Housing First moves people experiencing homelessness into stable housing with supports. A relatively new approach to homelessness, Housing First is based on the premise that people are more successful moving forward if they first have a home. Housing First, unlike traditional “Treatment First” approaches, doesn’t require individuals to undergo treatment or become abstinent. For some people, the lack of treatment and abstinence requirements makes Housing First a textbook case of enabling and Treatment First the more sensible option.
The thinking behind Treatment First goes like this: for people experiencing homelessness and substance use issues, having a home is one of the best motivations to quit using substances. When individuals are caught using substances in Treatment First programs, discharge is a necessary step in the individual’s path to “hitting rock bottom.” Only through further experiencing homelessness and substance use issues will the individual gain enough desperation to become abstinent. To not discharge an individual under these circumstances is enabling problematic behaviour.
While many housing providers long favoured Treatment First programs, research has shown that Housing First is more effective at reducing substance use and keeping individuals housed. If there’s one thing Housing First enables, it’s recovery.
Housing First reduces substance use
A 2010 study in Community Mental Health Journal compared participants with a history of homelessness, mental illness, and substance use issues enrolled in Housing First programs against participants in Treatment First programs. A year after entering their programs, Treatment First participants were nearly three and a half times more likely to use substances than Housing First participants.
The study states: “Without the rules and restrictions of mainstream programs, [Housing First] providers can genuinely engage with [clients] and respond to them individually instead of having to offer a ‘‘take it or leave it’’ proposition…”
Housing First improves housing stability
The largest Canadian Housing First study, “At Home/Chez Soi,” compared participants enrolled in Housing First programs against participants enrolled in Treatment First programs (referred to as “treatment as usual”) across five Canadian cities. During the last six months of the study, 62 percent of Housing First participants were housed all the time compared to only 31 percent of Treatment First participants.
A 2008 study in Psychiatric Rehabilitation Journal analyzed interviews with individuals who had experienced either Housing First or Treatment First programs. One man who had spent significant time in a psychiatric hospital said Housing First provided him life-changing stability:
“They said we’re going to give you an apartment with a phone and a TV. And I never had one. It had cooking things and everything there and it was great. I’d go to my meetings, do a little poetry or go to a movie with my girlfriend.”
Abstinence is not synonymous with recovery
Within Island Health’s Mental Health and Substance Use Services, “recovery” refers to:
“…individuals’ abilities to guide their own wellness journeys, and live satisfying, hopeful, and contributing lives, even though mental health and substance use problems may cause ongoing limitations.”
While abstinence may be a goal or outcome of an individual’s wellness journey, it doesn’t define recovery. When an individual has the stability of a home, many wellness improvements can occur without abstinence, including reduced substance use, improved life skills, and strengthened social networks. In this way, Treatment First can stunt an individual’s recovery. If an individual is discharged from a Treatment First program for substance use and is left homeless, their focus shifts from receiving support in stable housing to surviving on the street.
While Housing First doesn’t require abstinence, it doesn’t preclude it either. For many individuals, like Rocco in the video below, having a home provides the stability necessary to complete treatment and stay abstinent.
Connection, not punishment, is key
The need for individuals with substance use issues to hit rock bottom to recover is a central concept in Treatment First programs. Maia Szalavitz, in her 2017 book Unbroken Brain: A Revolutionary New Way of Understanding Addiction, says rock bottom is a problematic concept:
“From [the rock bottom] perspective, the more punitively addicts are treated, the more likely they will be to recover; the lower they are made to fall, the more likely they will be to wake up and quit.”
Szalavitz argues that these ideas are contrary to what the research says—that substance use issues are best treated by providing individuals with empathy, support, and healthy social networks. When an individual is discharged from a Treatment First program for substance use, empathy, support, and healthy social networks are the exact things that are taken away.
Goering, Paula, et al. “National At Home/Chez Soi Final Report.” Mental Health Commission of Canada, 2014, www.mentalhealthcommission.ca/English/document/24376/national-homechez-soi-final-report.
Padgett, Deborah K., et al. “Engagement and Retention in Services among Formerly Homeless Adults with Co-Occurring Mental Illness and Substance Abuse: Voices from the Margins.” Psychiatric Rehabilitation Journal, vol. 31, no. 3, 2008, pp. 226–233., doi:10.2975/31.3.2008.226.233.
Padgett, Deborah K., et al. “Substance Use Outcomes Among Homeless Clients with Serious Mental Illness: Comparing Housing First with Treatment First Programs.” Community Mental Health Journal, vol. 47, no. 2, 2010, pp. 227–232., doi:10.1007/s10597-009-9283-7.
“Recovery-Oriented Practice Framework.” Island Health, 2017.
Szalavitz, Maia. Unbroken Brain: A Revolutionary New Way of Understanding Addiction. Picador St. Martin’s Press, 2017.