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Housing FirstEnding Homelessness, Transforming Systems, and Changing Lives$

Deborah K. Padgett, Benjamin F. Henwood, and Sam J. Tsemberis

Print publication date: 2015

Print ISBN-13: 9780199989805

Published to Oxford Scholarship Online: October 2015

DOI: 10.1093/acprof:oso/9780199989805.001.0001

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Paradigm Shifts and Systems Change

Paradigm Shifts and Systems Change

Understanding Housing First and its Impact

(p.1) 1 Paradigm Shifts and Systems Change
Housing First

Deborah K. Padgett

Benjamin F. Henwood

Sam J. Tsemberis

Oxford University Press

Abstract and Keywords

This chapter sets forth a framework for understanding Housing First (HF) that draws on yet transcends its particulars. First, it addresses what is meant by “housing first” as it was developed by Pathways to Housing in the early 1990s. Next, it explores the mainstream approach to services for homeless adults, which has endured for over three decades in the United States and elsewhere, and which ultimately gave rise to HF. Finally, the chapter draws on theories of implementation science and institutional change to develop explanatory frameworks or theoretical lenses through which the rise of HF can be understood. The conceptual frameworks that emerge—addressing change at both the micro- and macro-levels—constitute the scaffolding for the remainder of the book.

Keywords:   linear approach, systems change, institutional entrepreneur, paradigm shift, HF, Housing First, consumer, institutional logic, neo-institutional theory

WHAT DO THESE cities have in common: Casper (Wyoming), Charlotte (North Carolina) Burlington (Vermont), Salt Lake City (Utah), Lexington (Kentucky), Honolulu (Hawaii), and Medicine Hat (Alberta, Canada)? All have endorsed Housing First as their approach to ending rather than managing homelessness. Little more than two decades ago, the “housing first” (HF) approach to homeless services was deemed irresponsible and doomed to failure. Today, some may still believe the first part about irresponsibility but no one can say HF has been a failure. The sea change in policy and practice wrought by this approach brought much-needed optimism to many homeless service providers for too long accustomed to revolving doors and patchwork solutions. Especially in its early years, HF unleashed reactions ranging from lingering doubts to outright hostility. From its humble beginnings in New York City in 1992, HF has become a catchword internationally; its promise fulfilled in some places and untested (or considered unnecessary) in others.

In this book we propose that the systems change wrought by HF is tantamount to a paradigm shift. The term, made popular through Thomas Kuhn’s (1962) Structure of Scientific Revolutions, has become a modern-day trope, shorthand for massive change that occurs relatively rapidly rather than gradually and incrementally. Kuhn challenged long-held perceptions that change in scientific knowledge was gradual, linear, cumulative, and orderly. Instead, he argued, major changes (p.2) in science happen as sudden and profound turning points or “paradigm shifts” needed to overcome natural conservatism.

Services for the homeless encompass not only shelter but assistance in meeting other basic needs such as food, clothing, and health care. Few social problems draw in as many stakeholders and service systems as homelessness; ameliorating the problem requires action at multiple levels involving multiple agencies. And few social problems and their solutions are as beset by definitional disagreement, starting with the term “homeless” itself.

The Contested World of Defining and Counting Who is Homeless (and Who is Not)

The subject of innumerable essays, policy initiatives, and researchers’ headaches, estimates depend upon consensus in defining who is (and is not) homeless (Hopper, 2003). Consensus is hard to come by, resulting in an uneasy compromise between governments (with lower estimates) and advocates (with higher estimates) (Hopper, Shinn, Laska, Meisner, & Wanderling, 2008). Even agreement on the definition does not mean that the counting is done well or accurately. The point-in-time (PIT) count method favored by federal, state, and municipal governments in the United States involves a dead-of-winter, late-night outreach in which trained volunteers canvass likely locations, adding these numbers to the census of shelter users. During the count, the balance of the ideal (effective outreach) with the real (holding back due to fears of intrusion or safety) often tilts toward the latter. Because funding allocations depend on the results, PIT counts are highly politicized as are the data.

