What is Housing First?
Housing First is one of the most direct and effective ways to solve homelessness: give people housing. Permanent and not conditional on solving other health issues or commitment to an institution first. As the National Alliance to End Homelessness states,
Housing First is an approach that prioritizes providing permanent housing to people experiencing homelessness, thus ending their homelessness and serving as a platform from which they can pursue personal goals and improve their quality of life. This approach is guided by the belief that people need basic necessities like food and a place to live before attending to anything less critical, such as getting a job, budgeting properly, or attending to substance use issues. Additionally, Housing First is based on the belief that client choice is valuable in housing selection and supportive service participation; exercising that choice is likely to make a client more successful in remaining housed and improving their life. Housing First programs remove barriers faced by households trying to attain permanent housing, and do not require prerequisites to access housing support beyond what is required in a tenant’s lease.
If you want to treat physical and mental health issues that lead to homelessness, you probably should give those patients a place to undergo long-term medical treatment that can involve medications that take weeks to notice a difference with, trauma therapies that take multiple phases across months to process a single traumatic incident during which a mental health crisis is still possible, and developing new healthy routines around diet and exercise that work alongside any other conditions.
If you want people to avoid using emergency services as a result of physical and sexual violence, preventable diseases and manageable disorders, exposure to the elements and pandemics, environmental pollution, and other nasty things, it would probably help to take someone out of the place where those things have a higher chance of occurring.
If you want to experiment with new approaches to addiction treatment beyond the Minnesota Model that was adopted in defiance of a strong scientific basis but has persisted in dominance thanks to regulatory capture from the private healthcare and insurance industries, create an alternative space to do that for a tiny miniscule fraction of the cost of a hospitalization.
To be blunt, it’s an extremely common-sense solution that you have to jump through many hoops and bend yourself into many pretzels to avoid. Meta-studies that explore these programs find strong quantitative evidence that it helps individuals stay housed and avoid using emergency resources that are far costlier than preventative measures. Every other intervention we propose is way more likely to succeed if we’re working with housed individuals. Obviously. Duh.
Recovery Requires Capital
The science of recovery and addiction treatment has moved away from focusing on total abstinence and CBT individualist therapies as a “gold standard,” and instead towards a holistic view of the way recovery capital influences quality of life for both an individual and their community.
Recovery Capital refers to the internal and external resources that an individual can access to begin and sustain recovery from addiction or mental health conditions. These resources span personal strengths, social networks, and community or cultural supports. Originally introduced by researchers Cloud and Granfield in 1999, Recovery Capital highlights that recovery success depends not only on individual willpower and abstinence but also on the broader social and environmental context. Unlike traditional abstinence-focused measures, recovery capital through the Recovery Capital Index evaluates the holistic components of wellbeing, enabling a person-centered approach to recovery.
If we accept that addiction is a complex biopsychosocial disorder with roots in personal trauma and genetic predisposition that cause physiological changes in the brain’s reward mechanisms after sustained exposure to a particular material environment, it makes sense to move beyond discussions about knowledge gaps and into capital gaps. All the diet, exercise, and spiritual changes in the world will not change the fact that people with diabetes need insulin, people who struggle to walk need wheelchairs, people who are deaf need hearing aids or sign language, people who are blind need Braille, and people who are suffering from multiple complex mental health disorders need a safe place with professionals, a bed, and running water to work through the instability of their lives.
Recovery Capital is generally split into three types, though this is more for convenience than an implication that these are independent categories:
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Personal: Physical/Mental/Emotional Wellbeing, Balanced Nutrition, Employment Status, Job Satisfaction, Workplace Support, Formal Education, Growth Opportunities, Financial Stability and Stressors, Stable and Safe Housing, Transportation Accessibility, Clothing Availability
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Social: Emotional and Practical Family Assistance, Relationship Support from a Significant Other, Friendships, Comfort and Aid Networks, Professional and Personal Mobility, Wellness Activities, Support Groups, Access to Healthcare, Community Safety
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Cultural: Alignment and Respect for Beliefs, Clarity and Strength of Principles, Integration of Spiritual Practices, Meaning & Purpose, Culturally Appropriate Support Groups, Feelings of Community Belonging
Although called “recovery” capital, the many dimensions to one’s health that are discovered in the process of recovery are applicable to practically anyone. We can see how complex of an issue addiction is when there’s so much overlap and intersection from the types of capital above. This isn’t a new idea either; this was identified as a model in 1999. Its lack of adoption has a lot to do with the shape of our institutions rather than scientific justifications.
