2. Is Housing First a solution to homelessness?
Housing First is one of the many deceptively simple concepts that emerge in this book. Just as the name suggests, the idea is to get people into housing as the first step. From there, if the person wants, they have the choice to access a range of support services. This idea is a departure from previous approaches in which people would have to prove themselves āhousing-readyā by meeting a specific set of qualifications, like abstaining from substances for a given period of time or having steady employment. Housing First reverses the order and says that everyone is ready for housing. It has been widely adopted across the country.
Before you begin working through the material in this section, we encourage you to stop and reflect upon the question, āIs Housing First a solution to homelessness?ā Housing First has existed ā in its current and early forms ā within Canada for decades. Yet, we still have crisis levels of homelessness across the nation. We encourage you to pause here and consider what you might have already heard about Housing First, why you think it has been so popular, and why we still have high rates of homelessness. We would also like to remind you that this answer is for your learning benefit only, so that you can take stock of your knowledge before you begin. You may write as much or as little as you wish.
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The framework of Housing First in Canada is adapted from the work of Dr. Sam Tsemberis, Founder and CEO of Pathways to Housing in New York. Before we begin our discussion of Housing First in Canada, we would like to set the stage with this brief 4-minute video in which Dr. Tsemberis outlines the core ideas of how his Pathways program began. It is important to remember as you watch this, that he is speaking about the original American program and that we will review the Canada data throughout the section that follows this video.
In the previous section, we said that it is important to know the history of housing policy in Canada to understand our current situation. Well, here we are, saying it again (and will continue to say it in the next section!) because now that you have read the history, it will likely not surprise you to know that early forms of Housing First emerged in the 1990s. As the federal government stepped back from funding social housing and mass homelessness began to emerge, advocates realized that what people needed most was housing. Dr. Nick Falvo explains the connection between the early roots of Housing First and historical policy decisions.
Dr. Nick Falvo: Is Housing First a solution to homelessness?
In this video, Dr. Nick Falvo provides background on how Housing First came to be adopted as a homelessness intervention in Canada. He traces the history to the 1990s when large scale cuts were being made to housing and social policy. Housing First was introduced by key advocates under the premise of reallocating existing funding, rather than requiring enhanced funding. Dr. Falvo argues that while taking people from homelessness straight into housing was framed as a new idea, it was a practice already being done in Ottawa and Toronto under the name āsupportive housing.ā While Dr. Falvo says key decision-makers believed Housing First would lead to dramatic reductions in homelessness, the data over time has not indicated a strong downward trend. This video is 3:32 in length and has closed captions available in English.
Key Takeaways ā Dr. Nick Falvo: Is Housing First a solution to homelessness?
- The 1990s were dark days for Canadian housing and social policy.
- Governments were cutting investments to social protections, having particularly negative impacts on vulnerable citizens.
- Advocates for the homeless at the time were asking for more social housing, raised incomes, enhanced income assistance, and generally higher levels of spending and an increase in taxes. Government officials were concerned with deficits and debts. They did not want to hear these messages and were reluctant to spend additional money.
- The idea of Housing First was not new, but rather was an effort to appeal to governments by asking decision-makers not to spend more, but to redistribute existing funding.
- Key advocates at the time argued the non-profit sector and grassroots frontline workers were not being efficient with the resources they had.
- The idea to house people directly from homelessness was framed as a new way of thinking yet had already been occurring from the 1980s onwards under the name āsupportive housing.ā This was particularly notable in Toronto and Ottawa, but those who were not aware of this picked up on the idea of Housing First as being something novel.
- Housing First is a narrative that decision-makers believed would have a profound impact on homelessness by redistributing existing resources, but the figures over the past few decades have not supported this dramatic downward shift in most cities.
Today, much of the work around Housing First across the country is informed by the ground-breaking $110 million Mental Health Commission of Canada study known as āAt Home / Chez Soi.ā This project operated from 2009 to 2013 and was a coordinated effort in the five sites of Vancouver, Winnipeg, Toronto, Montreal, and Moncton, to evaluate Housing First outcomes compared to āTreatment as Usualā in which people accessed the existing support services available without intervention. Each location had its own focus or speciality population. According to Waegemakers Schiff and Rook (2012), by examining the approach in various political contexts, and with different populations, it had the multi-cultural dimensions needed for Canadian adoption of the Housing First approach. New data is published regularly, providing further insight into this initiative. In the video below one of the participants speaks about her experience in the study.
