Decades of research have shown that focusing on housing, without making sobriety or mental health treatment a prerequisite, is the most effective way to reduce homelessness
26 January 2023
In the past few months, government officials across the US have announced initiatives to reduce homelessness, a problem that has become more widespread, visible and contentious since the start of the pandemic. Yet many of the proposals now being pushed ahead seem to ignore the evidence about what actually reduces homelessness, and instead perpetuate costly and ineffective strategies that are unlikely to make a difference in the long term.
Half of US adults say the problem of homelessness is a major worry. In cities including New York, San Francisco, Portland, Oregon, and elsewhere, concerns about the number and size of outdoor encampments has been growing.
This increased visibility does reflect a real rise in numbers in many places. In New York City, for instance, nearly 19,000 people slept in the city’s shelter system for single adults each night in December 2021 – a 91 per cent increase from 10 years ago, according to a recent report from the Coalition for the Homeless.
A rise in homelessness isn’t just happening in the US, either. In England, in part due to the ongoing cost of living crisis, more than 74,000 households were homeless or at imminent risk of losing housing between January and March of last year, according to the charity Shelter. That represents an 11 per cent increase compared with the previous three months.
The response in the US has been a flurry of announcements about efforts to reduce homelessness – mainly by increasing policing and changing rules to make it easier to place homeless people into mental health facilities. In September, for example, California ratified a law that will create a court system to get more people with severe mental illness, many of whom are unhoused, into care. And in November, New York City mayor Eric Adams announced a change in policy that makes it easier for officials to hospitalise unhoused people involuntarily for mental health treatment.
Many of these new initiatives rely heavily on an old idea known as “treatment first”. That is, government agencies provide people with housing, but only on the condition that they stay on mental health medications or not return to misusing drugs.
Yet we have known since at least the early 2000s that there is a better way. During the administration of George W. Bush, the US changed federal policy to prioritise a “housing first” approach. The fundamental idea behind it is that people are far more likely to manage serious health problems like addictions and mental illness if they have somewhere to live, as opposed to requiring abstinence and treatment compliance as a condition of having a home. When you are constantly cycling through rehab and temporary housing because you get expelled when you don’t maintain perfect abstinence, the instability itself makes recovery more difficult.
Since then, numerous studies have shown that, when funded and managed appropriately, housing first works: it is associated with significant declines in homelessness.
Between 2010 and 2022, after the Department of Veterans Affairs began a large-scale housing-first initiative, there was a 55 per cent decline in homelessness among people who served in the military. This progress was maintained, even during the pandemic. Cities like Houston and Abilene in Texas that have used this approach for chronically homeless people – and that are able to sustain availability of affordable housing – have seen similar success.
Studies that directly compare housing first to the old treatment-first approach consistently show that housing first keeps people sheltered for longer and improves quality of life.
Even though addiction recovery is not a prerequisite for housing under this approach, in most direct comparisons, substance use outcomes are equivalent or even better for housing first. In other words, fears that “enabling” people’s addiction by not requiring abstinence as a condition of housing are unfounded.
Moreover, one study found that in 86 per cent of cases, even the most severely mentally ill people with substance use disorders will leave the streets voluntarily if appropriate outreach is conducted and if their new housing has supportive services. A key factor though is that these services must be voluntary as well.
There is now ample evidence pointing to an approach that works to reduce chronic homelessness. While the research about cost-effectiveness is sparse, the approach has been shown to be cost-effective when used specifically among the most severely mentally ill, whether or not those individuals have substance use disorders. And, in a hopeful sign, the Biden administration recently recommitted to housing first, offering support for cities and states that want to expand it.
The major obstacles to resolving homelessness remain ideological. It is politically hard to sell the idea that people who take drugs or are disruptive should get free housing – even when the evidence shows that is actually what works.
Maia Szalavitz is the author of Undoing Drugs: How harm reduction is changing the future of drugs and addiction
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