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Housing First: An Interview with Sam Tsemberis
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Dr. Sam Tsemberis is the founder of Pathways to Housing, Inc., a non-profit organization that originated the Housing First program. Housing First is a highly effective housing and support services model that is used all over the U.S. in both urban and rural areas. Sam discusses the history of Housing First, which is based on the principles of client choice and offers housing as a basic human right to people with co-occurring disorders experiencing homelessness.
Housing First: An Interview with Sam Tsemberis

Pathways to Housing is the recipient of a Services in Supportive Housing (SSH) Grant for the Benefit of Homeless Individuals (GBHI) from the Center for Substance Abuse Treatment. The SSH program funds grantees to provide intensive services to prevent or reduce chronic homelessness.

Twenty years ago, Housing First did not exist. At that time, working with people who lived with mental illness was based predominantly on a disease model approach, which emphasized treatment as a means of achieving stability, which was considered essential before people could move into housing. People receiving treatment were often told that with rigorous adherence to treatment compliance (which included medication), the best outcome they could expect was symptom maintenance. Essentially, mental illness was considered a life long illness with a downhill course, says Dr. Sam Tsemberis, Founder and CEO of Pathways to Housing and the originator of the Housing First model.

Housing First grew out of working directly with people diagnosed with mental illness who were living on the streets of New York, where Sam learned that people needed services beyond hospitalization. Discharge back to the streets after repeated hospitalizations made people worse and they soon became disenchanted and suspicious of treatment, and eventually refused treatment altogether. Refusing treatment had many adverse effects, including disqualifying people from the possibility of admission to housing programs, which refused to accept referrals from people who were not medicated and already clean and sober.

A breakthrough occurred in 1992. Frustration led to the creation of a new agency funded by a grant from the New York State Office of Mental Health. “Pathways was the only agency that would provide housing for people who were still using [substances] and had active psychiatric symptoms. We developed the program in collaboration with clients who, to the casual observer, may have seemed disorganized, but when communicating with us, clearly and unanimously declared that what they wanted first and foremost was a place to live (housing first!). We quickly discovered it was much easier to engage people in the program when we began to follow their lead and honor their priorities,” says Sam.

Sam’s agency, Pathways to Housing, provides scattered-site apartments rented from private landlords in buildings that are just a regular part of the neighborhood. “It is not specialized housing, it is ordinary housing. What makes it different and what makes it effective is that people are also provided with lots of good services,” explains Sam. Services take place mostly in their home or in their neighborhood. “For people who have spent years excluded, in group homes, hospitals, jails, shelters, and other large public service settings, having a place of their own, their own home, has a huge appeal,” says Sam.

“Actually,” he says, “ending homelessness is the easiest part of the job. The real challenge is providing the support services to treat severe mental health and addiction problems. When a person is living at home, treatment has a much better chance of success.” According to their percentages today (twenty years later), approximately 5 percent of their staff work on housing, while 95 percent are interdisciplinary providers of clinical services.

The support services at Pathways to Housing are voluntary and not tied to keeping housing. Services are not time limited. “People receive support for as long as they need it, with a graduated level of services approach, so that people can use fewer services as their clinical conditions improve. People are free to stop treatment when they decide they do not need them or are not benefiting from them. They are also free to return to services if they feel they need additional support. Our overall goal is recovery and full integration into the community,” says Sam.

Services are provided using a team approach. Team members make house calls, usually once a week. The teams—staffed with a nurse; a psychiatrist; and supported employment, peer, and addiction specialists—usually use the ACT model, an evidence-based practice. The team works with the individual based on his or her priorities using a person-centered approach. “Everyone figures out how to piece their lives together in their own way,” emphasizes Sam.

Sam’s team was originally told that implementing Housing First would be too risky, enabling, impossible, ineffective, delusional, and that they were fools to take on such a huge liability on behalf of their clients. Fighting past personal fears, professional prejudices, and staying true to the commitment of helping clients realize their own goals, Pathways to Housing housed 60 people in the first year.

Much to the delight of clients, staff, and board members, the program demonstrated an 84 percent housing retention rate in the very first year. “We knew then that we were onto something special here,” says Sam. “Eighty-four percent of the people who had come directly off the street with significant mental health and substance abuse problems had been engaged into the program, received housing, and remained housed!”

“Looking back, I realized,” Sam continues “that someone who had figured out how to survive on the streets of New York during the early 1980s is an incredibly resilient person, and this was not apparent at first. The people we work with are incredible survivors, creative, resourceful, caring, and very good at making ends meet with very little money—all they needed was to be given a chance to demonstrate all their capabilities. It has long been known that many functional skills are intact even in the face of illness. This program provides an opportunity to demonstrate that fact.”

The success of the initial project led Sam’s group to conduct additional research, including a SAMHSA-funded randomized controlled trial with 225 people. Half received Housing First followed by treatment, and half received treatment first, followed by housing. The results supported the Housing First approach both in ease of access to housing and housing retention.

The National Alliance to End Homelessness, and later the US Interagency Council on the Homeless (USICH), took note of the research findings. In 2003, the USICH coordinated funding for a national replication of Housing First in eleven cities across the U.S. Results of that initiative were consistent with the 84 percent achieved by the original Pathways program. In 2008, the Mental Health Commission of Canada invested in a Housing First experiment in five cities across Canada. Results there are showing similar, very positive results.

The Housing First approach is now being implemented in Europe and Australia, and has ‘found a home’ for many thousands of people who had been homeless for years. Pathways’ Housing First has met the criteria as an evidence-based practice and is listed in SAMHSA’s National Registry of Evidence Based Practices.

“It’s been a great journey in learning how to solve some of these problems,” Sam says. “The most extraordinary and beautiful part is watching a person move into his apartment for the first time: he gets the keys, walks in, looks around, sits on his new couch, and then we see that smile of comfort and relief. That makes me want to keep doing this again and again.”

And he does…

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