Having housing stability is a critical social determinant of health because housing instability is significantly associated with higher acute care use, having unmet health care needs, and engaging in problematic substance use (Harris et al., 2019). Having housing stability also helps to reduce the stigma and discrimination people face when experiencing homelessness, and improves their well-being and quality of life (Mejia-Lancheros et al., 2021). Analysis of the At Home / Chez Soi project suggests that neurocognitive impairment was high amongst the people in the study (Stergiopoulos et al., 2019), and that Housing First can be beneficial for reducing further harm to people with traumatic brain injuries (Mejia-Lancheros et al., 2020)
Certainly, Housing First has many benefits as an intervention for people experiencing homelessness, particularly amongst those who experience chronic homelessness related to mental health and/or addictions challenges. In the next video, Dr. John Ecker provides an overview of its five main principles and additional supports. The principles are discussed further in the animated video that follows.
Dr. John Ecker: Is Housing First a solution to homelessness?
In this video, Dr. John Ecker argues that Housing First is not a silver-bullet solution, but that it is effective for the large majority of people experiencing chronic homelessness. He outlines the five key principles that inform the design of Housing First and reviews the associated aspects, such as support team models and housing subsidies. Dr. Ecker reflects on published evaluations of the Housing First model, noting it is highly effective at long-term housing, reducing use of emergency services, and enhancing well-being, but is less successful in outcomes related to community integration, substance use reduction, and improvements in mental health functioning. He concludes that the rights-based foundations of Housing First, such as client choice and being low barrier, are increasingly being taken up in homelessness sector programs. This video is 5:14 in length and has closed captions available in English.
Key Takeaways ā Dr. John Ecker: Is Housing First a solution to homelessness?
- Housing First is not a silver bullet fix-all solution, but it is effective for a large majority of people experiencing chronic homelessness.
- Housing First is a program that was designed to support individuals experiencing chronic homelessness, who also have mental health and/or substance use challenges. It is based on five main principles.
- The first principle is that there are no housing readiness requirements. People do not have to prove they qualify through sobriety or engagement with supports. They have the right to access immediate and permanent housing.
- The second principle is client choice and self-determination. People get a say in where they want to live and in what supports they feel they need.
- The third principle is that Housing First takes a recovery orientation, which is intended to support well-being in a holistic way.
- The fourth principle is individualized and client driven supports, to meet the unique needs of people as diverse individuals.
- The fifth principle is striving for social and community integration, such that the person feels they are part of the community they are moving into and are attached to local resources and supports.
- Housing First should have a housing subsidy attached to help offset the costs of housing. To be affordable, housing should not cost more than 30% of a personās income.
- Housing First should also be accompanied by a team of support workers.
- Assertive Community Treatment [ACT] is one approach that incorporates a multi-disciplinary team of community mental health support workers.
- Intensive Case Management [ICM] is another approach in which workers help to broker services and connect clients to local supports.
- When it is evaluated, Housing First is shown to be highly effective at housing people long-term, reducing emergency service usage, and enhancing well-being, but is less successful in outcomes related to community integration, substance use reduction, and improvements in mental health functioning.
- The principles of Housing First, such as being rights-based, focusing on social inclusion, and client choice, are increasingly informing design, even in programs that are not specifically Housing First identified.
Housing First is an important evidence-based approach towards ending peopleās homelessness, but as we have heard and will hear again, it is not a silver bullet that solves the problem entirely. In assessing Housing First, we must consider both its strengths and its weaknesses. For instance, research from Metro Vancouver has found the strengths of Housing First programs to be their ability to transition people into housing with individuals services, provide supports like rent subsidies, household goods, and connections to community resources, but also identified weaknesses related to eligibility criteria, limited financial subsidies, limited provider capacity, and workload burden for case workers (Canham, Wister, & OāDea, 2019). In the next video Dr. Rebecca Schiff further explains the benefits and drawbacks of Housing First.
Dr. Rebecca Schiff: Is Housing First a solution to homelessness?
