Housing First Literature: Different Orientations
and Political-Practical Arguments
Suvi Raitakari and Kirsi Juhila
University of Tampere, School of Social Sciences and Humanities, Finland
>>Abstract_ Over about twenty years, Housing First (HF) and its adaptations
have become internationally promoted housing models for long-term homeless
people with mental health difficulties or/and substance abuse issues. The
model called Pathways Housing First (PHF) created in New York by Sam
Tsemberis, the founder of the Pathway to Housing organization, is the most
well-known. PHF model is depicted in the research literature as the original
implementation of Housing First (HF). In addition to a housing model, HF has
been defined as a philosophy and it is a rapidly growing research branch. In
this review article, HF is approached first and foremost as a diverse research
branch and the aim is to map HF literature from 1990 to 2014. The article is
based on 184 publications. The main criterion for including a publication in the
database was that it takes as a starting point and/or comments on the original
PHF model. The following research questions were asked: 1) what are the
research types that are represented in HF literature? (we call these ‘literature
orientations’), and 2) what kind of political-practical arguments and objectives
are expressed within each type i.e. orientation? The review found nine different
types of research: 1) comparative studies, 2) guidelines and text books, 3)
evaluation reports, 4) commentaries, 5) reviews, 6) implementation and
outcome studies, 7) the development of scales and tests, 8) experiences and
interaction studies and 9) critical social science research. As a conclusion,
possible future directions of HF research are discussed.
>>Keywords_ Housing First, literature orientations, review, future directions and
ISSN 2030-2762 / ISSN 2030-3106 online
146 European Journal of Homelessness _ Volume 9, No. 1, June 2015
Homelessness is a globally persistent social problem. Long-term homelessness,
in particular, is an indicator of extreme exclusion, poverty and human vulnerability.
Long-term homelessness is often intertwined with severe mental health problems
and substance abuse issues (e.g., Waegemakers-Schiff and Rook, 2012; Watson
et al., 2013). It is a major burden on individuals and societies (Whittaker et al., 2015).
In order to understand long-term homelessness and tackle it successfully, we need
to scrutinize and influence societal structures, organization-level policies and
practices, and human agency (e.g., Watson et al., 2013). In Western societies,
governments and non-governmental organizations have made great efforts to
diminish long-term homelessness. For example, the Finnish government recently
launched two programmes to reduce long-term homelessness (running 2008–2011;
2012–2015) (Tainio and Fredriksson, 2009). Australia, Denmark and the Netherlands
also launched national level homelessness strategies and targeted initiatives to
decrease homelessness (Benjaminsen, 2013b; Whittaker et al., 2015). Van Wormer
and van Wormer (2009) describe nationwide developments in US. These initiatives,
programmes and strategies are seen to represent a homelessness policy shift from
the linear residential treatment (LRT) model (also called the continuum of care or
the staircase model) to the Housing First (HF) model
Over the last twenty years or so, HF and its adaptations have become internation-
ally promoted housing models for long-term homeless people with mental health
difficulties and/or substance abuse issues. It is often argued that the original
model called Pathways Housing First was created in New York by the Pathway to
Housing organization, founded by Sam Tsemberis (for a history, see Felton, 2003;
Waegemakers-Schiff and Rook, 2012). PHF is depicted in the literature as the
original and truest way to implement HF. In addition, it has been presented as an
evidence-based practice and, as a result of this research evidence, it has received
a great deal of international recognition (Johnsen and Teixeira, 2012; Johnson et
al., 2012; Pleace, 2012; Pleace and Bretherton, 2012a; b; Greenwood et al., 2013b)
and has been widely adopted across the US, Canada, Australia and Europe
(Greenwood et al., 2013b).
The aim of the HF model is to provide immediate access to permanent housing and
sufficient, sustained support for former long-term homeless people with their
special support needs. The HF model comprises the following principles: housing
is a human right and a precondition for a decent life and recovery; to be housed
should not require adherence to treatment and care and, thus, housing and support
are to be separated; and residents are to be encountered with empathy, respect
and patience without coercive practices. Freedom of choice and self-determination
are important preconditions in successful housing and recovery. Scattered housing
is to be the primary option. Both recovery-orientation and harm reduction are to be
combined in support services (e.g., Tsemberis, 2010a; Busch-Geertsema, 2013;
Gilmer et al., 2013; Kaakinen, 2013).