In the 1980s, American medical institutions that practiced psychology and psychiatry began seeking operationalizable methods that could fit into manuals and be readily tested with experiments. If you had a method that was 80% effective but took 3 years to do, you’re not going to get far compared to a treatment that’s 25% effective but can be tested in 3 weeks. A lot of comparative studies in therapy will do something like compare a standardized CBT regimen with worksheets to psychoanalytic therapy delivered by graduate students who had a couple days of rushed training from researchers who are biased by a prior body of work favoring CBT. Jonathan Shelder has a great set of criticisms that are really specific about the methodologies of these papers in promoting CBT as a “gold standard” modality. I had my own peek into the research world when I was in college, and I don’t have trouble believing much from the things he’s pointed out. The WEIRD problem feels especially salient.
One finding from recovery capital studies is that an individual’s recovery capital is not as strong in predicting sustained abstinence as social recovery capital. The difference between someone with a highly supportive relationship and without one tends to be larger than the difference between two individuals’ personality traits. Changes in social networks actually tend to precede changes observed in personal functioning. Someone can present in treatment with high motivation, confidence, and awareness, but they will still struggle to maintain abstinence if they lack consistent transportation, safe housing, sober friend groups, and employment opportunities. Someone with modest confidence in their ability to maintain abstinence can do better than someone with high confidence if they have access to a more supportive network.
Recovery capital is also a better predictor of overall quality of life than sustained abstinence, meaning someone with high recovery capital might relapse but not suffer from the same lowered quality of life as someone who relapsed with less recovery capital. Some people can spiral faster than others on this basis. By the same token though, recovery capital is capital; it tends to work like an investment where even a few months of stable living can dramatically improve someone’s ability to generate recovery capital.
How someone’s recovery capital changes during treatment is a better predictor for how they’ll do than the baseline recovery capital they start with. Someone who enters treatment and experiences a negative social environent might experience a net decrease in recovery capital that has more influence on sustained abstinence than the therapeutic and medication interventions. Because of diminishing marginal returns on any particular form of capital within recovery capital, those who have really low capital, who might feel the most desperate and hopeless, can actually make much more progress than those with high recovery capital at baseline. Some argue that treatment is effective because it helps increase recovery capital rather than directly addressing the compulsion to use or maintenance of abstinence.
What this means is that addressing addiction cannot come down to just teaching individuals ways to self-regulate their symptoms or keep up willpower through daily affirmations. The evidence is pretty clear that we need to expand access to social, environmental, and material resources if we want to make more effective, including cost-effective, interventions. Housing First is an extremely obvious way to start that process.
A Personal Note
Anecdotally, some of the most promising and inspiring recovering addicts I’ve ever met relapsed after returning to an unstable environment that they trusted to be stable so they could keep healing while reintegrating into some sense of normalcy.
I’ve seen people try to reconcile with violent partners for the sake of a roof. I’ve seen young people under 20 without safe families struggle over issues with insurance that led to being kicked out of sober living homes and into shelters, where they’ve been assaulted multiple times. I’ve seen elderly people struggle to get hired at minimum-wage jobs that strongly prefer desperate young people. I’ve seen people get diagnosed with other mental health disorders for the first time in treatment that they were obviously self-medicating through because of a prior lack of access, and they obviously haven’t had time to figure out how to stabilize from it during their brief time in addiction treatment. It takes weeks to even figure out how one adjustment to a medication can influence you, and it can take years to find a medication that works.
I’ve seen people of all ages get confused by their rights as people with disabilities. They have no clue what county, state, federal, and private programs exist dedicated for people in their situation with severe disabilities that impede a return to normal substantial employment and social relationships. These programs often require case managers or other professional staff to make a referral, but it’s been tragically common among my friends for their staff to have no idea what the county they’re working in even provides or how to put together the documentation for an application for benefits. That’s actually one of the reasons I chose to launch this site.
Someone needs to just make a pamphlet that says “Welcome to Addiction! Here are the rights you should know about, the public and private programs that you might be eligible for, the recovery meetings you can go to, the different ideas about how addiction and recovery work around the world and across time, the authorities in the field that do active research into new treatments, the common myths from pop culture that feed the stigma, the advocacy organizations you can join to fight for systemic reform, the stories that you might find inspirational, and some reminders that having a horrible disease does not make you a horrible person.”
Someone more qualified than me should do it, but until then, I’ll take a stab at it. I would like to prevent more of my friends from dying a preventable death.