Hello and welcome to Listen.Up.People., a podcast
of the USC Suzanne Dworak-Peck School of Social Work.
I'm Dr. Holly Priebe Sotelo, Associate
Teaching Professor of Practicum Education. We
have a special episode today because it is not
often that my guests have literally written the
book on the subject we are covering, but indeed
my two guests have, along with Deborah Padgett
at NYU Silver School of Social Work. So we have
an opportunity to take a deep dive into the model
that has been at the forefront of efforts to
end homelessness. Yet these results are now being
challenged by the federal government and Housing
First has become a somewhat controversial subject.
I'd like to welcome my social work colleague,
Dr. Ben Heinwood, the Frances L. and Albert G.
Feldman Professor of Social Policy and Health,
and Dr. Sam Tsemberis, who developed the groundbreaking
Housing First approach and founded the Pathways
Housing First Institute. Thank you so much for
joining me today. I'd like to start with a more
personal question about how you first became
interested in working with people experiencing
homelessness and how did your collaborations
start? So we'll start with you, Sam. Well, thank
you. Thank you, Holly. It's a pleasure to be
here. How did the interest in homelessness start?
I have to back up saying that I'm quite old,
which means I was around before homelessness
started. So that you know people have to imagine
a city where there aren't homeless people and
There's just you know business and families walking
around and suddenly a homeless person appears
Now if people can remember the first time they
see a homeless person. It's like there's a sense
of shock disbelief sadness Just confusion like
what's this person doing on the street? So my
interest in homelessness started when people
first began to arrive on the street. And I'm
a psychologist by training, so I was particularly
drawn to the people on the street that appeared
mentally ill. It's like, of all the people that
are on the street, why are these people on the
street? And that started me on a journey of questions
of like, where did they come from? And where
can we take them to? You know, kind of looking
for practical, sensible solutions to this issue.
So I was drawn to wanting to solve that problem.
And how did your collaboration start? With Ben?
Yeah. Well, I started this organization to do
housing first. And Ben was in social work school
and he appeared, you know, he came to do an internship
at Pathways to Housing in New York City. And
it wasn't hard to notice that there's a very
bright, caring, practical person here. It was,
you know, Ben was a pleasure to work with right
from the start. The other thing about our collaboration
is that I recognized we had a values compatibility,
you know, this is This is not just a program
that's practical or just clinical. You have to
feel a certain way about people. You have to
believe that they deserve housing, that there's
a social justice component to it. And it was
clear that Ben had the kinds of values and the
clinical smarts and it's like... You know when
when he finished his internship we immediately
offered him a job and wanted to keep him You
know with us and working love that. Thank you
Sam as well I remember that first time seeing
someone on the street and I had that same kind
of reaction like wow What just happened so love
that. Thank you and then what about you? How
did you become interested in this work for me?
I don't really ever I didn't think of myself
as getting into homelessness, because quite frankly,
by the time I learned about it, which was in
my first research class in my MSW program, where
Deborah Padgett was teaching, she was talking
about this research that was transformative that
came out on Housing First that sort of flipped
the homeless service system on its head, where
you were providing people, you know, immediate
access to a home. and then providing them support
services as opposed to making them go jump through
hoops and treatment programs before they could
ever get there. And I think I was really struck
by that approach. And then to hear about the
research that showed how effective it was, it
really got my interest. And so I ended up talking
to Professor Padgett after my class said I was,
you know, super interested to learn more. And
she directed me up to Pathways to Housing, which
was operating in New York and where the study
was conducted. So that's that's how I sort of
reached out to Sam to say I'd like to volunteer.
And so for me, I mean, I just think that's how
I kind of got into the space. And once I started
doing the work, right, I think it wasn't Yes,
it is quite moving to see sort of this transformational
impact that you can have when someone gets an
apartment for the first time. That sort of shared
narrative that you have with them when you watch
them walk into the door for the first time is
quite moving. But I think for me, it was really
understanding that given the history that most
of my clients had at the time where You know,
this was years of people looking right past them,
right through them, not acknowledging them sort
of as a human being. And how powerful that is
when you're able to do that. I think for me that
that was more transformational than the housing.
