack and suitcase, you generally don't get the job. Even a temporary job. Keeping your clothing clean while homeless is a major undertaking, because most of the time you're focused on survival.

The exceptions for storing your stuff?

• SHARE/WHEEL's Tent Cities (3,4,5); 
• SHARE/WHEEL's Storage Locker program; 
• United We Stand (an encampment);
• Camp Unity Eastside (another encampment); and 
• Nickelsville (another encampment). 

There may be others, but I have not heard of them (An interesting side note: All of those are related to SHARE/WHEEL in some way. Not necessarily a friendly way...).

Housing changes the equation. When you're housed, with a locking door: your stuff is a lot safer. When you're housed, and you have a shower available to you, you can keep a lot cleaner. And you can likely obtain employment much easier.

This is why Housing First is such a game-changing policy. Stabilize the housing situation first. Then fix the other problems.

There's an article here about an actual controlled study on Housing First. And an article here about an interview with some details about the man who originated it, and some more information.

4,505 homeless outside in King County

What are we doing to end this crisis?

The opinions expressed in this post are mine. They may not be anyone else's. The Board of Greater Seattle Cares may not agree with this opinion.

91 deaths of homeless in King County in 2015

The King County Medical Examiner's report on homeless deaths in 2015 can be found here.

There were 91.

6 were homicides. I count 28 that I can link directly to drugs and alcohol (acute toxicity, et cetera). There may be more that can be linked indirectly to drugs and alcohol (for example, why did someone step in front of a vehicle? Why did someone fall onto I-5? et cetera).

6 of them were Native American.
9 were Black.
4 were Asian.
4 were Hispanic.

16 were female.

Washington State is 4% Black, 2% Native American, 13% Hispanic, and 8% Asian -- and about 50% female (statistics from here).

Often, violence against the homeless goes unreported. The Seattle Times has an article about that here.

The homeless live on average about 30 years less than the rest of the population. Sad but true. Drugs, alcohol, and violence are some of the reasons.



Opinions expressed by me might not be the opinion of the Board of Greater Seattle Cares.