In this video, Dr. Rebecca Schiff argues that while Housing First has many good principles ā such as consumer choice, meeting people where they are at, and self-determination ā it is not the silver bullet that will solve homelessness because we still have further to go in adapting it to peopleās unique support needs. This video is 2:32 in length and has closed captions available in English.
Key Takeaways ā Dr. Rebecca Schiff: Is Housing First a solution to homelessness?
- Housing First has a number of good principles, including consumer choice, meeting people where they are at, and self-determination around services and involvement in treatment plans.
- Human nature is to come up with āsilver bulletā solutions. Housing First will not solve homelessness, because there are more complex issues involved. We have a lot further to go in terms of developing housing supports that are tailored to the needs of people as individuals.
What do you think?
We have looked at the principles of Housing First and how they are applied in practice, resulting in both positive and negative outcomes. What do you think are the biggest benefits and drawbacks of Housing First?
When we posed the question, āIs Housing First a solution to homelessness?ā to Dr. Stephen Hwang and Dr. Tim Aubry, both researchers in the At Home / Chez Soi study, they gave us very similar responses. In short, Housing First is highly effective for individuals but does not have the capacity to address the social factors that create homelessness. They tell us the key is not to fix people, but to fix their situations.
Dr. Stephen Hwang: Is Housing First a solution to homelessness?
In this video, Dr. Stephen Hwang discusses how Housing First is both a solution and not a solution to homelessness. At the individual level, research shows Housing First can be very effective for helping people achieve housing stability, particularly if they have mental health and/or substance use issues. However, Dr. Hwang argues that it is hazardous to think of Housing First as a solution to homelessness itself, because homelessness is fundamentally not caused by individual level vulnerabilities. While it may help people exit homelessness, Housing First does not address the structural forces and injustices that create it. He concludes that we need to examine our social, housing, and economic policies to find a solution. This video is 2:01 in length and has closed captions available in English.
Key Takeaways ā Dr. Stephen Hwang: Is Housing First a solution to homelessness?
- Research shows that as a program, Housing First can be a very effective solution for helping people achieve stable housing and exit homelessness, particularly if they have mental health and/or substance use issues.
- Beyond the individual level, it is hazardous to present Housing First as a solution because homelessness is fundamentally not caused by individual level vulnerabilities.
- Housing First helps individuals exit homelessness but it does not address the structural forces and injustices that create it.
- If we want to solve homelessness, we have to address social, housing, economic, and other policies.
Dr. Tim Aubry: Is Housing First a solution to homelessness?
In this video, Dr. Tim Aubry discusses the effectiveness of Housing First as a solution for housing the 15-20% of the homelessness population who have long-term histories. He argues that even though Housing First is intended to address chronic homelessness, its underlying approach ā of providing rent supplements and tailored supports ā makes it effective for addressing homelessness for other sub-populations as well. He provides the example of the Family Options Study conducted in the United States to show how Housing First principles can reduce poverty and help families get out of homelessness. Dr. Aubry argues that Housing First shows us the key is not to fix people, but to fix their situations. To do so, we need to give people who experience homelessness a sense of choice and agency back in their lives. Compared to other nations, Canada has not shown as strong a commitment to implementing Housing First, preferring instead to allow communities to determine their own approaches. He points to the success of Scandinavian countries in reducing homelessness, by making Housing First part of their national policies. This video is 5:45 in length and has closed captions available in English.
Key Takeaways ā Dr. Tim Aubry: Is Housing First a solution to homelessness?
- Extensive evidence demonstrates that Housing First works.
- It targets the 15-20% of the homeless population comprised of people who have long-term histories of homelessness. Housing First is incredibly effective to end this sub-populationās homelessness.
- Even though it targets people experiencing chronic homelessness, Housing First also works on a larger scale because it includes rent supplements and supports that can be titrated to align with what people need.
- The Family Options Study completed in the United States demonstrates that when families are given rent supplements and supports geared towards their needs, they can obtain secure housing.
- The success of Housing First shows the solution is not to fix people, but to fix their situation.
- Poverty and a lack of affordable housing are the immediate situations that need to be fixed, then longer-term needs can be determined and met.
- Homelessness is an experience that takes a lot away from people. It is essential that individuals be given choice and agency in their lives.
- Canada has not made as strong or formal a commitment to implementing Housing First as some other nations have.
