Decades of research have shown that focusing on housing without preconditioning alcohol or mental health treatment is the most effective way to reduce homelessness.
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January 26, 2023
Many US cities have cleared camps of homeless people over the past year Shutterstock/Philip Pirothian
In the past few months, government officials across the United States have announced initiatives to reduce homelessness. The issue has become more pervasive, visible and controversial since the start of the pandemic. However, many of the current proposals seem to ignore the evidence about what actually reduces homelessness, and instead focus on costly and effective measures that are unlikely to make a difference in the long run. It perpetuates a strategy without
Half of US adults say homelessness is a major concern. Cities such as New York, San Francisco, Portland and Oregon have raised concerns about the number and size of outdoor camps.
This increased awareness reflects a real increase in numbers in many places. For example, in New York City, about 19,000 people slept in the city’s shelter system for singles each night in December 2021. The Homeless Coalition recently reported a 91% increase from a decade ago.
The increase in homelessness isn’t just happening in the United States. Between January and March last year, more than 74,000 households were homeless or in imminent danger of losing their homes, according to the charity Shelter, partly due to the ongoing cost of living crisis. It was done. This represents an 11% increase compared to the last three months.
The response in the US has been a flurry of announcements about efforts to reduce homelessness. Largely due to stronger police and rule changes to make it easier to place homeless people in mental health facilities. California, for example, in September ratified a law creating a court system to treat more people with severe mental illness who are not incarcerated. And in November, New York City Mayor Eric Adams announced a policy change that would make it easier for authorities to involuntarily hospitalize unhoused people for mental health treatment.
Many of these new initiatives rely heavily on an old mindset known as ‘treatment first’. That is, government agencies provide housing to people, but only on the condition that they continue to take mental health medications or do not return to substance abuse.
But since at least the early 2000s, we knew there was a better way. Under the George W. Bush administration, the United States changed federal policy to prioritize a “housing first” approach. The basic idea behind it is that rather than requiring abstinence and adherence to treatment as a condition of owning a home, having a place to live can potentially address serious health problems such as addiction and mental illness. Not maintaining complete abstinence can result in expulsion, and the instability itself makes recovery more difficult if you are constantly cycling through rehab and temporary housing.
Since then, many studies have shown that housing works first when properly funded and managed. This is associated with a significant decline in homelessness.
Between 2010 and 2022, there was a 55% drop in homelessness among those who served in the military after the Department of Veterans Affairs launched a massive housing priority initiative. This progress has been maintained during the pandemic. Cities like Houston and Abilene in Texas have had similar success using this approach for chronically homeless people and being able to maintain the availability of affordable housing.
Studies directly comparing housing preference and conventional treatment-first approaches consistently show that housing preference protects people longer and improves their quality of life.
Although recovery from addiction is not a prerequisite for residence under this approach, in most head-to-head comparisons, drug use outcomes are equal to or better than for initial residence. In other words, the concern that by not requiring abstinence as a condition of residence “allows” people to become addicted is unfounded.
Moreover, one study found that even the most severe psychotic patients with substance use disorders voluntarily left the street in 86% of cases if adequate outreach was provided and supportive services were provided in their new residence. However, the key factor is that these services must also be voluntary.
There is now ample evidence pointing to approaches that can help reduce chronic homelessness. Although research on cost-effectiveness is sparse, this approach has been shown to be cost-effective, especially when used among the most severely psychotic patients, regardless of whether they have a substance use disorder. And in a hopeful sign, the Biden administration recently recommitted to providing housing first, offering support to cities and states that want to expand it.
The main obstacle to solving the homeless problem remains ideological. It is politically difficult to sell the idea that drug-using and destructive people should get free housing.
Maia Zarawitz is Putting Drugs Back: How Harm Reduction Is Changing the Future of Drugs and Addiction
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