New Zealand has some of the worst housing deprivation rates in the developed world per capita, and they appear to be getting worse. An article citing OECD statistics by Yale Global Online states that New Zealand has the worst homeless rate in the OECD adding that “more than 40,000 people live on the streets or in emergency housing or substandard shelters”, making up nearly one percent of the population. In recent years the issue of housing deprivation has received more political attention, culminating in a government announcement this year to tackle the problem with a $100 million emergency housing package. The previous and current government has also given considerable fiscal support to Housing First projects to significantly reduce chronic homelessness.
Dr Sam Tsemberis is a clinical psychologist and CEO at the Pathways Housing First Institute. He is also a faculty member at the Department of Psychiatry at Columbia University Medical Center in New York. Tsemberis is the co-author of Housing First: Ending Homelessness, Transforming Systems, and Changing Lives and author of Housing First Collection: The Pathways Model to End Homelessness for People with Mental Health and Substance Use Disorders. He is also the founder of the widely replicated Housing First model. Reuben McLaren spoke with Tsemberis to discuss the conception and structure of Housing First.
This interview has been edited for clarity and length
Reuben McLaren: How did you come up with the idea of Housing First?
Sam Tsemberis: It was not like it was a light bulb moment, if that is what you mean. It was really something that was arrived at after trying many different things with trial and error. Initially, what was consistent is the problem that I was trying to solve; which was, why were people with mental illness on the streets. I’m a psychologist by training so I’m not really a housing person. I’m more focused on how people are doing and what their mental state is. I was in New York City and there were an incredibly high number of people with mental illness on the street. This is a huge public health problem and as a psychologist I was trying to figure out how we can help this group of people. I wasn’t trying to solve homelessness, I was trying to help people with mental illness on the streets; that is a very different problem. And I say that because lots of organisations, for example, Coalition for the Homeless or other advocacy groups for homeless want to solve homelessness for everybody. What they end up thinking about is how to get people in affordable housing, and instead it becomes a conversation about housing affordability. That is not where it started for me. For me it was how I can help this person with mental illness on the street, and the work that I was doing initially was actually very clinical. I was working in a hospital and we had an outreach team, so I figured out that you’re not going to help someone by waiting for them to show up at the clinic for an appointment. So we had an outreach team and we would drive around the city and interview people and try and persuade them to come with us to a clinic or come to the hospital or see if there was something we could do for them that would be helpful. Mostly what we had to offer was a drive to a shelter, because that is what was available for homeless people, or maybe treatment. And you know people were very polite and mostly turned us down. Some people would accept the offer. We also had the authority in that programme if we thought that somebody on the street was possibly so incapacitated really that they were not able to take care of themselves — for example, they had pus oozing out of their shoes or they were coughing up blood, something really dramatic. We had the authority to take people involuntarily to the hospital if they were refusing treatment and we thought they were a danger to themselves or to others. We couldn’t bear to leave a person out there on a cold freezing night [if] it didn’t look like they’re going to make it.
We did that hoping that the person from the hospital would go and end up, after being discharged, in some nice residence or something but that didn’t happen as much as we would like. And often the people that we were hospitalising would be back on the street. It was these kinds of repeated failures that made us think we had to do something different. What we decided to do was to choose to let the person drive good treatment rather than assuming we knew what was best for them, like taking them to the hospital. We decided to just try and engage people and do whatever it is that they want. At the beginning for me, Housing First was like letting go of the idea that you actually know what you’re doing and instead see what the person wants. It moved from a clinician-driven system to a person-driven system. So, once we began to ask questions like that it was very clear that people want good housing, they didn’t want to go to a residence or a shelter, they want just a simple place to live. And then it became a bit of a practical problem because, when we would take people to the housing providers, they didn’t want to give [housing to] people who were actively symptomatic or may be actively using drugs. There was the culture, and [it] still is the predominant culture today, that people need to be taking medication in treatment, clean and sober, before you give them a home otherwise they won’t be able to manage a home. All the programmes that existed were like that, they were treatment first and sobriety essential, in order to get housing which is a bit of a hypocrisy really. When you think about it, how many of us would still be housed if we had to be completely sane and clean and sober every night?
RM: So basically people had to almost earn the right to have a house.