And that's what I understood the work to be about.
And I think that's what Sam sort of instilled
in everyone working at the agency, which then
is what I learned. And that's really how I learned
to become a social worker. So. In that whole
time, I never thought of myself as doing homelessness
work. I mean, ending homelessness was the easy
part. And for me, you know, it was really about
how do you support people with, you know, very
complex clinical needs after the fact, but at
least they're in. in a place where they can start
addressing these. So I think it wasn't until
I got to Los Angeles where we didn't have enough
of housing and Housing First to actually effectively
address it that I started to actually think of
myself more as looking at the problem of homelessness,
because if there's not enough of it, then what
are we going to do with the people left behind?
And so I think you know, this identity of my
own as being a homelessness researcher is kind
of a more recent in my overall trajectory. Excellent.
Thank you, Ben. Thank you, Sam. And Sam, you
know, as the person who developed the evidence
-based approach we now know as Housing First,
could you please provide our listeners with an
overview of how it began and why does it work?
Well, I think Ben led into that very nicely,
actually, because I think one of the little understood
things about housing first is that it's actually
not about housing. It's actually about listening
to people and providing people with complex needs,
mental illness, addiction, health problems, homelessness,
poverty, the thing that they want most. And when
you do offer that choice, when you turn to people
and listen to them and ask them what is the most
urgent need, they say housing. So we were prepared
to offer whatever it was, but we were led to
provide housing first because that was the thing
that most people wanted. And that was not available.
in any other organization. You had to be sober,
you had to be compliant with treatment, you had
to have curfews. There were all kinds of hurdles
that were out of reach for the people that we
saw on the street. So once we started listening
to people and they wanted housing, we had to
develop a program that could actually deliver
what they were asking for because otherwise...
kind of a breach of the promise that we had offered.
We're going to help you with whatever it is you
want. So we get into the housing business by
default. I also end up in housing conversations
and I'm not a housing policy person. I'm a clinical
psychologist. I know how to listen to people
and you end up in housing because that's what
people wanted. You end up doing a lot of things
that you never were trained to do. because people
have all kinds of needs for, you know, groceries
and reconnection and finding documents. And,
you know, you do the whatever it takes approach.
But I think that in addition to listening to
people, you have to have the kind of staff, you
know, that that Ben was talking about, that people
that have a philosophical approach and provide
services and treat people with a certain dignity
and respect so that it's actually the relationship
with the support services that keeps people housed.
Yes, offering them an apartment certainly gets
them off the street, but all of the support that
they need to stay housed and to begin to have
a life has to do with the quality of care and
support that they receive from people so that
they can succeed. And so it's the housing and
the support with a certain caring, consumer driven
philosophy that sort of makes the program. work.
And then once we were doing that, it was so off
beat. You know, we were the only program really
in the country initially doing this thing. And
it was so wacko compared to what everybody else
was doing that we thought we better do a study
to make sure this thing is working at least as
well as the other program. The other program
was achieving like 30 or 40 percent success,
you know, in getting people housed. And when
we started to do the studies, ours was like 80
percent successful. And we thought, wow, we're
onto something here. Yeah, so simply, like you
said, taking it back to basics of listening first
when you ask people. And so something as complex
as homelessness, but starting where the clients
are, right? And statistically, you know, Ben,
how has Housing First been successful in reducing
homelessness across the country? And how does
Housing First compare with Treatment First or
non -housing -based approaches? Yeah, I mean,
I think that's a really important question, and
maybe a more complicated question than it sounds,
right? Because, you know, anytime you're talking
about a complex psychosocial intervention, which,
you know, which this is, it involves, you know,
figuring out access to housing and support services,
often with the interdisciplinary team, you know,
it's hard to do research in that context. And
you very rarely can do You know, when we think
of like, well, what's the best evidence we have?
