Why does Housing First work?
I was genuinely delighted to receive an invitation to speak about ‘why Housing First works’ at Homelessness Link’s recent Housing First National Conference. It gave me an opportunity to share my musings on a question I’ve been pondering for nigh on a decade, that being: what is it about Housing First that fosters such positive housing (and other) outcomes for a group who have traditionally been poorly served by mainstream provision?
In reflecting on this question, I looked to the growing body of work on trauma – and adverse childhood experience (ACE) in particular – on the way affected individuals engage (or not) with support services. My thinking on this has been strongly influenced by the work of two people: firstly, Nikoletta Theodorou, a PhD student here at I-SPHERE, Heriot-Watt University, who is studying the influence of trauma on attachment styles and service use; and secondly, Dr Adam Burley, a consultant clinical psychologist who works in a specialist healthcare centre for homeless people in Edinburgh.
In an article in FEANTSA’s most recent Homeless in Europe magazine, Nikoletta and I review what is currently known about the links between ACE and homelessness. We point to increasing quantitative evidence that there is an over-representation of ACE amongst homeless populations. This corroborates the findings of years of qualitative research which highlights a need for early intervention. On a personal note, I have often been struck by the frequency with which homeless people answer a question about the triggers to their current situation with a comment along the lines of “Well, when I was seven…”
The best data we have on the prevalence and nature of ACE amongst homeless people in the UK comes from the Multiple Exclusion Homelessness study, which involved in-depth surveys with 452 users of ‘low-threshold’ services in seven cities across the UK. This indicated that sexual and physical abuse had been experienced before the age of 16 by 23% and 22% of respondents respectively. More than a quarter (27%) had witnessed violence between their parents or carers, and almost as many (24%) reported that one or more parents/carers had a drug or alcohol problem. A total of 15% had not had enough to eat at home during childhood.
Existing evidence indicates that adversity can not only predispose those affected toward severe and multiple forms of disadvantage later on, but can also create barriers to recovery. Whilst there is much more to be learned about why many people affected by ACE do not go on to experience severe disadvantage as adults, it is widely accepted that trauma can seriously influence the way individuals regulate emotions, cope with challenge, and sustain positive relationships with others – and that, of course, includes relationships with service providers.
I have found Dr Adam Burley’s work on this subject particularly illuminating. In an article in the Homeless in Europe issue referred to above, Adam explains that all health and social care is fundamentally relational: involving one group of people (service users, patients etc.) coming into contact with another group (support workers, doctors etc.) in a relational dynamic that centres around the need for and provision of care. He explains that when service users communicate their histories by behaving in distressing ways – or at best failing to ‘engage’ in the way they are supposed to – they can be (and often are) excluded or discharged. And so the cycle of exclusion and rejection continues, potentially exacerbating already vulnerable individuals’ reticence to seek and make use of support.
Providers are often guilty of behaving in an ‘institutionally autistic’ way, Adam argues, by assuming that everyone can make use of support in a straightforward and anxiety-free way – when in actual fact, while some clients desperately need and often want care, they may at the same time be quite phobic of it. Some can, as a consequence, react to offers of support in ambivalent or dismissive ways.
Mainstream services quite understandably struggle to cope with this ambivalence or dismissal. The increase in appetite within the sector for more personalised and psychologically-informed services reflects recognition of a need to do things differently for homeless people with complex needs. Housing First is just one (albeit a very important one) of a number of developments within the sector which aim to be mindful of such issues.
So, what is it about Housing First that appears to accommodate, and potentially overcome, the ambivalence toward and/or dismissal of care described above? To my mind, there are four key ingredients that underpin the success of Housing First with the client group traditionally targeted by the intervention, that being homeless people with co-occurring mental health and/or substance misuse issues.
The first is the longevity of secure housing and support. Dr Sam Tsemberis, the founder of Housing First, has always argued that providing someone with secure housing without first insisting that they are ‘housing ready’ gives them a stable platform from which they are in a much better place to address other issues in their lives. In short, assurance that the accommodation is theirs for as long as they need it obliterates users’ anxieties about ‘what happens next?’ housing-wise. This frees up headspace to devote to other things – and it is hard to overstate how significant this can be in facilitating recovery. The same is true of the fact that support will not end at some (often apparently arbitrarily) pre-determined point in time, but is available for as long as it is needed.
The second key ingredient is the flexibility of support, which allows for peaks and troughs in intensity, as well as ‘dormant’ periods if/when it is not needed; so too true flexibility as regards the type of support offered, such that it is not limited to that which is strictly ‘housing-related’ but can relate to all areas of someone’s life. This flexibility allows for the operationalisation of a truly client-centred approach which respects individual choice and gives users a greater sense of control over their own lives. It also enhances providers’ chances of remaining in a positive relationship with users – as residents are not constantly passed between providers with different specialisms (but often a shared disinclination to work with this client group), or have past experiences of being ‘let down’ by services repeated because what they need is outside of a specific provider’s commissioned remit or exceeds the maximum number of support hours costed for.
Third, the ‘stickability’ of Housing First fosters trust of, and receptivity to, support. Many Housing First users have been excluded from, and in their view rejected by, mainstream services for years. Some have rendered themselves ineligible for support time and again by failing to ‘engage’ in the way or to the extent they are supposed to, for example. For some, these patterns confirm their own long-held perception that they are not worthy of support, and/or that service providers (like so many other people in their lives) cannot be relied upon. Housing First also allows for greater ‘honesty’ in discussions with staff, in that users need not fear losing their accommodation if they disclose a relapse, for example. The realisation that Housing First teams will not ‘give up’ on them, but will persistently and respectfully continue offering support regardless of such instances comes as a (welcome) shock to many users.
Finally, I would argue that the normality of Housing First is integral to its success. It (typically) uses ‘ordinary’ scatter-site housing that is not differentiated in any way from other homes in that neighbourhood. The support is not delivered in specialist ‘homeless’ service settings, but in an individual’s own home and community. Housing First also offers what many perceive to be an invaluable ‘escape’ from potentially destructive cultures on the street and in congregate forms of accommodation. Critically, these aspects of normality mitigate stigma and facilitate an individual’s integration into mainstream society – if and when they feel ready to do so, at the pace they wish to do so, and to the extent they desire.
Why does Housing First work? It works at least in part because the approach adopted recognises the impact of adversity on a user’s often ambivalent or dismissive relationship with care. By allowing for longevity, flexibility, stickability and normality, Housing First avoids excluding people with difficult histories for behaving in ways that are not only entirely understandable, but also (to an extent) predictable.