Evidence at a glance: Housing First and choice

Housing First (HF) is an evidence-based approach to ending chronic homelessness among people with mental illness and helping them address their complex needs (e.g., chronic health problems, addictions).1 HF combines rent supplements with support, typically in the form of Assertive Community Treatment or Intensive Case Management.2 Rather than providing “treatment first” before providing housing, the focus of HF is to provide people with housing immediately. Choice is a key principle of HF.

Read the resource below or download the PDF.

Why is choice so important in Housing First?

In HF, participants have choice and control over their housing and support. In terms of housing, participants are provided with a rent supplement, so that they can choose an apartment from the rental market in the community. For support, participants are not required to engage in treatment, but they must agree to a weekly home visit from a support worker.2 In HF, housing and support are separated, so that support will continue to be provided wherever the person lives.

Choice is important for several reasons

HF views housing and self-determination as human rights. People have the right to choose where they want to live.

  1. A review of eight studies on the preferences of more than 3,000 people with mental illness, including individuals who were homeless, found that 84% preferred to live independently in their own house or apartment.3
  2. Research has found that having choice and control over one’s housing and support services are associated with positive mental health outcomes.4, 5, 6, 7, 8, 9
  3. Choice and control over housing and support services is significantly greater for participants living in their own apartments than for those living in group living arrangements.7,8

In summary, research has shown the beneficial aspects of people having choice or control over their housing and support.

How can you use this evidence?

  1. Offering people who are homeless only congregate housing ignores people’s preferences about where they want to live. The federal government’s proposed portable housing benefit should be widely implemented to promote choice and control over housing and support.10
  2. In New York City, the HF approach began by listening to the preferences of people who were homeless. When communities conduct Point-in-Time counts (i.e., 24-hour census) of the homeless population, they should include questions about the preferences of people for housing and support.
  3. HF programs should be expanded and adequately resourced with sufficient rent supplements, well-trained staff and intensive support services, including Assertive Community Treatment.11

This evidence summary is written by Dr. Geoffrey Nelson and Dr. Tim Aubry, co-leads of the Ontario Housing First Regional Network Community of Interest, part of Evidence Exchange Network. This summary is not a full evidence review of the topic, but highlights the evidence from key articles and subject matter experts on housing first and homelessness.

Additional resource: Rain City Housing First Choice Video (8 minutes, 26 seconds)

References

  1. Aubry, T., Nelson, G. & Tsemberis, S. (2015). Housing First for people with severe mental illness who are homeless: A review of the research and findings from the At Home-Chez Soi demonstration project. Canadian Journal of Psychiatry, 60, 467–474.
  2. Tsemberis, S. (2015). Housing First: The Pathways Model to End Homelessness for People With Mental Illness and Addiction. Center City, MN: Hazelden Publications.
  3. Richter, D. & Hoffman, H. (2017). Preference of independent housing of persons with mental disorders: Systematic review and meta-analysis. Administration and Policy in Mental Health and Mental Health Services and Research, 44, 81–823. Available:https://doi.org/10.1007/s10488-017-0791-4. Accessed July 29, 2020.
  4. Greenwood R.M. & Manning, R.M. (2017). Mastery matters: Consumer choice, psychiatric symptoms and problematic substance use among adults histories of homelessness. Health and Social Care in the Community, 25, 1050–1060. Available: https://doi.org/10.1111/hsc.12405. Accessed July 29, 2020.
  5. Greenwood R.M., Schaefer-McDaniel N.J., Winkel G. & Tsemberis S.J. (2005) Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness. American Journal of Community Psychology, 36, 223–238.
  6. Martins, P., Ornelas, J. & Silva, A.C. (2016). The role of housing quality and perceived choice to recovery: Am ecological perspective on a housing first program in Lisbon. Journal of Environmental Psychology, 47, 44–52. Available: https://doi.org/10.1016/j.jenvp.2016.05.004. Accessed July 29, 2020.
  7. Nelson, G., Hall, G.B. & Walsh-Bowers, R. (1999). Predictors of the adaptation of people with psychiatric disabilities in group homes, supportive apartments, and board-and-care homes. Psychiatric Rehabilitation Journal, 22, 381–389.
  8. Nelson, G., Sylvestre, J., Aubry, T., George, L. & Trainor, J. (2007). Housing choice and control, housing quality, and control over professional support as contributors to the subjective quality of life and adaptation to community living of people with severe mental illness. Administration and Policy in Mental Health and Mental Health Services Research, 34, 89–100.
  9. Piat, M., Seida, K. & Padgett, D. (2019). Choice and personal recovery for people with serious mental illness living in supported housing. Journal of Mental Health, Available: https://doi.org/10.1080/09638237.2019.1581338. Accessed July 29, 2020.
  10. Nelson, G. & Aubry, T. (2017). A Portable Housing Benefit as an Indispensable Component of Ending Homelessness in Canada. Toronto, ON: Evidence Exchange Network. Available: http://eenet.ca/initiative/housing-first-community-interest#about. Accessed July 29, 2020.
  11. Nelson, G. & Aubry, T. (2018). Assertive Community Treatment (ACT) and Housing First in Canada. Toronto: EENet, Ontario Housing First Regional Community of Interest. Available: http://eenet.ca/resource/policy-brief-assertive-community-treatment-act-.... Accessed July 29, 2020.

The Ontario Housing First Regional Network Community of Interest (OHFRN-COI) is intended to assist communities across Ontario to develop, evaluate, and improve Housing First (HF) programs based on the Pathways model tested, adapted, and shown to be effective in the At Home/Chez Soi Demonstration Project. This CoI is supported by Evidence Exchange Network (EENet), which is part of the Provincial System Support Program (PSSP) at the Centre for Addiction and Mental Health.