ST: They had to earn the right to housing — housing as a reward. It was often considered that way as an incentive or the carrot approach, like housing is the reward for good behaviour. This moralistic sentiment is even more prevalent now. The more conservative the government, the more punitive the social programmes; because the assumption is that they’re out there because they’ve made bad decisions, they’ve squandered what they had and they’re just lazy. They’re loitering and trespassing, and they should get their act together. There is not only a clinical but a moral dimension to it. So that is the only way that people would be given the opportunity to be housed. I did try to persuade the hospital to start a housing programme, because I knew what we were doing wasn’t working. The hospital was not really interested in that kind of business, so I left. I then started a non-profit, which is very easy to do, to get a grant from the money available for what they called supported housing. Now most of the people who supported housing were running it exactly the way I described, clean and sober and then you get housing, but there was nothing in the stipulation of the contract for that grant that said you had to follow a particular sequence. You had money for the rent and you had money for case management. The sequence was up for grabs. So that is how we ended up going back to those people on the street and they’d say, “I want a place to live”. So I’d say, “You know what, I can help you with that. Now I’m going to help you find a place to live. Where do you want to live?” And so instead of going from streets to hospitals or streets to shelters. It went right from the streets to homes.
RM: How exactly does the Housing First programme work?
ST: You identify people that are eligible, the people who need support after they’re housed. Remember the programme is really about helping people, housing is just the first step. So you identify people, you help them find a place to live of their choosing to the extent possible. You don’t get a ton of money, you have to rent cheap apartments, sometimes in difficult neighbourhoods. But people love the privacy and security of their own home and having the dignity of a lease and everything else — they could watch their own TV. A lot of the people that we’ve housed have never even had a place of their own. So they get a place of their own but that is when the programme actually begins. Housing is step one of a multi-step process that is years and years long in some cases. All you’ve done is you’ve brought someone who has mental illness, who has addiction, is poor, has no social ties at that moment, all kinds of health problems and heaven knows what else. And now you brought them inside: that is all you’ve done. Now the work of addressing all of those issues can begin because the person can look at those things. When people are on the street it’s instinctual, a survival instinct. All you can think about is “I’m thirsty. I’m hungry. Where am I safe to sleep? Where am I going to spend the night without getting arrested?” It’s just adrenaline-driven survival, kind of living in a state of trauma all the time with no time to reflect or think, “What is my plan?” Rather than thinking about getting to the next moment. The housing begins the possibility of recovery.
RM: Basically you put people into a house, give them a safe place to sleep, somewhere permanent or semi-permanent, and then you treat the other conditions. How is it at odds with other programmes? Is it a better model?
ST: Most other programmes have an approach that says if you’re homeless you come into the shelter, you have to complete a certain period of time getting yourself ready. You try and go to treatment and then they will move you into some transitional housing because you need to learn how to live — indoors again, essentially; how to manage a house. The person must be compliant with the rules of the programme and the demands of the treatment. Some of the programmes have admission criteria. Like you have to be sober for three months or six months or twelve months or eighteen months. Or you have to be on medication or seeing a psychiatrist, you have to be willing to go to group [therapy]. There are all these conditions not only to get in but conditions that you have to meet in order to stay in housing. So that is how it’s different, there are no conditions here. Well, there are conditions — the same conditions that you and I have — you sign a lease, you pay thirty percent of your income towards the rent, and you have to abide by the terms and conditions of a standard lease, you can’t be doing illegal things in the apartment, you can’t have traffic in the apartment, you can’t be making all kinds of noise that disturbs your neighbours. The same kinds of things that would get any tenant into trouble or get the tenants of the programme into trouble. But it’s very different, it’s housing that is normal housing. It’s not a programme. You don’t have social workers living there, and it’s different in that, if people are using, if they’re smoking dope or drinking beer, it’s like everybody else smokes dope and drinks beer — you do it sensibly, you don’t make a show of it or you don’t get yourself into trouble using or drinking. You try and manage their behaviour, to help them manage money, just harm reduction. To help people minimise risks associated with behaviours that may have gotten them addicted maybe the first time and you try and support them into a positive lifestyle. That is very different than requiring that they have a positive lifestyle before they move into housing. That is what is different.
RM: What are the main principles the housing first model is based on?
ST: There is a social justice component to it because we think that housing should be a basic right for everybody, so that is sort of foundational. You don’t have to earn housing, everybody deserves a right to housing. The operational principles of the programme are very much born out of the kind of consumer movement, or the movement that represents people with lived experience of mental illness, which is the right to self-determination, the right to choice and services, the right to refuse treatment if that is not what is working for you. So there is a lot of choice and self-determination as a philosophical approach to how services are offered. There is a principle that we call the separation of housing and services, which is if you don’t want treatment, we will visit. We visit everybody in the apartments; no one is left alone. But that is not treatment, that is a visit to check if you’re okay and the apartment is okay. The separation also refers to the fact that if somebody leaves that apartment or is evicted from it they will not lose the support of the team of service providers, they will be helped to either get another place or wherever it is that they’re going so people don’t get lost. People don’t get discharged from this programme. The programme stays connected to them. It’s very difficult to get discharged for some kind of infraction of the rules, because we try and minimise the rules, so that is a principle. There is a principle that says it’s our responsibility to make sure the person is getting the services they need for all of what ails them. If they’re not doing well, we’ve got to figure out where to get them to a doctor or a doctor to them. We take responsibility for their well-being, not leaving it up to them so much. But that is done artfully because at the same time we’re not insisting on treatment, it’s a dance. Those are some of the principles that guide it, people should have the right to a life of their choosing the best way they can, given their circumstances.
