‘Housing first’ and helping the homeless

In its recent series on a controversial program for the homeless, The Times described a project called Project 50 that seeks to put a roof over the heads of substance abusers without requiring them to undergo substance-abuse treatment, while still offering them as many services as they would use.

The new approach, known as “housing first,” has been heralded in communities across the nation as a promising solution to end homelessness and save taxpayer money. Skeptics have asserted that the program is both wasteful and immoral because it simply warehouses substance abusers, enabling them to continue their self-destructive lifestyles with the support of taxpayer dollars.

The best answers to this debate will come through careful research. My colleagues and I are evaluating a similar program in New York City, which three years ago began the effort to house 500 chronically homeless individuals with alcohol and drug-abuse problems. While the results of this study are forthcoming, our initial findings on this and similar programs can help inform the current debate.

As with any social program, questions about the success of housing first depend on the expectations. Here are three useful measurements: Does it reduce homelessness, save taxpayer dollars and help rehabilitate individuals compared with other programs?

Certainly, the program has done a good job of providing stable housing. In New York City, 84% of the active alcohol and drug-user population remained in housing 18 months after the start of the program, a figure that was higher than another housing program that required clients to get substance-abuse treatment. These results are consistent with other research on the subject.

Housing first programs are thought to save money because homeless substance abusers are perpetually in crisis and, as a result, use such expensive services such as emergency rooms, ambulances and hospital detoxification services. The cost of these crisis services can run well over $100,000 a person in one year, far greater than the cost of a housing first program.

Is that actually what happens in practice? Early findings are promising. In one study, chronically homeless alcoholics in Seattle were selected on the basis of their extensive use of crisis services in the prior year and placed in a housing first program. After one year, the cost of services was $13,400 a client, a savings of more than $42,000 a client.

These results cannot be extrapolated to suggest that housing first will uniformly save money. More studies are needed. However, they illustrate that the current system incurs large costs to care for homeless substance abusers with little tangible gain for them or the public, and that housing first may offer a better option.

Finally, do housing first programs successfully rehabilitate clients, or do they simply allow self-destructive behaviors to continue? Unfortunately, there is substantially less data to answer this question. Given the lack of firm information, housing first should neither be denounced as immoral nor extolled as the single best answer. What is known is that, based on the science, most addiction treatment professionals support programs that make few or no demands on the homeless as one useful strategy for working with vulnerable or disabled clients. Accumulated evidence indicates that for the chronically homeless, refusal to seek treatment may reflect a deep sense of hopelessness and distrust of all social institutions, as well as a myopic preoccupation with daily survival on the streets that overwhelms the ability to consider the future.

Findings in our study support this perspective. More than half of the clients entering housing first expressed the desire to quit drinking or using drugs altogether. At the same time, most of them rejected treatment for their problem as well as other help such as medical care, suggesting that hopelessness and mistrust of help appear to be bigger issues than a desire to drink or use drugs at all costs.

As often happens around hot-button social issues, rhetoric on each side of the issue threatens to eclipse informed debate. Though more studies are needed, evidence to date supports housing first for active substance abusers as a helpful solution to chronic homelessness and a possible cost-saver.

Jon Morgenstern is a vice president at the National Center on Addiction and Substance Abuse at Columbia University and a professor of clinical psychology in psychiatry at Columbia University College of Physicians and Surgeons.