Not surprisingly, definitions have been codified by government entities to reduce ambiguity about who might be eligible for services. Government definitions are also influenced, however, by the willingness to acknowledge the magnitude of the problem and to provide services. This propensity narrows or increases estimates as a function of cultural norms, attitudes concerning the deserving and undeserving poor, and availability of safety net services. According to the U.S. Federal government 1994 definition (Stewart B. McKinney Act, 42 U.S.C. § 11301, et seq.), a person is considered homeless if he or she “lacks a fixed, regular, and adequate nighttime residence and … has a primary nighttime residency that is: (a) a supervised publicly or privately operated shelter designed to provide temporary living accommodations … (b) an institution that provides a temporary residence for individuals intended to be institutionalized, or (c) a public or (p.3) private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.”

The vast majority of homeless adults and families exit homelessness in a few days or weeks and find a way to get re-housed through the help of informal or formal support (Culhane, 2014). As a result, the contours of homeless services are shaped by the needs of those who are left behind, a group more likely to include persons with serious mental illness, substance abuse, health problems, or some combination of these. Most “single” homeless adults have families and children but when they enter the system solo, they are served in that way, not in the way that homeless families are treated. The latter group tends to be younger, female-headed, and relatively healthy by comparison. Their needs are by no means simple, but they are different from the needs of adults who are chronically homeless and high-service users. These individuals are the focus of this book.

Defining Housing First (HF) and Pathways Housing First (PHF)

Beginning with Pathways to Housing (“Pathways”), the HF approach has since come to be defined in differing ways such that we reserve “PHF” for the original model or direct and faithful replications. Not all HF programs follow PHF (hence the need for the distinction). As we will see in subsequent chapters, HF has recently been invoked by programs seeking to align themselves with the zeitgeist. As the term has come into vogue, so has its usage become stretched, at times beyond recognition, testifying to snowballing HF endorsements from high government entities. So where—and how—do we draw the definitional line(s)?

As noted by its founder, PHF is a complex clinical and housing intervention that comprises three major components: (1) program philosophy and practice values emphasizing consumer choice; (2) community based, mobile support services; and (3) permanent scatter-site1 housing (Tsemberis, 2010). Permanent housing is necessary but not sufficient to fulfill what PHF means in practice—housing must be paired with adequate support services. Because PHF does not require psychiatric treatment or sobriety as preconditions for attaining housing, the model includes a fourth component, harm reduction, so that support services can help reduce risks associated with psychiatric or addiction-related behavior.

Although merged into a novel approach, each of these four components has its own history predating and transcending its use by PHF, and several were innovations supported by research evidence in their own right. Consumer choice, for example, stems from a wider movement for patient and human rights dating to (p.4) the 1970s and is a core principle in psychiatric rehabilitation (Anthony et al., 1982; Anthony, Cohen, & Farkas, 2002). Community-based mobile services originated with Assertive Community Treatment (ACT) as developed in the 1970s (Stein & Test, 1980) to support persons with serious mental illness living in the community, thereby reducing the need for hospitalization. The idea of scatter-site apartments as permanent housing came from consumer advocates who argued that persons with psychiatric disabilities should have the same “normalized” housing choices as those with other disabilities (Carling, 1993; Howie the Harp, 1993; Ridgway & Zipple, 1990). Thus, a version of permanent and independent supportive housing (PSH)—community-based living with flexible support services—was promoted as an ideal before PHF made it a reality. The alternative—congregate living and on-site services—risks recreating the institutionalization that undermines social integration and independent living.

Harm reduction achieved greater acceptance in the United States during the HIV/AIDS epidemic through clean-needle sharing and safe sex practices (Inciardi & Harrison, 1999; Marlatt, 1996). Still considered controversial in some circles, the principle of working with clients to minimize harm rather than forbid or extinguish the targeted behavior was extended to substance abuse and influenced by the “Dutch model” from the Netherlands (Marlatt, Larimer, & Witkiewitz, 2011). Harm reduction has aroused suspicion within the abstinence-based addiction treatment community, where it is viewed as condoning or enabling use. Although tolerant programs (and case workers) no doubt existed before PHF, the incorporation of harm reduction as programmatic policy was new.