In addition to a housing model, HF has also been defined as a philosophy and it is
a rapidly growing research branch. Some scholars even talk about a paradigm shift
in homelessness and mental health policy and practices (Nelson, 2010; Bostad
först som.., 2013; Kaakinen, 2013). As stated by Greenwood et al. (2013a; b),
research was a crucial precursor to the implementation of HF from the 1990s in the
US and Canada, and from the 2000s in many European countries. Commonly, HF
initiatives are demonstration projects with strong research and evaluation compo-
nents and political-practical objectives (Greenwood et al., 2013a).
In this review article, we approach HF first as a diverse research branch and our
aim is to map and give an overall view of the HF literature, from the 1990s to 2014.
The review identified nine different types of literature: 1) comparative studies, 2)
guidelines and text books, 3) evaluation reports, 4) commentaries, 5) reviews, 6)
implementation and outcome studies, 7) the development of scales and tests, 8)
experiences and interaction studies and 9) critical social science research.1 HF has
thus generated a wide range of homelessness research and societal discussion on
homelessness. The starting point of this review is the idea that, after twenty years
of HF research, it is worth taking the time to analyse and classify the growing
number of publications that relate to applying, translating, evaluating, examining
and discussing HF across many Western countries. By doing this, the review also
captures future directions of HF research. Before presenting the nine different types
of literature identified, we clarify how the literature was collected and mapped in
the database and how the analysis was conducted.
The Review: Data and Research Questions
In this review article, the aim is to map HF literature from 1990 to 2014. The first
objective is to classify publications according to the scientific genre they represent
– i.e., what kinds of research tasks are set and data and methods used. The review
covers HF literature broadly, and includes e.g. policy reviews, debate papers,
reports and textbooks. The second objective is to study the publications in terms
of the political-practical arguments and objectives they set forth. This aim is
grounded in the assumption that the HF literature is linked to promoting the HF
model itself as a practical and working solution to homelessness, and that the
1 Waegemakers-Schiff and Rook (2012, p.11) categorize HF literature in the following way: a)
quantitative studies, b) qualitative studies, c) program descriptions, d) program outcomes, e)
policy review, f) health outcomes, g) cost-effective studies, and h) population studies.
148 European Journal of Homelessness _ Volume 9, No. 1, June 2015
literature thus primarily produces knowledge and arguments that are useful for
political decision-making and for implementing local HF models (Stanhope and
Dunn, 2011; Waegemakers-Schiff and Rook, 2012; Greenwood et al., 2013a).
Accordingly, scrutiny of the political-practical arguments contained in the literature
constitutes the core conceptual framework for this review. The following research
questions were asked: 1) what are the research types that are represented in HF
literature? (we call these literature orientations), and 2) what kind of political-prac-
tical arguments and objectives are expressed within each type i.e. orientation?
The database of the review was created and reported on in two phases. The first
publication search was conducted in November 2013 (in total, 77 publications) and
reported on as a Finnish review article (Raitakari and Juhila, 2014). In the second
phase, a supplementary data search was done in November 2014, which increased
the total number of publications to 184. This article is based on the 184 publications
identified by these first and second publication searches. We included a variety of
literature produced within different genres and using different research designs, and
also literature that represents non-scientific contributions, such as policy reviews
and debates. The main criteria were that a publication was officially published (at
least on the internet) between 1990 and 2014 and that it takes as a starting point
and/or comments on the original PHF model. Accordingly, the database comprises
academic research articles, evaluation reports, literature reviews, textbooks,
manuals, policy reviews and debate papers. In the publication search we used
‘Housing First’ and ‘Asunto Ensin’ (‘Housing First’ in Finnish) as keywords. Only one
key word was used to find a wide range of HF literature types (academic and policy
literature) that explicitly use the term Housing First. We searched publications from
different sources and used search engines, such as Google Scholar and Academic
Search Premier. Important sources turned out to be the reference lists of previous
publications. They led us to new publications and ensured that we had relevant
literature included in the database. Although we aimed for a comprehensive review,
there are certainly publications missing. This is mostly due to the fact that we only
read publications in English and Finnish (excepting two texts in Swedish) and that
the search engines used are not all-inclusive. Another major challenge has been the
accelerated speed at which new HF publications are appearing. Despite these
notable limitations, the large data corpus makes it possible to specify the different
orientations of literature on HF, and the political-practical arguments expressed by
each of them to a sufficient extent.