RM: Has this approach received much criticism?
ST: Most of the criticism early on was that it doesn’t work: “You can’t possibly turn over that much decision making to people that are obviously diagnosable as either having a mental health or an addiction problem”. There was a great disbelief in the capabilities of people, not so much from policymakers or from people that were in programmes but from other providers using the other model. There was a disbelief that this could actually work. You know just that there was this disbelief in the credibility of the results — which were, by the way, incredible. When we did randomised controlled trials of people going into Housing First versus the treatment first then housing model, it was like eighty percent success in housing stabilisation over two years and longer periods versus thirty to forty percent housing stabilisation for the treatment first group. It’s very hard for people, especially because these conditions are relapsing conditions, to stay clean sober and in treatment. If their housing was connected to it they would often drop out. So the results were incredibly powerful for a social services intervention. There was also pushback on the idea that harm reduction works. People are attached to the ideas of once an alcoholic [always an alcoholic], the 12 step [programmeme], but the sobriety driven treatment model for addiction did not welcome a harm reduction approach. There was pushback around that. I would say those are the main arguments that we had.
RM: I’m reading an article from The Huffington Post criticizing the Housing First model as moving funding away from maybe more traditional shelters to organisations that are running the Housing First programme. The headline is: A ‘Housing First’ Solution Could Actually Stimulate Homelessness.
ST: Really, how? Is it because people would leave and walk on the streets because they figured out they can get an apartment instead?
RM: Denise Andorfa of the Vincent Villages says the Government is now just giving vouchers out which puts people in homes and the government pays their rent. But the behaviour doesn’t change and most end up homeless again. How would you respond to that?
ST: First of all, it’s not true, it’s factually false. There are many studies now that show that when someone does get a voucher and is placed into a home [then] the behaviour changes; they are not on the street, they’re at home. They’re cooking at home, living at home, they’re inside. And that last part, especially, is a completely false statement that they end up back on the street. I just finished telling you about the randomised controlled trials, well documented in peer-reviewed journals, done by not just me, but many, many other social scientists, that show there is an eighty percent housing retention rate with Housing First. That is the reason people are looking to use this Housing First intervention everywhere because it actually works. So that is a very misleading and inaccurate statement.
RM: Do you think some of these criticisms come from an ideological background that is adverse to this sort of thing?
ST: I think there is an ideological background that believes that people have to earn it. I think it’s very strong. That is the culture, that is the Anglo-Saxon culture. You know if you think back to the early shelters, I don’t remember where I read this, a book on homelessness by Carol Caton maybe. She describes the early London shelters. You don’t have to know a lot of history to remember that there was a pauper’s prison, and it was like people who were poor and couldn’t pay their bills were put in jail. It started in England and similarly in London around that same time, this is around the 1700s, beginning of the industrial revolution. They had a shelter in the east side of London and a shelter on the west side of London and you can only stay one day in each shelter. These individuals and families would have to carry their belongings all the way across town, which took them a whole day and just kept them in perpetual motion because they didn’t want people getting too comfortable. There is this very strongly held belief that if you make services too easy people will take advantage of them and so there is a real fear about things like giving away an apartment to somebody who has mental illness and addiction, like somehow you’re making life too easy for them. It’s not enough that they’re poor on the streets, have mental illness and addiction — as though they have not suffered enough.
RM: Some studies have found that providing housing and support services for homeless alcoholics actually cost taxpayers less than leaving them on the street, with taxpayer money going instead towards police and emergency health care. Is this a common finding?
ST: Though I’m not an economist, I think even if this intervention cost more we should do it because it’s the right thing to do. It was not something I had anticipated or thought about very much, but it did occur to me when I was doing that hospitalisation programme — for example, we take somebody off the streets, we put him into Bellevue Psychiatric Hospital in New York at $1500 a day and the average length of stay was about a month. So we just spent $45,000 for a one-month hospitalisation and then the person was back out on the street because the person would say, “I’m going to my aunt’s house”, and they walk out of the hospital. It’s not a pleasant place, especially psychiatric hospitals. So that was interesting and very surprising and substantial. I don’t know what study you’re referring to, but there is one by Mary Latimer in Seattle where they put people in permanent housing, all in one building, not their own apartment but that sort of same deal and used a harm reduction approach. These were people that were in downtown Seattle and they were heavy drinkers and they were falling and hurting themselves, there were sutures and emergency rooms and detox. They saved millions of dollars in acute care services by having folks go into housing and having the support services on site. I have to say… the cost argument has actually in many cities become the winning arguments for the conservative element of a community that is like, “Well, I may not believe that giving housing away, and I may not believe in this harm reduction, but I do believe in saving taxpayers money and if it’s a lot cheaper, let’s just do it and look the other way on the values piece.”