The synergy of these four essential but disparate components endowed PHF with a unique purpose and approach to housing and services, one that required a sea change in the organizational culture of existing programs serving homeless adults. The environment from which PHF emerged operated under very different assumptions, including the role of consumers.

Consumer Input in the Development of Pathways Housing First: The Earliest Days

The Pathways Housing First model emerged from an ongoing dialogue among consumers, staff, and researchers (Barrow, McMullin, Tripp, & Tsemberis, 2007; Lovell & Cohen, 1998; Tsemberis et al., 2003) who initially developed an outreach and drop-in center program (known as “Choices”) as a research demonstration project (Shern et al., 2000). An ethos of respect for consumers and their ideas was fostered by training staff in consumer-centric clinical approaches such as (p.5) psychiatric rehabilitation (Anthony et al., 2002), trauma-informed care, and harm reduction as well as including consumer advocates like “Howie the Harp” (Howard Geld) as members of the project’s advisory board.

Hiring people with lived experience to provide case management services further contributed to the inclusion and incorporation of consumer input in the Choices program. Moreover, the governance and day-to-day operation of the program included regularly scheduled community meetings that served a quality improvement function. At these meetings, when issues were raised that required a vote, consumers were included as voting members. Staff, administrators, and program participants acted as decision makers and thus shared responsibility for policy and program decisions. In addition to advocacy, Howie the Harp and others brought to the program a commitment to social justice and a revolutionary fervor to change the mental health system (Tsemberis & Asmussen, 1999).

In the Choices drop-in center where the Pathways HF program was originally conceived, neither status nor salary distinguished peer specialist staff from nonpeer staff. Every effort was made to reduce power differentials and operate as collaboratively as possible. This approach blurred boundaries between staff and program participants and fostered a program culture where proposals and ideas were evaluated on the merit of their content rather than by the social or professional status of the source.

Lengthy conversations and debates ensued over how best to secure access to the existing supportive housing programs. The harm reduction practice at Choices was very effective for engagement but conflicted with the sobriety or abstinence requirements of housing providers. Program participants and staff were aware of and deeply unhappy that existing housing providers used the need for housing as leverage to ensure consumer acquiescence to treatment and abstinence requirements (Allen, 2003). After repeated failures to secure housing either by persuading programs to change their admission requirements or by convincing consumers that they had to comply with the rules, the group began a trial and error discussion centered around designing a housing program that would be both desirable and acceptable to consumers and manageable by staff.

In the course of these conversations about the stigma associated with single-site housing set aside for the “mentally ill,” the decision was made to seek out a supported housing contract that provided rent stipends and the possibility of renting an apartment of one’s own with case management support. The scatter-site supported housing model met consumers’ requirements for normal housing (“We just want a simple ordinary apartment.”), tenancy rights (“a place that is mine”), privacy (“I can wake up when I want.”), freedom separate from program demands (“I don’t want to have to hide my beer under the couch when (p.6) you come to visit.”), off-site rather than on-site services (“I may want to go to treatment but I don’t want to be living in treatment.”), and affordable rent contributions (30% of income).

Consumers and staff worked collaboratively on the operational details including occupancy policies and program and consumer fiscal responsibilities. This included setting up a bank account to pay the consumer’s portion of the rent and required both staff and consumer signatures for checks to be cashed.

Once Housing First was launched by creating Pathways to Housing, Inc., steps had to be taken to ensure and sustain the continued input of consumer voices within the program. The program was designed collaboratively and steps were taken to ensure that this ethos would be carried forward to all levels of the operation and management of the nascent Pathways. This was considered central to sustaining the consumer-centered origins of the program.

Several administrative practices were used to promote consumer voices more broadly within the agency: (1) as tenants, consumers participated on an advisory committee that met regularly with agency heads to express tenant concerns and provide programmatic input; (2) every executive officer of the organization had an open door policy for consumers; (3) people with lived experience (peers) were hired as service providers and managers and were elected to the Pathways board of directors.

In everyday group or program meetings accommodations were made to ensure full participation by appointing a moderator, taking turns speaking, and having an active, moderated, question-and-answer period. In addition, social and recreational events provided opportunities for staff and consumers to meet informally and expand the repertoire of their dialogue. Both the service approach and the organizational environment were designed to foster empowerment for greater community, civic, and political participation.