We sort of know scientifically doing like a randomized
control trial is or the apex of, you know, that
that that really tells us we know it's about
the intervention and not, you know, not something
else going on in the environment. But there are
very few randomized control trials in this context.
And so typically what you see is a lot of programs,
you know, they'll be an evaluation and they'll
tell you how they did. But then how they did
compared to what? Sam really, I think, had the
foresight to think about that ahead of time and
to, you know, when he was starting the program
to actually implement a randomized control trial.
Again, very, very rare in this kind of social
service space. And that's what I learned about
in my first class, the results of that of that
randomized control trial and heard about the
like the 80 plus percent effectiveness versus,
you know, 30 percent in treatment first. And
You know, 80 % success in kind of anything, especially
something so complicated, I think just for the
listeners, I mean, that that is, it's kind of
unheard of, you know, you'd be happy getting,
you know, the majority of the people that this
is helpful. But if four out of five people are
going to do really well by this kind of intervention,
then then yes, you, you know, you kind of listen
to that. It wasn't just the one randomized trial
that Sam did. But I think Based on that work,
there were other parties that were interested,
and including the Canadian government, and Sam
might want to talk more about this because he
was intimately involved in that too, but to have
five different cities across Canada all doing
a randomized controlled housing first, and to
come up with pretty much the similar results,
you know, that's what replication of of empirical
evidence looks like that's how you actually build
knowledge. So there have been multiple trials,
experimental trials on, and it always comes back
looking the same. And so that gives us confidence
in what we're looking at. But in addition to
that, there have been dozens and dozens of evaluations
of the program that also come up with that 80
% 80 plus percent effectiveness. So We're pretty
confident in those results, as confident as I
think one can be as a social scientist. To your
question, though, right? So that's talking about
if people end up in housing first, how do they
do? And I think the short answer is they do quite
well, right, in terms of not going back to the
streets. But when you're talking about, oh, is
that actually reducing homelessness? That's sort
of a different question, right? And so that's
about Well, how much capacity do we have and
how much do we scale the intervention? And if
you don't scale the intervention, then it is
true that you can have an effective intervention
to address homelessness and homelessness can
also be increasing at the same time. Like there's
nothing inconsistent about that. Both things
can be true at the same time. So I just wanted
to point that out. You know, I think your question,
I think it's how successful has it been, you
know, just from a social science point of view,
I would say very successful. Excellent. Thank
you, Ben. Sam, would you care to add? Well, a
couple of things Ben alluded to. Why do a randomized
control trial? Well, we had done the other trials.
We had done the pre -post and we had done some
comparisons. We were compelled to do research
just to know that what we were doing wasn't harming
people. And the simpler studies were enough to
do that. The problem was that I thought we were
on to an intervention that everybody would want
to take on. It's like, just figured something
out. Like, why don't you do it in, you know,
Washington? Why don't you do it in Detroit, Chicago?
And I would go to conferences and present this
and people were like, no way. No way. You're
taking the easy people off the street. You're
taking those people that are well organized.
And just the opposite was true. This program
targets people that have failed in other programs
repeatedly. We were taking the people with the
most complicated needs that other programs either
would not admit or had tried and failed with.
So we needed a randomized controlled trial because
that was the only way that we could legitimately
say no, the people we're taking are just like
the people you're serving. Your people are, in
fact, our people. And I would say publishing
that changed the conversation from something
that wasn't acceptable. Housing First initially
was not acceptable. It was shunned primarily
by other providers who would not believe in the
results and didn't want to change their system.
People are not comfortable with harm reduction.
