Housing First Models to Homeless Persons with Serious ...

[Pages:209]The Applicability of

Housing First Models to Homeless Persons with Serious Mental Illness

U.S. Department of Housing and Urban Development Office of Policy Development and Research

The Applicability of

Housing First Models to Homeless Persons with Serious Mental Illness

final report

Prepared for: U.S. Department of Housing and Urban Development

Office of Policy Development and Research

Prepared by: Carol L. Pearson, Ph.D., Walter R. McDonald & Associates, Inc. Gretchen Locke, Abt Associates Inc. Ann Elizabeth Montgomery, Walter R. McDonald & Associates, Inc. Larry Buron, Ph.D., Abt Associates Inc. Walter R. McDonald & Associates, Inc., Rockville, MD Abt Associates Inc., Cambridge, MA

july 2007

ACKNOWLEDGMENTS

Many individuals have assisted us on this project. We would especially like to thank the following:

? The formerly-homeless men and women who agreed to participate in the study;

? The staff from the U.S. Department of Housing and Urban Development (HUD) and program administrators who nominated potential sites;

? The staff of the Housing First programs, whose time, energy, and knowledge, as well as their diligence in providing monthly data, made this study possible;

? We would particularly like to thank our primary contacts at each of the programs:

Greg Jensen and Daniel Malone Downtown Emergency Service Center (DESC), Seattle, Washington

Pat Precin and Sam Tsemberis Pathways to Housing, New York City, New York

Pat Bathurst, Gary Hubbard, and Roxanne Rosemire Reaching Out and Engaging to Achieve Consumer Health (REACH), San Diego, California; and

? Paul Dornan, our Government Technical Representative from HUD, whose commitment to this study and the report added immeasurable value. Other HUD staff members who provided helpful comments throughout the study include Marge Martin, Marina Myhre, and Kevin Neary from the Office of Policy Development and Research, and Mark Johnston from the Office of Special Needs Assistance Programs.

In addition, we would like to acknowledge Anja Maguire of Walter R. McDonald & Associates, Inc., who provided editorial assistance, and Jessica Bonjorni, Naomi Michlin, and Jody Schmidt Muehlegger of Abt Associates Inc., who assisted in data collection, analysis, and reporting.

We appreciate the significant contributions that the above individuals made to carrying out the research and writing of this report. They are not responsible for any remaining errors or omissions.

The findings and views herein are those of the authors and do not necessarily reflect the views or policies of the U.S. Department of Housing and Urban Development.

Foreword

Understanding homelessness is a necessary step toward ending it, especially for those persons living with a chronic condition such as mental illness, an addiction, or physical disability. Ending chronic homelessness remains a national goal for President Bush, the Department of Housing and Urban Development (HUD), and many within the homeless advocacy community.

In recent years, an approach known as Housing First has emerged as one model for serving chronically homeless people. HUD began this study as a first step in describing how Housing First programs actually work and what sorts of short term outcomes are realized by the people they serve.

This report, The Applicability of Housing First Models to Homeless Persons with Serious Mental Illness, provides a basic description of several programs that represent a Housing First model. The report should help clarify the issues and inform the policy discussion about how best to address the most vulnerable in American society.

Darlene F. Williams Assistant Secretary for

Policy Development and Research

Preface

This report presents the findings from an exploratory study of the Housing First approach of providing permanent supportive housing to single, homeless adults. Those served have mental illness and co-occurring substance-related disorders, and frequently come directly (or nearly directly) off the streets. Congress and the U.S. Department of Housing and Urban Development (HUD) have encouraged the development of permanent supportive housing for homeless people since the inception of the McKinney-Vento Act in 1987. In recent years, increased public attention has been focused on the hardest-to-serve, chronically homeless population, a substantial number of whom are mentally ill. Because it addresses this population and its needs, the Housing First approach has emerged as a favored policy response among many in the advocacy and practitioner communities.

