Homelessness and Housing First Initiatives vs Treatment First
Part Two of Three
One of our regular support line callers has been experiencing more than 2 years of being under-housed in a service desert in Raleigh, NC. A Person of Color in her late 20’s, she gave birth to a beautiful baby during Covid and she and the child, now 3 years old, have been living in various motels in an attempt to stabilize their lives. She trades sex to survive and barely gets by these days. She has no supportive family or friends and has not been able to access critical services to improve her situation due to a high number of “kinks” in the institutional systems that have created barriers that she has not been able to overcome.
Her unstable phone service - difficulties in navigating the 73rd worst transportation WalletHub rated system in the United States, and complete lack of internet access (the motel does not provide free wifi) prevent her from applying for services online because she can’t print out applications and fax them back.
Leaving an Abusive Relationship is what started her Spiral Downward
All of this "homeless situation" started when she left an abusive relationship, including kidnapping of her child, physical, psychological and emotional abuse and an incredibly complicated situation where she was being constantly harassed and stalked by her abuser. She reported the abuse of herself and her child to police and he was eventually arrested but because she had ads posted on escort websites and was an exotic performer at a local strip club, they made the process of prosecuting him impossible and they withdrew their charges against the abuser, even though the investigation revealed strong evidence that the abuse had taken place.
Raleigh knows they have a “Homeless Problem”
According to the Wake Partnership to End Homelessness and the Executive Director of the project, Kim Crawford, called the situation a "pandemic within a pandemic."
"Homelessness is a life and death situation. It's not necessarily a characteristic of a person, but it happens to be the situation they find themselves in. And it's a precarious, dangerous situation to be in. With that being said, we have seen a large increase in our unsheltered population over the last two years." -Kim Crawford, Executive Director at Wake Partnership to End Homelessness
Raleigh's Homelessness increases are not just concerning, they are staggering. The 2022 count for Wake County showed a 68 percent increase from 2021 and a 99.5% increase from 2020 and the barriers to access literally any kind of shelter - with or without a child - are quite literally face-palm worthy.
Urgent housing is available at three distantly separated locations and the person seeking shelter has to get in one of the lines around 4pm in the afternoon and wait to see if there is an available bed and even if they successfully access a bed at one of the three Urgent Housing Shelters, it is only guaranteed until 8am the next morning, at which time the homeless population is evicted from the premises and cannot return until a new line opens the following day.
And if you are in one urgent shelter line, you can’t be in the other two.
The problem is multi-level. In addition to insufficient shelter beds, a lack of affordable housing units continues to remain another reason for the prevalence of homelessness.
"Homelessness ends with a home, and we don't have enough," Crawford said. "We already know that; we hear that every day. We hear the price of homes is skyrocketing. The same thing is happening in our rental market. The rents are going up as well. What that means is that we have less and less and less units that are available at, or below fair market rent."
As in every area of the country, homelessness disproportionately affects Black people in Wake County. According to the 2020 U.S. census, Black individuals made up 21 percent of Wake's population, but make up about 73% of this year's count of the homeless population. And, surprising no one, the major cause of this remains generational poverty, systemic oppression, historical injustices and a lack of equity in institutions like the criminal justice system, health care and education.
Housing First is the Simple but also Complicated Solution
Housing First is an alternative to a system of emergency shelter/transitional housing “progressions”.
Rather than moving homeless individuals through different "levels" of housing, whereby each level moves them closer to "independent housing" (for example: from the streets to a public shelter, and from a public shelter to a transitional housing program, and from there to their own apartment or house in the community), Housing First moves the homeless individual or household immediately from the streets or homeless shelters into their own accommodation.
Housing First approaches are based on the concept that a homeless individual or household first and primary need is to obtain stable housing, and that other issues that may affect the household can and should be addressed once housing is obtained. In contrast, many other programs operate from a model of "housing readiness" — that is, that an individual or household must address other issues that may have led to the episode of homelessness prior to entering housing.
The History of Housing First Initiatives
In 2000, the National Alliance to End Homelessness launched the campaign to end the problem in 10 years. “People should be helped to exit homelessness as quickly as possible through a housing first approach. For the chronically homeless, this means permanent supportive housing (housing with services)—a solution that will save money as it reduces the use of other public systems. For families and less disabled single adults, it means getting people very quickly into permanent housing and linking them with services. People should not spend years in homeless systems, either in a shelter or in transitional housing.”
