Program Pioneering ‘Housing First’ Is Catching On Across the Country

Sam Tsemberis spent years in squalid alleys and dank corners of subway stations searching for mentally

ill homeless people who could be a danger to themselves or others and required hospitalization.

As an employee of the New York City mental-health department, Mr. Tsemberis’s job was to figure out what to do with the people he found. To help come up with an answer, he asked each one: What is the first thing you want? The almost universal reply: a place to live.

Mr. Tsemberis took this information to heart, and in 1992 opened Pathways to Housing, a New York nonprofit group that has helped pioneer an approach known as “housing first.” Pathways takes homeless people who are mentally ill, many of them drug addicts, off the streets and puts them directly into their own private apartments. It also offers participants access to social services and health care.

But unlike many housing programs — where sobriety, psychiatric counseling, and drug and alcohol treatment are mandatory — Pathways tenants must do nothing more than meet with the charity’s employees twice a month.

“Other providers thought it was crazy and it would never work,” says Mr. Tsemberis. But every homeless person I spoke to was like, ‘Oh, it’s about time.’”

The approach has since garnered strong support, including from the State of New York, and is now spreading around the country.

About 90 percent of Pathways’ annual budget of nearly $12-million comes from government sources, including contracts with the New York State Department of Mental Health and Medicaid. Mother Jones magazine recently called Pathways “perhaps the most radical program for the homeless anywhere in the country.” And its results show that it could be one of the most effective programs in the country: Eighty-five percent of the people it houses don’t return to the streets.

Still, some remain skeptical. Woody Curry, program coordinator at the Baltimore Station, a 50-bed dormitory-style recovery program in Maryland for homeless people who are addicted to drugs or alcohol, says housing with few strings attached can be a recipe for disaster when dealing with the so-called chronically homeless — people who have spent years without any permanent shelter. A formerly homeless addict himself, Mr. Curry says that staying clean and sober must be a prerequisite for dealing with all the other issues a homeless person might have.

“We tried the putting-people-in-houses approach and found their psychological, emotional, and physical instability pretty much made wreckage of whatever house they were in,” he says.

Achieving Personal Goals

Pathways currently provides apartments and services for some 500 formerly homeless New Yorkers. And in 2004 the group started an organization in Washington, D.C., that has successfully placed 43 homeless people in apartments.

The charity seeks out people who might benefit from its services, and also accepts referrals from shelters, drop-in centers, and sometimes prisons.

Once the charity finds housing for its clients, it helps them fulfill other personal goals. “It could be work, it could be reconnecting with their family, it could be drug treatment,” Mr. Tsemberis says. “But whatever it is, we’ll offer them that. The choice principle operates continually through the program. They set their own goals.”

The charity has staff members who specialize in providing health care and social services, including psychiatric counseling, drug treatment, and vocational assistance.

It also offers art and photography programs — “the creative stuff that makes life more interesting,” Mr. Tsemberis says.

Outside the required biweekly meetings, Pathways residents are free to select the services they want. Or opt for no services at all.

Pathway’s largely laissez-faire approach to leading a person out of homelessness and back into society contrasts with the more common “linear continuum of care” method. This approach generally places homeless people in group housing, where they often must follow curfews, remain sober, and undergo mandatory therapy and counseling. Residents gain independence through a step-by-step, counseling-heavy process designed to make them “housing ready.”

Mr. Tsemberis is highly critical of such programs. It is as if an apartment of one’s own is a “graduation present,” he says. “After years of being a good tenant in a congregate building, you earn your way to be treated like a real person.”

Sarah Stanton, who leads a team of social workers at Pathways DC, says the prevalence of such programs has made homeless people skeptical at first about accepting help from Pathways. “Very often,” she says, “people will ask, ‘What’s the catch?’”

Perhaps not a “catch,” but Pathway’s tenants are responsible for paying 30 percent of their rent, typically $200 to $250 a month. Most receive Supplemental Security Income, a federal program that provides elderly or disabled people with money for their basic needs. Some also qualify for veterans’ benefits, and others get jobs after being housed.

Pathways usually manages a participant’s benefits and oversees the rent payments, at least at first. The program also takes new tenants shopping for basic furniture, bedding, and household needs, providing then with around $1,200 to spend.