RM: It seems almost a cynical approach but fine if it brings about the same result. Can you tell me about the Housing First projects in New Zealand? I understand there is a programme being run in Auckland in partnership with Lifewise and the Auckland City Mission. They have received millions of dollars in funding from the government last year and also $10 million from a public trust.
ST: I was there from the beginning. I was there about four years ago, I guess, initially at a conference with people from an organisation called the Wise Group and Moira Lawler from Life Wise. Anyway, they [were] like, “We have to do this”. When I came I thought, “There are two hundred something [homeless] people in all of New Zealand, you can actually end this in a year.” I visit Los Angeles and there is twenty-four thousand. I don’t say we can end it in a year there, but two hundred and seventy or whatever the number was in New Zealand, it definitely could be done. They were very keen and I think they really advocated very well too. Initially they were going to do it on their own and then government began to recognise that there was merit to that approach and it’s really taken off in a fantastic way. I think there are five organisations altogether, not just in Auckland, but the surrounding areas too. I was there when we launched the programme, I trained the staff for a few days that had been hired to do it. I’ve been following it closely now, I think it’s a tremendous initiative communitywide on a good scale where hopefully it’s going to have a real impact on the quality of life of everybody. Ultimately this solution is not going to be a clinical conversation like the way I’m emphasising it. It’s going to be someone that is going to step up and actually build affordable housing, because all we’re doing with Housing First is, we’ve learned how to take pretty much everybody and if you can house the people that Housing First puts into housing and helps them stay stably housed, you can house everybody. But then you get quickly to the conversation about the affordability of housing. What about people that don’t need Housing First? They don’t need a case manager or a nurse, they just need money for rent. So at some point the housing affordability crisis is going to be the real end to homelessness, not just for the very vulnerable. If we don’t take care of that we’re just going to have more people falling into homelessness, it’s just going to be like, “Oh, we’re getting more and more efficient at getting people off the street”. We have to actually get them to stop falling into the street. There has got to be prevention there at some point.
It’s all about distribution of income and how we’re spending money. It’s all about the social safety net. I usually look at something called the Gini coefficient which measures income disparity. There has been a couple of papers that talk to the fact that the higher the Gini, the more homeless and the less services and housing that supports for them. There is a correlation there across nations. And so that is why I was a little surprised because New Zealand has become a little more like Australia, sadly, and Australia is like a wannabe America. So I’m thinking why aren’t they looking at Europe, that is a much better system. Scandinavians, their capitalism doesn’t create the same level of disparity because their tax system is still holding in and much of the housing is owned by non-profits. It’s all about this drive for profit on the housing, you need to get some limits on rent control or non-profits owning the housing, so it doesn’t become one of those commodities on the market because salaries aren’t keeping up.
RM: These are likely consequences from the change of the socio-economic approach New Zealand veered towards in the 1980s, basically privatisation and deregulation, and now we’re seeing all these rents seeking and predatory behaviours.
ST: Right. So that is what I mean, people are all like, “Homelessness, it must be about mental illness and addiction”. No, not at all. It’s not about that, it’s about this. It’s about the larger market factors disproportionately hurting the people who don’t have jobs. And the people with mental illness and the people struggling with addiction who don’t have the jobs are the ones that fall into homelessness because now the market has become out of reach for their very meagre means or government benefits. They’re the first ones to fall out and — I think because they don’t have a good public relations firm for the homeless — they get labelled, as though the homelessness is their fault. But you didn’t have homelessness before the 1980s, before all of these structural changes came into being and the privatisation. It was the privatisation that created the homelessness, not the mental illness and addiction. They’re just the most likely victims.
RM: I suppose there is the idea that treating the symptoms — such as homelessness, substance abuse, and mental illness — may actually reinforce the socio-economic status quo. This is because charities and non-profits are stepping up to fill the void and the problems created by government policies, enabling them to continue what they’re doing.
ST: That is right, and I think if you look at that across countries, places like the U.S. have an enormous number of non-profits, and places like Sweden don’t, because the gap is just so much bigger. But I don’t know what to do with that dilemma, because leaving people on the street to make a point of political principle, however correct it is, is not really an option. How do you address that?
Reuben McLaren is a Politics and International Relations student at the University of Auckland and hosts ‘The Wire’ current affairs show at 95bFM.
Disclaimer: The ideas expressed in this discussion reflect the views of the guest and not necessarily the views of The Big Q.