- Canada adopted Housing First, then backed off it. Canadian governments have preferred to say that communities know what is best for them and to not prescribe anything, including Housing First, as a solution.
- The United States has integrated Housing First into the Department of Housing and Urban Development [HUD] policies.
- In Scandinavia, notably Finland, Norway, and Denmark, they have had large reductions in homelessness because Housing First has become a central part of their national policies.
As you consider the videos you just watched, we encourage you to take a moment and read Dr. Aubryāsanalysis of Housing First as a practical and policy relevant intervention.
Featured Reading:
Aubry, T. (2020). Analysis of housing first as a practical and policy relevant intervention: The current state of knowledge and future directions for research. European Journal of Homelessness, 14(1), 13-26.
At this point in our discussion, we hope that it is becoming clear Housing First is much more complicated than it may originally seem. The ten-year story of At Home / Chez Soi demonstrates how Housing First contributed to transformative change from ātreatment firstā to āhousing firstā for individuals with severe and persistent mental illness, but it needs to be enshrined in public policy to maximize its impacts (Nelson et al., 2020). Rather than blaming the person or the program when long-term housing stability is not achieved, it is important to consider the system-level forces that create and sustain poverty and inequities (Wallace, Pauly, Perkin, & Cross, 2019). Most notably, Housing First is limited by the availability of affordable housing and inadequate income assistance (Canham et al., 2019; Macnaughton et al., 2018).
In the video that follows Dr. Jonathan Greene explains that an early form of Housing First emerged in Toronto beginning in the 1980s, albeit without the wrap-around supports that are fundamental today. He has written that the changing urban landscape in the 1980s and 1990s also gave rise to new kinds of political activism, such as was seen in the City of Toronto as advocates defined the homelessness crisis as a direct effect of urban restructuring (Greene, 2014). Whether referring to the past or the present, there is a clear and continuous message that we cannot end homelessness with Housing First until we ensure there are mechanisms to address the wealth inequality gaps that make housing financially inaccessible to a large number of Canadians.
Dr. Jonathan Greene: Is Housing First a solution to homelessness?
In this video, Dr. Jonathan Greene argues that the Housing First philosophy ā including the right to housing and choice ā is a good idea, but that it cannot solve homelessness by itself because there is nothing within it that mandates the development of affordable housing. Dr. Greene discusses programs that preceded Housing First, in Toronto in the 1980s, in which advocates argued for āhousing, not hostelsā demonstrating that the idea of rapidly housing people is not entirely new. He concludes that we must continue to evolve our understanding of Housing First, as even when all supports are put in place not every person will remain stably housed long-term. He challenges us to ask ourselves, āWhat else do we need to learn and know about these approaches?ā This video is 4:19 in length and has closed captions available in English.
Key Takeaways ā Dr. Jonathan Greene: Is Housing First a solution to homelessness?
- Housing First is a philosophy about the right to housing and choice, making it part of the solution to homelessness.
- On its own, Housing First will not solve homelessness because there is nothing within it that mandates the creation or establishment of affordable housing to accompany client choice.
- If there is not enough affordable housing for people to go into, then homelessness will continue to exist.
- When it was first created as a program model by Pathways to Housing in New York, it included rent geared to income, so people paid no more than 30% of their income. The idea to put people in housing quickly has carried over, but not the same accountability to making housing affordable.
- An early form of Housing First has existed in Canada since the 1980s.
- In the City of Toronto in the 1980s activists were mobilizing around homelessness, with the slogan āhousing, not hostels.ā
- There did not exist the same level of supports that accompany Housing First, but it demonstrates that the idea to provide housing instead of emergency shelters, is not entirely new.
- Housing First must constantly evolve to meet the needs of every individual.
- Even in the largest trial ā the At Home / Chez Soi study ā which was the gold-standard and had all the supports in place, some people were unable to remain housed long-term.
- We should constantly revisit Housing First design concepts and ask ourselves, āWhat else do we need to learn and know about these approaches?ā
Dr. Greene raises the important point that we still have much to learn about Housing First, and we continue to learn more as new research is conducted and published. For instance, we continue to learn about the benefits, such as that the presence of resources rather than risk factors as a key determinant in whether participants achieve housing stability (Aubry et al., 2021). Additionally analysis of the Vancouver At Home / Chez Soi data indicated that employment was associated with an increase in psychiatric recovery and had both immediate and longer-term outcomes (Yazdani et al., 2020).