They didn't want to put you know, people who
are actively using or actively psychotic in apartments,
it was too dangerous because the whole system
is very risk aversive. This is not a risk averse
kind of program. You have to be willing to take
the chance to give people an opportunity to succeed,
whereas most systems refuse to take the chance
because they're afraid people will fail, you
know, but that precludes the opportunity to succeed.
So it was uphill. It was uphill. And the research
was a huge part of changing the narrative and
having this thing accepted. And then by the time
the Canadians did their randomized control trial,
and it was a similar trial in France, and then
the thing began to have legs, if you will. People
stopped saying, you can't do it here. Could you
come here and show us how to do it? Yeah, wow.
And you know, I know that in a recent article
in The Guardian in the UK, you spoke about how
the current administration has come out against
housing first approach. And now you feel like
you're back as an outlaw in the US. Can you talk
a little bit about what is happening with the
federal funding and why this administration has
seemed to target housing first specifically,
despite all the evidence that it works? The thing
about Back to being an outlaw is because when
we were first applying for a grant from the federal
government It was under the George W Bush administration
and we couldn't use the word harm reduction in
the application You know, it was like it was
an outlaw kind of a program to begin with and
then it got to be mainstream And now here we
are outlawed again, you know this administration
and I think this is I'm not sure exactly what
to say about the rhetoric and how to combat propaganda
with evidence. Because evidence is what we're
talking about. There's a kind of a rational discourse
based on data. Propaganda is free from truth.
You know, people can lie, say anything they want,
and as long as it's a compelling narrative or
said in a particularly catchy way, you know,
as we witness every single day, you know, in
the country right now, the battle for our reality
is at stake here. And, you know, so Housing First
is no different than any of the other things
that are being distorted. And now Housing First
is, you know, not useful because we still have
homelessness. For example, that's one of their
arguments. or that it doesn't work because there
are examples of people moving into housing and
doing terribly, which is true. I mean there is
a lot of implementation of Housing First that's
not well done. So there is some legitimate concern
about how the program is operating, but to dismiss
the evidence by using a kind of a rhetorical
narrative that's completely manipulative of facts
is really what's going on there. But the thing
that they're doing also is that they're cutting
the funding. There's two reasons I think the
government is pushing back against Housing First.
They've changed the tax structure so they want
to not fund any social programs and this would
be one way of cutting it. It also is pushing
against the fact that we have systemic problems
that are causing homelessness. Rents are too
high, benefits are too low, salaries are too
low. But rather than talk about that, they would
rather talk about the fact that homelessness
is caused by addiction and mental illness. And
if people are mentally ill and homeless, you
can't house them. which is exactly the opposite
of what we've been demonstrating for 30 years.
In fact, if people are mentally unhomeless and
you house them, they do much better. But you
know, we're going back to that early narrative
because that shifts the blame from the government
to the individual. See, it's this person's problem
for being homeless because it's something that
they're doing. Thank you. Wow. And Ben, would
you care to add any additional thoughts on that?
When we in 2016 first published the book that
was led by our dear friend and colleague, Deborah
Paget. That was at a time where, right, this
was a program idea that had empirical results
that caught the attention of the federal government,
in part because of those research results, in
part because what we haven't talked about was
that actually this was a cost -effective way
of addressing homelessness because the people
being targeted You know, if you if you leave
them on the streets and you don't give them access
to the housing and the supports. then they will
end up in the hospital, in the emergency room.
They will get arrested. They will end up back
in the hospital. Very, very expensive, right?
And when you provide someone an apartment and
you give them support services, then guess what?
You're not spending all those public dollars
on these emergency systems. And there's research
on that. I do think, I think back to Malcolm
Gladwell wrote an article about Million Dollar
Murray, where he actually was looking at an individual
the man named Murray in Las Vegas and just sort
of documenting how much did it cost to watch
Murray go in and out of systems. And his conclusion
at the end was sort of, you know, you could have
bought him a home and got him a private nurse
for what you spent on all those, you know, the
tax dollars on all those other emergency services.