Each of the three Housing First programs studied here use a low demand model to respond to substance abuse among their chronically homeless target populations.1 What is low demand? This report defines it in this way:

The [low demand] approach addresses the harms caused by risk-taking behavior without forcing clients to eliminate the behavior altogether (Marlatt and Tapert, 1993). For example, abstinence is a form of [low demand] for those who want to quit using drugs, but for those who are not ready, case managers must start with interventions that can help a substance user improve his or her life. Interventions might include reminding the client to eat, drink water, sleep, pay rent and other bills before spending money on drugs, and to educate users about the negative effects of drugs and encourage them to use less frequently, if not quit using entirely.

One recent review of the literature indicates that the fundamental assumption of low demand "is that substance use falls along a continuum from abstinence to problematic use or abuse. While abstinence and a substance-free life represent long-term goals, any immediate step in that direction, such as reducing the quantity and/or frequency of use, should be viewed positively and reinforced." (Connors et al. (2001)

Clearly, any public program or policy that countenances the use of illegal drugs under any circumstance runs the risk of violating other Federal, state and local laws and policies. The Department then must weigh competing social values to arrive at a policy relating to low demand approaches.2 This is not the place to set that policy, but we do believe that clarifying what is at

1 Throughout this report and this preface we shall use the term "low demand" where others might use "harm reduction". As Zerger (2002) observes, "...[P]olitically, the harm reduction approach has been aligned with the contentious debate of drug legalization, resulting in rhetoric which has implications for the clarity of any pursuant discussion on which drug policies might actually work." In this regard, it is difficult, if not impossible, for the government to support a set of policies, some of which are objectionable on legal grounds, that have been grouped under the category of "harm reduction". Under the circumstances, it is necessary to use the less politically and emotionally freighted term "low demand".

2 Recent studies document that keeping homeless people housed benefits society quite apart from the person directly assisted. For example, Kidder et al. (upcoming) find that keeping someone housed reduces the incidence of risky sexual behavior, thereby reducing significantly the risk of HIV/AIDS transmission. Graham et al. (upcoming) conclude that keeping an ex-offender housed after a stay in prison or jail reduces substantially the likelihood that

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stake will further the debate and ultimately work to reconcile what might be preferred practice by some providers and public law.

Certainly current research challenges the presumption that substance abusers can't and won't change. Beyond that, though, the reasons why people change addictive behaviors are still not well understood. As one close observer writes, "The simplistic account that people change because they receive treatment is wanting in many ways. Many people who recover do so without formal treatment. Even relatively brief interventions seem to trigger changes, and the dose of treatment delivered is surprisingly unrelated to outcomes. Client compliance with many different approaches, including placebo medication, has been linked to better outcomes." [Miller (1998)] One of the most prominent theories outlines a series of phases through which addicts proceed. What is clear, though, is that the rehabilitative process is neither unidirectional nor regular. For the vast majority of those dependent on drugs and alcohol, in fact, the process of choice and change is characterized by fits and starts, occasional relapse and, for some, chronic failure. Substance abuse policies, to be effective, must accommodate these dynamics. Clearly existing research, divergent as it is, does not recommend a single program or policy.

On the other side are the realities of chronic homelessness. We know, for example, that a significant portion of those living on the streets use drugs and alcohol; frequently, they suffer from mental illness as well. We also understand that for some part of that number getting them off the street will require at least temporary accommodation to drug and alcohol use in the facilities in which they are housed. On the other hand, the statutory purposes of the McKinney Vento Act homeless programs are to move homeless people toward stable housing and the greatest independence of which they are able. Persistent dependence on drugs and alcohol, whatever it is, is not a manifestation of independence.