As research results are published, we also continue to learn about the areas where further study and/or resources are needed. In a sample of participants with mental illness from the At Home / Chez Soi Toronto site, researchers did not find significant impact on primary care retention over time, suggesting that the program may need to be supplemented with additional efforts to connect people with health care (Whisler et al., 2021). Neighbourhood factors also need to be considered when matching a person with housing in Housing First programs, as long-term housing stability is a key determinant of well-being (Distasio et al., 2021).
There is also on-going analysis of the cost-benefit of providing Housing First. Using data from 937 participants in the five cities from the At Home / Chez Soi study, Latimer et al., (2017) calculated the average annual cost of services for those who were absolutely homeless or precariously housed, and not receiving Intensive Case Management [ICM] or Assertive Community Treatment [ACT] to be between $29,610 on the low end in Moncton and $58,972 on the high end in Toronto. To evaluate the cost-effectiveness of Housing First with ICM intervention, compared to treatment as usual, Latimer et al., (2019) recruited 1198 participants in the 5 At Home / Chez Soi study sites and found the intervention costs to be an average of $14,496 per person per year. In Calgary, researchers conducting pre-post assessments of Housing First programs estimated that for every $1 spent on Housing First, the savings from multi-sector usage could be between $1.17 and $2.84 (Jadidzadeh, Falvo, & Dutton, 2020). Dr. Stephen Gaetz and Dr. Tim Aubry explain the cost-benefits further in the next two videos.
Dr. Stephen Gaetz: The cost of homelessness
In this video, Dr. Stephen Gaetz argues that the current emergency-based approach to managing homelessness is expensive and detrimental to individuals, families, and communities. He cites research on the financial costs of keeping someone homeless for a year, which range from $50,000 to $65,000 in cities across Canada, due to shelter use, hospital visits, and law enforcement. He concludes that Housing First is a better alternative. This video is 1:26 in length and has closed captions available in English.
Key Takeaways ā Dr. Stephen Gaetz: The cost of homelessness
- The current emergency shelter response to homelessness in Canada is very expensive and has a negative impact on individuals, families, and communities.
- Financial analysis of the At Home / Chez Soi study demonstrated that keeping a person in a state of homelessness for a year, rather than housing them, costs between $50,000 ā $65,000 depending on the city in which they live.
- This cost analysis includes emergency services, hospital care, and law enforcement.
- The cost of Housing First is considerably lower.
Dr. Tim Aubry: The modest costs and transformative benefits of Housing First
In this video, Dr. Tim Aubry argues that the cost of ending peopleās homelessness by implementing Housing First is very modest. In 2021, the estimated cost of providing supports and rent supplements ranges between $18,000 and $24,000 per person annually, depending on the type of supports provided. Having housing changes the way people tell their story and opens opportunities, such as for them to cook independently. Dr. Aubry notes that alongside rent supplements, it is important to increase overall financial supports such that people can purchase their own food and engage in ācitizenship buildingā by undertaking activities within their community. This video is 4:45 in length and has closed captions available in English.
Key Takeaways ā Dr. Tim Aubry: The modest costs and transformative benefits of Housing First
- Comprehensive analysis shows the cost to deliver Housing First, including the rent supplements and supports, is very modest.
- Per client, Assertive Community Treatment [ACT] and rent supplements, costs approximately $24,000 a year.
- Per client, Intensive Case Management [ICM] and rent supplements, costs approximately $18,000 a year.
- The benefits of the Housing First investments are transformative in peopleās lives.
- Research shows that having their own housing, even if a one-bedroom or bachelor apartment, changes the way people tell their story and talk about their lives.
- Similar results occurred in Gilmer and Buccieriās own research in the City of Kawartha Lakes, as people found housing under the guaranteed income pilot project conducted in Ontario. The loss of the income when the project was cancelled was devastating.
- The use of food banks increased with housing security, as people had a place to cook but still not enough money to purchase food. This demonstrates a need to increase financial supplements in addition to rent supplements.