The Linear Approach to Homeless Services

PHF came to life at a time when services for the homeless operated according to the principle of a “linear continuum of care” predicated on consumers’ behavior change as the key to progress made—step-by-step—to the idealized endpoint of independent living in one’s own dwelling. This arrangement has been characterized as a staircase2 (Sahlin, 1998), starting with low demand and low service provision (such as in an emergency shelter, safe haven, or drop-in center) and ascending through increasing demands and more services associated with transitional housing programs (Atherton & MacNaughton (p.7) Nicholls, 2008). The staircase’s top step is the attainment of one’s own housing and a minimum of services required to maintain independent living (see Figure 1.1). Most of the services along the continuum are delivered in supervised settings where residents are required to follow the rules of congregate living and show progress toward “housing readiness” or “housing worthiness” (Dordick, 2002).

Paradigm Shifts and Systems ChangeUnderstanding Housing First and its Impact

Figure 1.1 The Continuum or Staircase Approach to Homeless Services.

The intuitive draw of the continuum approach was and remains powerful. It also aligns closely with the step-by-step ethos of personal responsibility and behavioral change deeply rooted in American values. Thus, homeless men and women with serious mental illness and co-occurring substance abuse are the authors of their destinies, arriving at such a debased state of existence through bad luck, poor decisions, and avoidable circumstances. Only with the expert assistance of psychiatrists, social workers, case managers, and addiction counselors can their lives be turned around. Complying with treatment and program requirements serves as a demonstration of the willingness to work harder and this effort leads to a reward (i.e., moving a step up the staircase). Refusal to comply is seen as further evidence of poor decision-making and a lack of “housing readiness,” typically resulting in discharge and cautions that a return signals that the consumer is ready and willing to change his or her behavior.

The reality on the ground in cities across America was a hodgepodge of services heavily weighted toward the bottom of the continuum with varying access to anything beyond an emergency shelter (e.g., transitional housing such as a single-room occupancy building or a halfway house). Thus, the principle of a (p.8) linear continuum or staircase existed even if individuals did not always proceed through it in an orderly fashion or encounter anything beyond the lowest step. Some never got beyond that first step, some skipped steps, and far too many fell off the “staircase.” For these individuals, life is lived on the “institutional circuit” (Hopper, Jost, Hay, Welber, & Haugland, 1997), travelling from shelter to hospital to jail and back to the streets. The linear continuum was (and continues to be) a cruel and costly circle of futility.

The rise of the continuum service philosophy was probably inevitable given deeply rooted Anglo-Saxon values requiring a demonstration of worthiness by the poor and destitute. Yet, even as the limitations of this approach became evident, it not only continued but also became entrenched as the normative mainstream in homeless services. From a supply and demand perspective, the number of homeless people who needed services far exceeded the slots available so that programs having even the strictest rules were able to enroll clients and operate at full capacity. In turn, operating at full capacity was accepted as the definition of a successful program. But this “success” was predicated on a form of creaming (i.e., selecting applicants who were willing and able to comply with treatment and sobriety demands). This left the more troubled, and those less able or willing, on the streets to fend for themselves.

Whether for reasons of economy or efficiency, transitional housing programs toward the bottom end of the staircase typically placed consumers in tight living quarters within a single building, an arrangement well-suited to the careful supervision deemed necessary to help consumers adjust to their posthomeless living situation. Congregate living also required rules—curfews, meal times, bed checks, treatment attendance, sobriety, limited or no guests—in order to ensure the safety and comfort of all residents. Relapse into substance abuse or a psychiatric crisis meant discharge (to hospitalization, street, or rehabilitation facility). Once discharged from the program, the consumer returned to the bottom of the staircase and started all over again. Despite or because of these demands, dropout rates were high (Hopper et al., 1997).