So there was a, you know, a compelling reason
for sort of, let's say both sides of the aisle
to want to do this, right? It reduced homelessness,
it saved money. It's kind of what's not to love
there. And really at the time when the book came
out, it was this really unique story of evidence
-based practices becoming policy and really rewriting
how we should approach homelessness in this country.
That was 10 years ago, and a lot has changed.
And I don't want to just put it on. the current
administration right because I do think that
you know we did have this intervention that worked
there were a lot of promises that were made like
there were all these like you know 10 -year plans
and homelessness and in a lot of places homelessness
kept getting worse I think of like in Los Angeles
when I got here in 2012 you know our homeless
population has doubled since then and I think
there's look I understand if you're not following
this issue you think how I'm hearing all about
these, you know, effective practices and yet,
you know, now I'm seeing more and more people
on the streets. So I think that there was lots
of frustration. There was sort of no explanation
for it. And so when the current administration
came along and said, you know what, that stuff
doesn't work. People were, you know, tend to
tend to believe what they were hearing because
that's what reflected what they were seen on
the streets, right? And I think to Sam's point,
right, there's nothing inconsistent about that.
If you have these structural issues where people
more and more people are becoming homeless, if
there's not enough affordable housing, you know,
not just for people at the very low. I mean,
everyone feels that housing is very expensive.
And if you get priced out of a basic need, What
does that mean? That means that you're going
to end up without a home. And lots of people
are ending up on the streets. Some people have
capitalized on that confusion and that change
and that over -promising that has led us to this
current situation. which I agree is very, it's
very challenging when you have the evidence in
one hand and rhetoric in the other. And the evidence
is not counteracting that rhetoric. Yeah. And
you know, Ben, this is a really excellent opportunity
for us to talk about the book because I understand
that you've been writing another book on housing
first with Sam and Deborah Padgett. Can you tell
us more about the book? Happy to so this is a
it's a work in progress. The first book that
came out was 2016 So we're 10 years later and
it seems like you know a particularly apt time
to revisit the story because where the story
ended last time was hey, we have the success
story and you know, we were looking at housing
first expansion internationally and thinking
about how to bring it to scale and imagining
the future in which actually we were going to
get a hold of this situation, but you know, the
cracks and the structural issues were there.
We sort of knew it. But imagining we'd get to
a place where affordable housing would be back
on the on the table to talk about as a sort of
a necessary issue that we have to address in
society. But we never did. Right. And I think
and so here we are 10 years later. And I think
what this book is looking at is it's a continuation
of the story to some extent, but it's really
starting with a simple question, which is you
know one that I think a lot of people in the
public have that if we have this evidence -based
practice and it's been widely adopted and the
federal government says oh let's do housing first
then why is homelessness getting worse and again
I think current administration is using that
to to say it doesn't work I think as you've heard
in this conversation that's that's not our take
right I think we argue the problem isn't the
idea it's not the intervention there's lots of
evidence it's you know one it was implemented
in a system of scarcity where there was not enough
housing and that was sort of never addressed.
I think we over promised in terms of right it
became housing first was going to solve everything
which was not you know never going to be the
case. There were we you kind of had to talk that
idea through how does providing access to housing
to people who need it going to reduce homelessness.
That is something we should be talking about
and I think we just lost the kind of conceptual
clarity along the way of what is and isn't housing
first. And even though Sam has, over the years,
done a lot to work on a fidelity instrument to
say, this is housing first. And if you're not
doing this particular intervention, then you're
actually not doing it the model the way it's
intended. We've gone pretty far afield in terms
of that. And so you have a lot of programs saying
they're housing first. But if you're not practicing
that person -centered approach and listening
and helping people solve the problems that they
have, You know, you're not actually doing Housing
First, even if you may have provided someone
access to the park. I'm looking forward to reading
the book. And I understand there's a that you
did a conference in Berlin last November and
that you have another one coming up in May. So
can you both talk a little bit about your experience
at the conference and how Housing First is being
received in Europe and around the world? Well,
the conference in November was in Berlin. The
one coming up in May is in San Francisco. May
12 to 14 up in San Francisco, Ben will be presenting
Ben's last comment about why Housing First got
into a problem here. And the scarcity is not
only the housing as far as I'm concerned, but
the level of support people get. In Housing First,
you're providing housing for people often with
severe mental illness and addiction and health
problems. You can't have one well -intentioned
case manager taking care of 30 people like that.