- Research shows that having their own housing, even if a one-bedroom or bachelor apartment, changes the way people tell their story and talk about their lives.
- Citizenship building is a new project being tested alongside Housing First, to provide people with money to pursue meaningful activities and recreation within their communities.
Longitudinal mixed-methods data from participants within the At Home / Chez Soi study, indicated social integration increased over time, and that the Housing First intervention may have led to larger social networks, increased social interest, and psychological integration compared to the ātreatment as usualā group (Kirst et al., 2020). For people living with mental illness, having interventions aimed at preventing chronic homelessness is a positive step towards strengthening social networks and community involvement, in addition to providing case management services to help with mental health recovery (Kerman, Sylvestre, Aubry, & SchĆ¼tz, 2019). However, a systematic review of Housing First evaluations shows that there is inconsistency in the degree to which these programs are being implemented with community integration as an intended outcome (Marshall et al., 2020).
Dr. Aubry spoke about the importance of citizenship building and ensuring people had access to nutritional supports and meaningful activities once they are housed. His research shows that participants within a Housing First program who achieved housing stability had decreased use of psychiatric hospitals and increased use of food banks (Kerman, Sylvestre, Aubry, & Distasio, 2018). Housing First makes it possible for people to engage with food in ways they could not before ā such as storing, preparing, cooking, and eating what they wish ā which can have a positive impact on their health and well-being, but without financial resources they remain dependent on charitable food programs which may lead them to feel marginalized (Hainstock & Masuda, 2019).
Within Housing First programs, the types of support and extent to which people need them will vary by individual. Dr. Jeannette Waegemakers Schiff and Dr. Nick Kerman explain that while some people may require high levels of intervention, with continuous supports, others may just require housing in order to stabilize.
Dr. Jeannette Waegemakers Schiff: Is Housing First a solution to homelessness?
In this video, Dr. Jeannette Waegemakers Schiff argues that being housed is a human right and should not be conditional on meeting certain behavioural, emotional, and moral standards. She notes that the level of support people need alongside their housing will vary, with some people just needing housing and others requiring more intensive interventions. This video is 2:14 in length and has closed captions available in English.
Key Takeaways ā Dr. Jeannette Waegemakers Schiff: Is Housing First a solution to homelessness?
- Housing is a human right.
- Housing First is a principle that says everybody deserves a home of their own without needing to show they meet behavioural, emotional, and moral preconditions.
- If a person does have issues they need to work on, the best place for them to do so is somewhere with a roof and safety.
- The levels of support people need along with their housing will vary.
- Some people may just need housing and targeted supports, such as a woman leaving domestic violence.
- Some people may be living with severe mental illness and/or addictions issues and require wrap-around interventions to help them maintain their housing long-term.
Dr. Nick Kerman: Is Housing First a solution to homelessness?
In this video, Dr. Nick Kerman argues that solutions to homelessness need to be tailored to individual and population specific needs. He discusses Housing First, which he says is highly effective for individuals who experience long-term homelessness related to serious mental illness, substance use issues, and/or other complex needs. However, Dr. Kerman notes, there are others experiencing homelessness who may not require the same intensive levels of support that accompany Housing First. He provides the example of families, who often are in financial need and would benefit most from affordable housing and rent subsidies. While Housing First programs may be highly effective for some, they may not be the best solution for others. This video is 1:59 in length and has closed captions available in English.
Key Takeaways ā Dr. Nick Kerman: Is Housing First a solution to homelessness?
- Housing First can be highly effective at helping people who have serious mental illness, problematic substance use, other complex needs, and lengthy histories of homelessness to achieve long-term housing stability and lead meaningful lives in the community.
- At the same time, not everyone who experiences homelessness needs the extensive supports that accompany Housing First. Some people would benefit from simply having access to affordable housing and a rent supplement.
- This is particularly true for families experiencing homelessness, who often experience homelessness because of financial strains and a lack of resources, such as affordable housing and rest assistance.
Many researchers have advocated for the importance of choice, in both the videos and in their writing. Yet, the lack of affordable housing makes it difficult to provide people with choice in their housing. Interviews with service providers involved in Housing First suggest that high rents and low vacancy rates create delays in housing clients, may make them feel pressured to accept the first apartment they are offered, and have profound impact on their ability to operate the program and ensure fidelity to the Housing First model (Anderson-Baron & Collins, 2019). In the video that follows Dr. Tim Aubry weighs in on the importance of fidelity to the core Housing First principles.