In practice, the review was conducted in the following way. We spent a great
amount of time reading through the publications from the angles of the different
scientific genres and research questions, and eventually grouped the texts
according to: a) what kind of data was used, b) what kind of research design and
method was established, c) how the text was written, and d) for whom and for what
purpose the publication was intended. Nine ‘literature orientation charts’ were
created to document the publications within each orientation; these charts included
the names of the authors, the year of publication and the political-practical
Each of the orientations represents a different way of doing HF research and
discussing HF. Thus, the content of the publication was not the criterion for the
grouping, but rather the way the publication was composed and the scientific genre
it represented. When categorizing the literature orientations, we were influenced
both by established methods of naming different publication types and by the terms
used in the HF literature itself (e.g., in evaluation reports and reviews), and we
applied them to the specific purposes of the article (Waegemakers-Schiff and
Rook, 2012; Publication Characteristics, 2014). Categorizing was not a straightfor-
ward task. For example, only fine-grained differences exist between some qualita-
tive evaluation reports, implementation studies and experiences and interaction
studies, as they all are based on grassroots-level experiences and views of HF.
Thus, in some cases a publication could straddle two orientations and we were
forced to choose one over the other, depending on the publication’s dominant
features. In so doing, we concentrated on the main features of each orientation and
the factors that differentiate the literature orientations from each other, thus
bypassing many details when sketching the ‘big picture’ of the HF literature.
The order of the literature orientations displayed in the article shows how HF publi-
cations have changed over time; the ‘comparisons’ orientation is the ‘root’, from
which the current diverse HF literature sprouted. Research orientations are built on
previous research, inspired by perceived gaps and deficiencies. The orientations
also move from less critical modelling, testing and evaluating of HF to more critical
research. As HF practice and research diversifies, the vocabularies become richer;
alongside the original PHF come many different applications and translations of the
HF model, and this produces new concepts including ‘housing-led’, ‘light HF’ and
‘mixed-model’. This trend in HF research literature also brings conceptual variety
to the article.
150 European Journal of Homelessness _ Volume 9, No. 1, June 2015
Table 1. Comparative Studies
PUBLICATIONS (36) POLITICAL-PRACTICAL
Tsemberis 1999; Tsemberis et al., 2002;
Gulcur et al., 2003; Tsemberis et al., 2003;
Tsemberis et al. 2004; Greenwood et
Padgett et al., 2006;
Gulcur et al., 2007; Stefancic and
Yanos et al., 2007; Gilmer et al. 2009;
Larimer et al., 2009; Robbins et al., 2009;
Gilmer et al. 2010; Tsai et al., 2010;
Edens et al., 2011; Goering et al., 2011;
Henwood et al., 2011;
Padgett et al., 2011; Appel et al., 2012;
Collins et al., 2012b; Hwang et al., 2012;
Padgett and Henwood 2012; Watson
Collins et al., 2013;
Henwood and Shinn et al., 2013;
Montgomery et al., 2013; Palepu et al.,
Patterson and Moniruzzaman et al., 2013;
Patterson and Rezansoff et al., 2013;
Somers and Patterson et al., 2013;
Somers and Rezansoff, 2013;
Srebnik et al., 2013;
Tinland et al., 2013;
Patterson et al., 2014; Russolillo et al.,
1. HF clients’ housing is more
sustainable than LRT
clients’ and thus HF is a
more effective solution to
2. HF decreases the use
of emergency and
inpatient services more
than LTR and is thus a
more cost-effective option
3. HF clients use alcohol and
they have mental health
difficulties to the same
degree (or less) than LRT
4. Permanent housing, client
choice and self-determina-
tion decreases mental
health symptoms and
increases quality of life; HF
thus supports mental
wellbeing better than LRT
5. Social integration is
an essential element
in successful housing,
yet multifased and
6. The essential principal of
HF i.e. adherence to
mental health treatment is
not a requirement of
obtaining housing is well
met in practice according
to the residents’ accounts
Convince the politics, civil
that HF is more cost-
effective way than LRT to
tackle with long-term
homelessness, and that
individuals with major
deficiencies in daily
functioning can live in a
scattered housing if
sufficient support is
Advocate for support
services based on
support and harm
reduction and recovery
In the ‘Comparative Studies’ orientation we included publications that are based
on comparative research designs. The publications make use of different types of
experimental designs to compare LRT and HF housing models and their client
outcomes, including pre-test and post-test designs, quasi-experimental designs
and true experimental designs, or RCTs. Studies commonly utilize administrative
documents (registers), client surveys and different kinds of ability-to-function tests
as data.2 A common way to collect data is to do baseline survey-interviews with the
clients and renew them every three to four months for a one- to two-year period.