You know, you need much lower caseload ratios,
you need an interdisciplinary team, people knocking
on the door and offering the help because often
people are reluctant to seek it on their own.
So it's interesting to see this intervention
in different countries, I have to say. Everything
we've been talking about has been the United
States context. So when you go over to Europe,
Now, not all of Europe, but let's say especially
the Western and Northern countries, all of the
Scandinavian countries down through Denmark,
Holland, Belgium, France, Spain, Italy, England,
the United Kingdom and Ireland, all of them.
At the Berlin conference, we had 21 different
countries showing up. It was the first time we
had a Housing First Partners Conference, although
They've been doing Housing First for years. There's
something called the Housing First Hub there
that does technical assistance. But Ben and I
and others had organized this conference just
for the Housing First community of Europe. So
in Europe, they have something called a national
health plan. They have something called social
housing. they have something called a taxation
system that people pay according to what they
earn. So all of their infrastructure is completely
different. What that means immediately is that
there are many fewer per capita people who are
homeless in Europe than we have here in the United
States. We have the highest number of people
per capita homeless because of all of the failed
non -safety net programs that don't exist here.
Also, it was kind of incredible to me at this
conference, everyone talks about housing being
a basic human right, and no one's calling them
a socialist or a communist. It's like, of course
housing is a basic human right. Most countries
have it in their social contract that we're going
to take care of people in terms of their health,
their education, their housing as a matter of
right, not as something to be earned. So context
and the conversation is very different. The countries
have, for the most part, implemented housing
first programs as best they can. I mean, in terms
of the housing is a little less challenging for
them, although there's a housing shortage everywhere.
But what they tend to do is to increase either
their portfolio of social housing programs or
make room for people who are homeless in the
social housing program. The health systems are
quite well established. They don't have a lot
of community health or mental health. So one
of the challenges is to get people out of the
clinic to make house calls. So there's conversations
about that. Things like harm reduction are not
at all controversial. It's a very common practice
in Europe to have a harm reduction practice.
So in many ways, a model like this fits better,
fits easier within the European context than
it does here. Thank you, Sam. Ben, would you
care to add? You know, I agree. I mean, I think
it was just a different tone being in Berlin
and listening to the way people talk about, you
know, housing as a right. It just it wasn't controversial.
You know, they had it in place. So to do housing
first there, there's, you know, it's not an uphill
battle in the same way. Thank you so much. And
and Sam, can you talk a little bit about Pathways
Housing First Institute? The Pathways Housing
First Institute is pretty much a consultancy.
So I work with a bunch of experts in homelessness.
certainly including Ben who's on the board. I
would say that we help in different ways. We
help communities locally to implement Housing
First. We advocate. We do training. We do program
fidelity. Those are the primary things. I mean,
I think we work with cities or states or organizations
or countries to implement the model. Wow, I have
just learned so much and I'm so grateful for
the two of you. Unfortunately, we've run out
of time, but I want to thank you Ben and Sam
for joining us for a great discussion.
If you want to learn more about the
Pathways Housing First Institute, please visit pathwayshousingfirst.org.
And the book Housing First: Ending Homelessness,
Transforming Systems, and Changing Lives is available on Amazon.
And if you would like to network with
our guests regarding their work or want to support
our transformative research and programs, please
email us at listenuppeople@usc.edu.
We would love to hear from you and thanks for listening.