Dr. Tim Aubry: The importance of choice in Housing First
In this video, Dr. Tim Aubry raises the concern that many Canadian communities are moving towards creating congregate quasi-institutional buildings, under the name of supportive housing, to group together people who have severe mental illness and/or addictions. He notes these programs are not in-line with the Housing First principles of client choice and recovery-orientation. This video is 3:48 in length and has closed captions available in English.
Key Takeaways ā Dr. Tim Aubry: The importance of choice in Housing First
- Many communities across Canada are creating congregate quasi-institutional buildings, under the name supportive housing, to group together people who have severe and persistent mental health problems and/or addictions.
- This approach is not Housing First, because clients do not have the fundamental principle of choice over where they live or with whom.
- There is often a waitlist system, where a unit becomes available and the person either has to take it or move to the bottom of the list, even if the housing unit is unsuitable for them.
- This approach also does not meet the recovery-orientation principle in which the aim is to help people become integrated into the community in which they live.
A review of Housing First programs found that the majority self-reported high fidelity to the model (Nelson et al., 2017). However, capacity building is needed for communities implementing Housing First such as to help with clarifying principles, enhancing clinical skills and landlord engagement, client prioritization, and conducting fidelity assessments (Hasford et al., 2019).
Fidelity to the principles is important, but so too is adaptability. Different subpopulations have unique needs that are not always well served by the traditional Housing First model. For instance, adaptations may be needed for Indigenous persons (Bowra & Mashford-Pringle, 2021; Kidd, Thistle, Beaulieu, OāGrady, & Gaetz, 2019), women (Jadidzadeh & Falvo, 2019; Oudshoorn, Forchuk, Hall, Smith-Carrier, & Van Berkum, 2018), youth (Gaetz, Walter, and Story, 2021; Gaetz, OāGrady, Kidd, & Schwan, 2016; McParland, Rousseau-Thomas, & Waegemakers Schiff, 2019), seniors (Canham et al., 2018; Chung et al., 2018), and veterans (Bourque et al., 2017; Marsella, Forchuk, & Oudshoorn, 2020).
Dr. John Ecker and Dr. Stephen Gaetz speak about population-specific Housing First approaches in the videos below. Additional information on the unique needs of these subpopulations can be found in this bookās chapters on Indigenous Studies, Gender & Queer Studies, Child & Youth Studies, and Social Work respectively.
Dr. John Ecker: Population-specific approaches to Housing First
In this video, Dr. John Ecker discusses population-specific adaptations to the Housing First model. He begins by reviewing the Winnipeg site of the At Home / Chez Soi study, which focused on Housing First for Indigenous persons, and credits Jesse Thistleās definition of Indigenous homelessness in Canada as being an excellent source of information for thinking about community and wellness needs. Dr. Ecker then discusses work that is being done by the Making the Shift project to adapt Housing First for youth. He notes that developmental needs require considerations about housing style, transitional lengths, supportive family relationships, and life skill building for young people. Finally, Dr. Ecker briefly discusses Housing First for women as being grounded in safety considerations, particularly for women experiencing domestic violence. This video is 4:55 in length and has closed captions available in English.
Key Takeaways ā Dr. John Ecker: Population-specific approaches to Housing First
- Adaptability is a key ingredient in the Housing First model.
- In the At Home / Chez Soi study, the Winnipeg site focused on Housing First for Indigenous persons experiencing homelessness.
- Housing First is based on a westernized model, so adaptations are needed for Indigenous clients, including Indigenous service provision and service providers.
- The Indigenous definition of homelessness, as put forth by Jesse Thistle, identifies many areas of housing that need to be considered. These include the importance of community, family, and kin, communal living and gathering, and holistic approaches to healing and wellness.
- The Housing First model needs to be adapted to suit the unique developmental needs of youth experiencing homelessness.
- Making the Shift is a partnership between the Canadian Observatory on Homelessness and A Way Home Canada, that is focused on Housing First for youth.
- Considerations for youth-specific Housing First include whether independent or communal housing is best, extending the length of time for transitioning out of supportive housing, determining whether any healthy family relationships exist, focusing on education, and building employment and life skills.