The McKinney-Vento Act provides for a variety of HUD housing options to help stabilize the lives of homeless persons. These include emergency, transitional and permanent supportive housing. The law further allows for tenant-based and project-based assistance. A common tie to all these housing options is the principle that HUD's homeless housing programs are intended to help persons through the provision of services to address their special needs in order to become more independent. For instance, in describing the purpose of the Supportive Housing Program (SHP), the McKinney Act states that the program is to "promote the provision of supportive housing to homeless persons to enable them to live as independently as possible." (Title IV, C Section 421; emphasis added.) This emphasis on assisting clients with housing and services in improving their lives is also highlighted in the Act's provisions for the Emergency Shelter Grants Program. By law, this program requires that applicants assist homeless individuals to obtain "appropriate supportive services, including permanent housing, medical and mental health treatment, counseling, supervision, and other services essential for achieving independent living...." (Title IV, B Section 415 (c) (3) (A)) (emphasis added). These provisions are mirrored in the Code of Federal Regulations. HUD further reinforces this principle in its program grant application and grantee performance reports.

he/she will return to a criminal justice facility. Culhane, Metraux and Hadley (2002) make a compelling case that providing appropriate housing and services is cost-neutral when the alternative is the street and all the public costs that entails.

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With this focus on helping persons become more independent--emphasized in the law, regulation, application, and performance reporting--grantees are to assist clients in achieving this goal and to provide environments in which this progress can take place. By law, HUD's permanent supportive housing programs for homeless persons are designed to serve persons who are disabled, including those who are currently seriously mentally ill and/or who have chronic problems with alcohol, drugs, or both. For example, the fact that Shelter Plus Care statute specifies substance and alcohol abuse services as eligible supportive services for matching purposes presumes that some clients will be actively using drugs and/or alcohol at program entry, either before or during occupancy of the Shelter Plus Care housing.

Given these conditions that exist at the time of entry into housing, providers need to work individually with clients to address and resolve these issues. The law (SHP law) requires that the applicant "provide such residential supervision as the Secretary determines is necessary to facilitate the adequate provision of supportive services to residents and users of the project." Accordingly, HUD requires in its grant agreement that providers cannot knowingly allow any illegal activities, including illicit drug use, to be conducted in the project. This provision was added expressly to maximize the likelihood that clients struggling to overcome substance abuse addictions would have the most supportive environment possible in which to succeed in rehabilitating their lives. Many providers also prohibit the use of any alcohol while in a HUD homeless project and find this to be a necessary and effective approach for rehabilitation.3

It is important in this connection to distinguish Departmental policy related to public and assisted housing from that for McKinney-Vento Act homeless programs. Homeless people affected by substance abuse are a target population for the Department's homeless programs. They are not for the Public Housing or Housing Choice Voucher programs. When Congress sets forth a target population and the Administration subsequently proposes to end chronic homelessness, there is an underlying presumption that a not inconsiderable part of the target population will be using those drugs/alcohol at entry and perhaps for some time thereafter. Similarly, Congress has instituted such policy initiatives as safe havens as intentionally "low demand" alternatives to more orthodox approaches. [Note that safe haven is probably the closest statutorily-based conception to the Housing First concept]. The presumption is that such low demand programs will "do anything it takes" to engage chronically homeless people and then maintain them in housing. And, "doing anything it takes" presumes acceptance that some of those who are agreeing to come in off the street have not agreed or are not able to stop an existing addiction upon entering the program.

3 Illegal drug use is no guarantor of eviction even when that is the housing provider's intent. For example, the Corporation for Supportive Housing, in its Between the Lines: A Question and Answer Guide on Legal Issues in Supportive Housing, comments, "The use of illegal drugs should generally be sufficient grounds for eviction; however, it is advisable that leases contain a provision prohibiting the use of illegal drugs so the eviction is based on a lease violation. Most jurisdictions allow eviction for criminal activity, including illegal drug use. Housing providers should be prepared for the resident to assert the need for a reasonable accommodation in any eviction. Although it is difficult to think of what the reasonable accommodation would be in the instance where the housing provider has clear evidence of illegal drug use, providers should be prepared for creative defenses asserted by tenants who are being evicted for drug use.

Housing providers may have difficulty obtaining convincing evidence of the tenant's drug use. Rarely will a tenant use drugs in front of staff and other tenants are often reluctant to testify against fellow residents. Evidence based on behavior may not be convincing or explained away by the tenant."

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