That the continuum service model was predisposed to excluding (or ejecting) those with the most problems resulted in a greater concentration of severely disabled people living on the streets. Advocates for the homeless were quick to point this out, but governments appeared stymied and unable or unwilling to move toward more permanent solutions. Instead, they did more of the same, giving rise to more and more homeless service programs and to thousands of jobs in a homeless “industry” (e.g., outreach workers, caseworkers, van drivers, security guards, maintenance staff, cooks, building managers, and other supervisory positions). In the next section, we expand our framework to understand (p.9) how an innovation such as HF can set in motion fundamental changes in policies and practices.

Institutional and Organizational Change

Thomas Kuhn’s (1962) Structure of Scientific Revolutions offers an oft-cited thesis on change that has proven to be influential far beyond his original intent. Similar to Kuhn’s cycle of long stretches of stability marked by disruptive paradigm shifts, institutional change does not come easily or inevitably. Max Weber (1952) referred to the “iron cage” that bureaucratization brings to institutions, an image that DiMaggio and Powell (1983) invoked to explain the increasing homogeneity of institutions acting within a common sphere. Large institutions may have bricks-and-mortar visibility for example, the Roman Catholic Church, but they can also be defined through social meanings and connections, such as the institutions of marriage or the nuclear family. The challenge in institutional theory is less one of explaining endurance—inertia alone can be powerful—than in understanding how institutions change at all. The most expedient explanations are external events—wars, natural disasters, epidemics, and economic depressions. There are also internally disruptive forces such as social movements that can overthrow institutions if powerful enough.

DiMaggio and Powell’s (1983) neo-institutional theory refers to three pillars or structures that maintain institutions: (a) regulative—laws and contractual obligations; (b) normative—assumption or ideals governing behavior; and (c) cultural–cognitive—schemas or taken-for-granted scripts underlying behavior. Accordingly, institutional change can be coercive (top-down enforcement), normative (altering perceptions of what is expected and desirable), or mimetic (copying best-practice models). Whatever the pathway to institutional change, its success is heralded by the appearance of a new institutional logic and set of norms. Together, these confer legitimacy to the new institutional form. Without such legitimacy, institutional change will founder.

So how and why did the regulative, normative, and cultural–cognitive pillars that supported the staircase approach shift such that HF became a legitimate (and legitimizing) force with its own distinctive institutional logic? In order to understand this shift—where obtaining federal dollars became contingent upon adopting a HF approach, where there was an expectation that HF would be implemented, and where immediate access to housing became ingrained as the go-to response of homeless service providers—one must understand not just the larger institutional forces that were at play, but also those individuals who served as catalysts for change. See Box 1.1 for a discussion of organizations and the nonprofit distinction. (p.10)

Institutional Logics, Actors, and Entrepreneurs

Neo-institutional theory encompasses various levels of activity: macro (institutions), meso (organizations), and micro (individuals or small groups). It is considerably harder to apply empirical research methods to the study of large-scale (p.11) systems and institutions compared with the meso-level of organizations or the micro-level of individual actions (Macfarlane, Barton-Sweeney, Woodard, & Greenhalgh, 2013). At any level, it is not uncommon for multiple, even conflicting institutional logics to develop—all fertile ground for researchers seeking to understand change. Institutions, organizations, and practices often endure, but the rise of multiple logics can introduce volatility and seed change (Binder, 2007; Greenwood, Díaz, Li, & Lorente, 2010).

Too much focus on logics and norms, however, can overlook the role of individual actors and personal agency (Suddaby, 2010). Although institutional actors are presumed to reinforce dominant logics, institutional entrepreneurs (IEs) are change agents (Rao & Giorgi, 2006). Working from the outside or from within, IEs take advantage of weaknesses or contradictions within the dominant cultural logic of an institution. The stability of taken-for-granted behaviors that form the glue of institutional stability thereby becomes disrupted (Battilana, Leca, & Boxenbaum, 2009; Clemens & Cook, 1999).

Successful entrepreneurs frame the issues convincingly and mobilize support, drawing on new or revised cultural logics to advance their cause (Lockett, Currie, Waring, Finn, & Martin, 2012). Unlike economic entrepreneurs who take risks to reap profits, IEs are more often driven by ideology. Suddaby and Greenwood (2005) refer to issue-framing by IEs as using rhetoric to achieve legitimacy—rhetoric that may draw on values or ideological arguments.