- Housing First for women tends to focus on considerations of safety, particularly if domestic violence is a factor.
Dr. Stephen Gaetz: Is Housing First a solution to homelessness?
In this video, Dr. Stephen Gaetz identifies Housing First as an evidence-based best practice in homelessness policy and program design. He argues that it represents a shift in thinking towards seeing housing as a human right ā that everybody deserves ā and not as something that is earned by going through multiple steps. For Housing First to be implemented properly, Dr. Gaetz argues there needs to be fidelity to the model but also considerations of how it can evolve to suit the specific needs of populations such as Indigenous persons, women, families, and youth. This video is 3:35 in length and has closed captions available in English.
Key Takeaways ā Dr. Stephen Gaetz: Is Housing First a solution to homelessness?
- Housing First is one of the few evidence-based best practice approaches used in homelessness policy and program design.
- Housing First represents a shift in logic to seeing housing as a human right rather than something that can be earned after going through multiple steps.
- Everybody is ready for housing, whether they are a newborn baby or a person struggling with mental illness and/or addictions.
- Homelessness may contribute to struggles people have. For them to recover they need housing and wrap-around supports.
- Housing First is a basic model that works but should be adapted and modified in order to be successful.
- Modifications may be done for specific populations, such as Indigenous persons, women, families, and youth.
- Housing First could be used as a preventive program, such as being used with youth leaving the child welfare system, who are at high risk of homelessness.
- Fidelity to the Housing First model is important. If not done properly, programs can do a lot of harm.
What do you think?
Fidelity to the Housing First model was a key consideration that emerged throughout several of the researcher videos. At the same time, Housing First needs to be flexible enough to meet the unique needs of populations such as Indigenous persons, women, youth, seniors, and veterans. Do you think we can achieve fidelity to the model and have flexibility? If so, how? If not, which do you feel is more important?
We end this section with the briefest of clips from Dr. Cheryl Forchuk because it leads us nicely into the final section on where we are heading with housing and homelessness policy today.
Dr. Cheryl Forchuk: Is Housing First a solution to homelessness?
In this video, filmed at a hospital during the COVID-19 pandemic, Dr. Cheryl Forchuk succinctly frames Housing First as an important human-rights based strategy, although not the whole solution to homelessness. This video is 0:27 in length and has closed captions available in English.
Key Takeaways ā Dr. Cheryl Forchuk: Is Housing First a solution to homelessness?
- When you look at housing as a basic human right, Housing First is a really important strategy and part, although not all, of the solution.
In this section we asked you to consider the question, āIs Housing First a solution to homelessness?ā We then set out on a winding journey to find the answer. We started in America with the work of Dr. Sam Tsemberis whose program Pathways to Housing has been greatly influential in developing the Canadian approach to Housing First. You may have been surprised (or not!) to learn that we actually had earlier forms of Housing First that developed around the time mass homelessness emerged in the 1980s and 1990s, but that the early forms had fewer intensive supports associated. Today our approach to Housing First is based on 5 principles and has wrap-around supports in the form of Assertive Community Treatment [ACT] or Intensive Case Management [ICM] depending on a personās support needs. You can learn more about both of these treatment approaches in the chapter on Mental Health.
The evidence for Housing First in Canada comes largely from the ground-breaking At Home / Chez Soi study. While the research clearly points to the success of the model, it also identifies gaps in its ability to address underlying issues, like wealth inequality and the lack of affordable housing available in many cities across the country. Housing First has been shown to be cost effective, but also requires more work to ensure people feel connected to their communities after being housed. Fidelity to the Housing First principles is critically important, and with this in mind there have been many adaptations made to meet the needs of populations such as Indigenous persons, women, youth, seniors, and veterans.
Housing First is a big idea that, while seemingly quite simple, is actually rather complex. If you wrote down a response to the opening question, āIs Housing First a solution to homelessness?ā we encourage you to return to your answer now and see whether your views have changed at all. While we know a lot about the effectiveness of Housing First, we still have a lot more to learn.
Podcast: Is Housing First a solution to homelessness? (47:59)
Click the link below to listen to all of the researchers answer the question āIs Housing First a solution to homelessness?ā in audio format on our podcast!
