The Applicability of Housing First Models to Homeless Persons with Serious Mental Illness


This report presents the findings from an exploratory study of the Housing First approach of providing permanent supportive housing to single, homeless adults with mental illness and cooccurring substance-related disorders. In recent years, Congress and the leadership of the U.S. Department of Housing and Urban Development (HUD) have encouraged the development of permanent housing for homeless people. Concurrently, there has been a shift toward committing a greater proportion of HUD McKinney-Vento Act funds toward housing as opposed to supportive services and an increase in attention toward the hardest-to-serve, chronically homeless population, a substantial number of whom are mentally ill. Because it addresses this population and its needs, the Housing First approach is currently experiencing increased attention as a method of serving this population consistent with the above-stated goals.


Housing First programs may be constructed in a number of ways, but share the following features:

  • The direct, or nearly direct, placement of targeted homeless people into permanent housing. Even though the initial housing placement may be transitional in nature, the program commits to ensuring that the client is housed permanently.
  • While supportive services are to be offered and made readily available, the program does not require participation in these services to remain in the housing.
  • The use of assertive outreach to engage and offer housing to homeless people with mental illness who are reluctant to enter shelters or engage in services. Once in housing, a low demand approach accommodates client alcohol and substance use, so that “relapse” will not result in the client losing housing (Marlatt and Tapert, 1993).
  • The continued effort to provide case management and to hold housing for clients, even if they leave their program housing for short periods.

The first and most well known Housing First model is Pathways to Housing, located in New York City. Established in 1992, Pathways to Housing offers individuals, who are homeless and have psychiatric or substance-related disorders, direct access to permanent, independent apartments without requiring participation in psychiatric treatment or sobriety as a precondition for entering housing (Tsemberis, Gulcur, and Nakae, 2004). Housing and treatment services are separated. Clients rent apartments—with the lease held by Pathways to Housing—from landlords who do not have a direct relationship with the treatment agency. The program uses a low demand approach that does not prohibit substance use as a condition for obtaining or retaining housing. The program requires that clients pay 30 percent of their income for rent and participate in two home visits by their case manager each month. Following housing placement, interdisciplinary Assertive Community Treatment (ACT) teams are available 24 hours a day, 7 days a week to provide treatment, support, and other needed services to the client in a neighborhood office or in the client’s home.

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