In 2015, the University of Illinois Hospital & Health Sciences System (UI Health) partnered with the non-profit All Chicago, launched a pilot program based on a much simpler formula for access. If a person had visited an emergency room 3 or more times within 90 days, they were offered entry into “free” subsidized housing and offered - but not mandated - services to support underlying factors such as access to medications, managing substance use and gaining access to skill building education and permanent employment.
The idea of Housing FIRST Initiatives is: Take people who are chronically abusing drugs and alcohol, resisting help, unable to keep a job and committing petty crimes. Give them an apartment, no strings attached. Even buy them furniture and appliances. And watch their use of emergency rooms drop.
And in many cases, it worked.
One of the earliest “chronically homeless” people accepted into the program was visiting the emergency room 2-3 times per week at a cost to taxpayers of $3,700 per visit, and after 90 days in their own private 1 bedroom apartment, costing the hospital and the non-profit organization managing the program $1000 per month with no taxpayer cost, the Emergency Room staff hadn’t seen any sign of them. Their healthcare, medication and elective social services were provided on site and they thrived.
In many cases it didn’t work.
Homelessness, Substance Use and Mental Health Disorders
The early days of the program stuttered over mental health disorders and the difficulty of finding the right medications to manage the mental health issues that may have led to the homelessness in the first place. There was a lot of anxiety around the issue of substance use, sometimes because of the stigma that is associated with drug use, but also because opponents of Housing First Initiatives were insistent that the only way someone could stop using drugs was to endure some sort of residential program where the ONLY option was abstinence.
An abstinence-based approach means that clients must completely abstain from drugs and alcohol. Practitioners believe that people with substance use disorders cannot successfully moderate their use in a way that does not lead to addiction and negative consequences.
While there is some “first glance” wisdom in this approach as using substances lowers a person’s inhibitions and impairs their ability to make good judgments.
For example, a person in recovery for opioid use disorder who continues to drink alcohol may be at risk of relapsing due to lowered inhibitions and poor judgment while under the influence of alcohol.
Similarly, some people with substance use disorders are not willing to completely stop using drugs and alcohol but are willing to practice moderation. In these cases, clients may be more successful working with a harm reduction provider in a Housing First Model.
The harm reduction model prioritizes reducing the negative consequences of a person’s substance use over complete abstinence. This model recognizes that drug use is complex, and abstinence may not work for everyone. Harm reduction aims to reduce harmful consequences like:
Risk of death
Some people with substance use disorders struggle to identify their drinking or drug use as a problem. However, they may be able to admit that they are having some medical, financial, or relational issues in their lives.
There was a great deal of politically charged pushback and the program fought significant challenges in finding funding but also accessing critical care services and support that were willing to “go to them” rather than insist on having participants navigate their way to their office, often located in government buildings that didn’t allow homeless people to bring their meager possessions with them. It was also difficult to convince landlords to offer their rental properties to stigmatized homeless populations - even though rents were paid by non-profit and government subsidies - instead of more lucrative traditional tenant or, even worse, Vacation Rental Properties like VRBO and AIRBNB.
Housing First is a Harm Reduction Initiative
A 2021 study found that Housing First programs decreased homelessness by 88% within the first year and improved housing stability by 41%, compared to Treatment First programs.
Housing first works because, like harm reduction initiatives, it simply eliminates barriers.
Our caller doesn’t have a drug addiction, hasn’t visited a hospital except to deliver her child and is more than willing to accept more traditional employment, but the barrier of paying for the weekly rate motel has trapped her into a cycle that is not easy to snap out of. And the more than 2 years of basic human need survival living has exhausted her and she can no longer fight or fly. She is now “frozen” in place, with little motivation to continue to travel to “walk in only services” that will do little more than accept an application and add her and her child to the bottom of the waitlist. Her biggest fear is that formally registering as a homeless person with a child will invite Child Services into their rapidly shattering lives and she will be forced to give him up, or even more torturous, have him forcibly taken from her. Our biggest fear is that she will eventually go from being homeless, to being exploited and will end up in yet another abusive relationship.
If a Housing First Model were applied in Raleigh, she would be able to get access to job training, education, traditional employment and, most importantly, assistance for her child to eat and be healthy.
Oh! Wait a minute! Isn’t that what we could do if we fully decriminalized sex work as they did in New Zealand in 1999?
Yes. We could. The question again…is will we?
Our beloved client and stressed out mother told our CSL agent:
“I’m completely at rock bottom..I don't want to be forced to give him up but there's NO HELP here in Raleigh...I can't even get to the parenting classes that I signed up for voluntarily because I just want to be the best mom I can be. I don't know what else to do.”
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