By definition, IEs seek to reframe a problem and stimulate fresh thinking about new and different solutions to the problem. Their message may be reformist or subversive. Of course, success depends not solely upon rhetorical skills so much as upon timing and the context or receptivity to the message. The message’s capacity to stimulate change and attain legitimacy may come from broad grassroots agreement, from powerful elites, or from both. Its impact may be immediate or need time to take hold. One thing is certain: There is almost always resistance from individuals and organizations seeking to defend the status quo. Failure for an IE implies that the message was not welcome, was inadequately framed, was resisted successfully, or all of the above. Kuhn and Weber pertain here, given that the inherent conservatism of bureaucratic institutions serves as a bulwark against change.

IEs may be insiders familiar with the inner workings of the institution or they may be less knowledgeable outsiders seeking change (Rao & Giorgi, 2006). Following Maguire, Hardy, and Lawrence (2004), outsider IEs have less to lose and greater exposure to innovative ideas, but insider IEs have greater knowledge of how the system works and its flaws. Optimal impact is likely to come from insider IEs at the top of the hierarchy (using knowledge plus coercive authority) but they also have the most to lose in power and resources. (p.12)

All of this emphasis on individual agency is at risk of being oversold. Its centrality to traditional American values renders it an often-invoked yet facile explanation, obscuring the role of social and structural factors. This tension between micro- and macro-level explanations, with their contrasting values of individualism and collectivism, animates public policy debates. The challenge is to contextualize individual actions, to understand what came before and what comes after and what larger forces enable and impinge on these actions.

A Framework for Understanding Housing First and its Impact

Two decades and counting after the founding of Pathways, HF has spread so quickly that one has to ask the question: What exactly is HF? Is it a program model? An approach? A paradigm shift? All of the above? HF had its beginnings in a specific program at a specific time and place and its model of practice (including an overarching philosophy) is one that can now be replicated (Tsemberis, 2010). Over time, however, HF has acquired a much broader and deeper meaning, perhaps inevitable given its marked departure from business as usual and its widespread adoption.

The growing momentum supporting HF has spawned a propensity for homeless service providers to: (a) invoke HF in a vague way to indicate they are “on board” with what funders expect regardless of how much HF is actually in place at their particular program; and (b) view HF as having an unfair competitive advantage in funding decisions. With respect to the former, the staff of a rescue mission could insist that they “do HF” because they provide immediate access to a bed and hot meals. Or consider the proprietor of a board and care home saying they “do HF” because residents have minimal rules to follow and are rarely evicted. Such invocations of HF are understandably made but incorrect. Yet they are likely to increase in number as HF expands nationally and internationally.

As this book will demonstrate, HF has acquired the gravitas of a paradigm shift. Its widespread adoption has inspired systems change well beyond what a model could accomplish. That said, HF started out as a program model—that was the only way it could become embodied or realized in the first place. This book is about that journey from a small but determined opponent of the status quo to the challenges that come with success as well as critical scrutiny. Figure 1.2 depicts how HF skipped over the steps and placed consumers directly into their own independent housing. Going directly from “streets to homes” (Tsemberis, 1999) was, for its time, virtually unheard of.

Paradigm Shifts and Systems ChangeUnderstanding Housing First and its Impact

Figure 1.2 The Housing First Approach.


Conclusion: Opening the Door to Broader Considerations

A coauthor of this book, Sam Tsemberis, was an institutional entrepreneur who worked on the margins of an expansive service system in New York City to establish Pathways to Housing. Pathways was based on an institutional logic that stood in opposition to the mainstream or staircase continuum then dominant in homeless services. The HF program, however, was not developed solely to enact a new theoretical perspective.

As described earlier in this chapter, many of Pathways’ original staff members had been working in crowded drop-in centers where they kept trying and failing to refer their clients to existing continuum programs. It was this experience of repeated failure that moved Pathways staff and consumers to work together to bring about change. Although some of the central components of this alternative logic were not new, their combination and actualization into a real-world service organization, one that considered housing as a basic human right, was unprecedented. In keeping with the power of the status quo ante, the rise of HF was not without resistance, its institutional logic contested.