Mr. Tsemberis calls the landlords that rent to his clients “the unheralded partners in the program.” Few landlords ever know the background of their Pathways tenants.

Some Pathway participants have been kicked out of their apartments for drug-fueled misbehavior. Jerome, a Pathways client who asked that his last name not be used, says he lost his first three apartments as he slowly made the transition from the “feral” life of an addicted street person to the “mainstream.”

“It’s been a long trying road with lots of setbacks, but the Pathways people stuck by me,” he says. “I would have been tossed out of other programs on Day 1 for the things I did.”

‘Keys in Hand’

For the majority of Pathway’s clients, Mr. Tsemberis says, the transition from homeless to housed is dramatic but largely uneventful.

“The first day the person moves in they have these ragged plastic bags and torn clothing,” Mr. Tsemberis says. “The next day they’re there with the keys in hand, they’ve showered, they have new clothes, and you will not be able to tell when looking at who’s going in and out of the building who is a tenant of Pathways to Housing and who’s not.”

Robert, a 46-year-old recovering alcoholic who asked that his last name not be used, cried his first night in the apartment Pathways provided him seven years ago. “It was so beautiful,” he says. “If you don’t have your name on a lease, then you’re still homeless.”

Although Pathways focuses on the most problematic segment of the homeless population — those afflicted with various forms of psychosis, bipolar disorders, or other mental disabilities, and most often a history of drug or alcohol addiction — its 85-percent success rate is far superior to that achieved by other programs.

A 2000 study Mr. Tsemberis and an associate conducted using data from New York’s more traditional, regimented group-home programs showed that fewer than half the chronic homeless who entered those facilities were still in housing after two years. The study was published in the journal Psychiatric Services. Similar findings were achieved in a follow-up study published last year in the American Journal of Public Health.

Pathways has also been praised as being cost effective. When left on the streets, the type of clients that the charity helps often bounces among mental hospitals, emergency rooms, shelters, and prisons — running up annual costs far in excess of the roughly $22,000 a year that Pathways spends to provide an apartment and social services.

A Model for Others

Pathways’ approach has inspired many similar efforts. The Colorado Coalition for the Homeless, for example, started a housing-first program 18 months ago that now has 80 people set up in apartments.

“Eighty percent of the people are doing extremely well and their health is improving,” says the Colorado Coalition’s president, John Parvensky. “For the other 20 percent, we’re still dealing with how to make the transition from the streets.”

Philip Mangano, executive director of the Interagency Council on Homelessness, a federal group that coordinates 20 federal agencies that work on homeless issues, says the Pathways model has done much to prompt housing advocates to rethink their approaches.

“By providing housing first and then applying the services a person needs, Sam changed the equation of how to end homelessness,” says Mr. Mangano. “Having a place to live is the nexus point for getting a job, dealing with an addiction, or dealing with mental illness.”

Mr. Tsemberis says his experiences over the years have taught him that after a chaotic life on the streets, many chronically homeless people cannot adapt to programs that force them to follow strict schedules or that kick out anyone caught with drugs or alcohol. And failure usually meant a return to homelessness and a greater reluctance to seek help.

Carla Javits, president of the Corporation for Supportive Housing, an Oakland, Calif., charity, agrees that “for people who have been out on the streets a long time, it’s most effective to have the lowest barrier you can to getting them into housing, and then the most flexible service approaches once they are housed.”

“If a service is mandated,” she adds, “and the penalty for not complying is eviction, then you’re not ending their homelessness.”

Not everyone, however, agrees that the approach is best for combating all forms of homelessness.

“Housing first, in our experience here in Portland, works best for people whose chronicity is so extreme that they have failed at all other attempts at housing,” says Ed Blackburn, director of health and recovery services at Central City Concern, an Oregon housing charity.

“Different populations need different housing,” he says, “including options where treatment is a condition of the housing.”

For his part, Mr. Tsemberis feels that if his model works for the most entrenched homeless people, it can surely work for “homeless families and everybody else along the line.” He concedes, however, that some people feel more comfortable having the added support offered by group homes.

Mr. Tsemberis says even with his successes, he still has much to do to counter some long-held public views. “Giving someone housing goes against the grain because they haven’t done anything to earn it,” Mr. Tsemberis says. “Research is the only way to fight these assumptions.”