It can take time for some people who have been homeless for years to adjust to being housed. But our experience shows that people both want housing and do much better when they have it.

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A persistent topic in the community conversation on homelessness is what to do about people who appear to need treatment but aren’t getting it. The homelessness crisis is bad, especially, of course, for people living it. But it’s bad for the rest of us, too. Nobody likes being confronted with the obvious suffering of others, not to mention the byproducts so prevalent over the last several years, including blocked sidewalks and discarded debris, even hazardous used syringes.

Frustration with these conditions is often followed by frustration with the people creating them. “Why aren’t they doing anything to help themselves? Why won’t they accept help? They should just be put in treatment.”

At Downtown Emergency Service Center, we have learned it’s backward to focus on treatment without first resolving a person’s homelessness. People on the street are not strangers to “treatment.” On the contrary, many have been to treatment so many times they have lost count. We did a study that documented an average of 16 prior treatment episodes for a population group thought of by many as not wanting help, people some would call “homeless by choice.” They did want help and used available treatment as the way to get better, but without the stability of a home it didn’t work despite repeated attempts.

While treatment for conditions like serious mental illness and longstanding substance addiction is very important, it can be difficult to get great results even under the best of circumstances. For example, it’s rare to hear that one round of treatment results in sustained abstinence from substances. And medications, talk therapy and case management services aren’t always highly effective against the most debilitating psychiatric illnesses like schizophrenia.

At DESC, we believe in treatment for behavioral health conditions like mental illness and addiction so much that we are licensed to provide it, and it constitutes half of all the work we do. But what we have learned in doing it for so long is that it works a lot better when we are able to first get someone into stable, permanent housing. The stress of homelessness is a real detriment to treatment effectiveness, even when a person has a temporary place to be indoors. Feeling long-term security is a necessary condition for making the most out of treatment.

An example is Marvin, a man who lived outdoors for many years suffering from voices in his head, clothes disintegrating off his body, malnourishment, and open wounds on his arms and legs. He cycled between the streets and hospitals until finally accepting permanent supportive housing thanks to the dedication of outreach workers. Once housed, Marvin began to welcome the mental-health care and other services he had rejected on the streets. His psychiatric symptoms decreased, he reconnected with family, and he has achieved the longest period of stability in his life.

What is true for Marvin is true for others. The innovation known as Housing First has shown that everyone can be housed, even when their underlying disabilities haven’t gone away. It can take a while for some people to adjust to being housed when they haven’t had it for many years, but our experience shows that people both want housing and do much better when they have it.

The idea of Housing First doesn’t mean Housing Only. To be successful, the housing needs to be paired with robust services that people make use of on their own terms. That’s what makes it work, giving people the platform they need to make productive use of treatment and begin the process of reintegrating with the life of the community. Research at DESC and elsewhere has shown this to be the intervention most acceptable to people experiencing long-term homelessness, and the one most successful at keeping them housed while dramatically lowering their use of expensive crisis services. It’s better for everyone and lays the foundation for lasting stability and recovery.

Not all homeless people need the level of intervention and support provided by the kind of permanent supportive housing described here. We estimate that 4,500 such units of housing are needed for homeless people with the most difficult situations. Around 1,000 of those units are either in development now or able to be created using resources expected to be available over the next five years, so significant work remains to be done to bring this highly effective intervention to the scale it needs to be. But given the relief Housing First provides to crisis systems, a significant portion of the costs will be offset by lower spending elsewhere.