As we will see in Chapter Two, the homelessness epidemic (as it was called) had diverse and poorly understood causes but its impact was undeniable. Not surprisingly, the policies and practices designed to end or at least manage the epidemic were rooted in a sense of urgency and finitude. In Chapter Three, we describe the institutional actors and entrepreneurs who charted the mainstream or dominant course in homeless services, starting from various lineages or premises but ultimately converging into an unwieldy but massive bureaucracy. Chapter Four is (p.14) devoted to HF and its evidence base, a body of research that helped shape the new paradigm and set in motion wide dissemination and occasional contestation.

Chapter Five summarizes the qualitative research on HF and non-HF programs, providing themes derived from research that gives a voice to consumers as study participants. In Chapter Six, we feature consumer experiences in their own words through vignettes of life experiences before and after enrolling in a HF or non-HF program. Chapter Seven employs implementation and diffusion theories to describe HF as it spread to other cities in the United States and underwent the inevitable alterations and divergent opinions regarding the core ingredients of the model. Chapter Eight covers the adoptions of HF internationally, introducing new complications in culture and social norms surrounding definitions of homelessness and the services deemed appropriate to help those most in need. Chapter Nine takes a longer view of HF and the problem of homelessness in a world characterized by increasing disparities and inequality.

This broader context is critical to understanding the success as well as the limitations of HF. It is also necessary to avoid decontextualizing, that is, implying that individual actions are all that matter. Changes in the modalities of behavioral and social services usually happen at the micro-level, for example, family preservation programs to prevent foster care placement or cognitive-behavioral treatment for depression. This is a logical consequence of a fundamental premise of these services: The beliefs and behaviors of individuals and families need altering, not the environmental conditions that surround them. If the locus of change is the patient or client, its instigator is the provider—the social worker, psychiatrist, shelter director, or rehabilitation counselor whose authority is socially sanctioned.

HF changed these terms of engagement at the micro-level, but it also opened the door to broader considerations of power in determining access to a scarce and precious resource (housing). It spotlighted the individual client as agent of change as it rewrote the rules regarding access to what endowed that person with client-hood in the first place (homelessness). Shifting to a HF approach demanded major changes in funding priorities and policies. It also depended upon transforming organizational and practice culture, reaching down into the everyday interactions between a psychiatrist (or social worker or case manager) and a client (or tenant).

Beyond the individual and organizational levels are larger structural factors that shape the course of change. These factors often get lost in discourses on the causes of and solutions to homelessness. Structural barriers do not negate individual acts—whether committed by institutional entrepreneurs or homeless persons—but they do place profound constraints on how well or poorly (p.15) such actions fare. Shortages of affordable housing and living wage jobs, when combined with negative attitudes and stigma, are hardly inconsequential. In the following chapter, we examine the historical antecedents of the homelessness “epidemic” of the 1980s in the United States, setting the stage for the beginning of Housing First.


(1.) PHF began as a scatter-site model, that is, clients were placed in apartments in diverse neighborhoods and no more than 20% of the apartments in any building could be PHF clients. As we will see, this aspect of the model underwent modification in later iterations of HF.

(2.) The term “staircase” is a metaphoric description of homeless services. In large cities like New York, the existence of the staircase is apparent because there is a full array of shelters and transitional housing programs offering step-wise increases in independence (immediate access to the topmost step—permanent independent housing—was rarely available before Housing First). In smaller cities and towns, the bottom steps, such as shelters and temporary apartments or rooms, are the most common form of homeless service.


(1.) PHF began as a scatter-site model, that is, clients were placed in apartments in diverse neighborhoods and no more than 20% of the apartments in any building could be PHF clients. As we will see, this aspect of the model underwent modification in later iterations of HF.

(2.) The term “staircase” is a metaphoric description of homeless services. In large cities like New York, the existence of the staircase is apparent because there is a full array of shelters and transitional housing programs offering step-wise increases in independence (immediate access to the topmost step—permanent independent housing—was rarely available before Housing First). In smaller cities and towns, the bottom steps, such as shelters and temporary apartments or rooms, are the most common form of homeless service.