As seen in the forthcoming sections, the data of the comparative studies can also
be used in other kinds of research designs and publication types (e.g., in evaluation
reports and in outcome and implementation studies).
The HF model itself and comparative studies concerning it are motivated by the
critics of the LRT model (e.g., Tsemberis and Henwood, 2011). The early HF litera-
ture was almost solely about comparing HF to other treatment/housing models or
to existing services. In the LRT model, the basic idea is to build a continuum of
treatment-accommodation units (such as a hospital-shelter, group home, supportive
housing or normal apartment) to help people recover from mental health and
substance abuse problems and homelessness. Thus, adherence to treatment and
recovery endeavours are embedded in accommodation solutions. The transition
from homeless to housed is thought to require abstinence and, at the beginning of
the continuum (more or less), professional control and regulations. Many contribu-
tors (e.g., Tsemberis and Asmussen, 1999; Atherton and McNaughton-Nicholls,
2008; Johnsen and Teixeira, 2010; Pleace, 2011; Haahtela, 2013; Granfelt, 2014)
have brought up that the LRT model is not suitable for those categorized as the
‘most difficult to house’ and ‘having severe mental health and substance abuse
problems’, and that it has many deficiencies, including the fact that many individuals
with severe conditions have difficulties going along with the restrictions, fulfilling
recovery expectations and moving forward in the continuum. Thus, the model easily
excludes those with the greatest needs. In contrast, the HF model is argued to
serve the most needy individuals. Long-term homelessness is not perceived as
being caused by ‘difficult to house’ individuals but rather by unsuitable housing
solutions and structural obstacles (Tsemberis and Asmussen, 1999).
‘Comparative studies’ is a strong research orientation in the HF field (36 publica-
tions). From the 1990s, the Pathways to Housing organization was successful in
arguing for the (cost-) effectiveness of PHF compared to LRT, or ‘treatment as
usual’ (TAU). Tsemberis’ article ‘From Street to Home: An Innovative Approach to
Supported Housing for Homeless Adults with Psychiatric Disabilities’ (1999)
started a series of articles that constituted the foundation of the international
debate on PHF. In this way, PHF grew from a small-scale, innovative experiment
to an acknowledged programme model with the status of an evidence-based
practice (Pleace and Bretherton, 2012a; Greenwood et al., 2013a). This research
2 The following studies represent exceptions to this: Patterson et al. (2013) carried out the first
study “to use longitudinal, narrative data from adults with mental illness who were randomly
assigned to HF or TAU.” Henwood et al. (2013) conducted a mix-method comparison of the
persp ectives and values of HF and LRT p roviders. Watson (2012) comp ared HF and LRT by using
interviews of HF clients and staff members.
152 European Journal of Homelessness _ Volume 9, No. 1, June 2015
orientation achieved a major reinforcement in 2009 when the Mental Health
Commission of Canada funded a five-year, randomized controlled trial (RCT)
study called ‘At Home / Chez Soi’, which implemented and evaluated PHF in five
Canadian cities (Goering et al., 2 011) .
The ‘comparative studies’ research orientation is based on the making of a distinction
between the HF and LRT models. It reinforces the idea that the models are clearly
separable and ideologically different. In recent studies, comparison is additionally
made between different applications of HF – i.e., between scattered and congregate
housing (e.g., Somers, Patterson et al., 2013; Patterson, Moniruzzaman et al., 2013;
Russolillo et al., 2014). The other, more resent research publications utilize, repeat
and expand this polarized view and also the main political-practical arguments of this
orientation (e.g., Johnson et al., 2012; Johnsen and Teixeira, 2012).
The main political-practical arguments of this research orientation are: 1) HF client
housing is more sustainable than that of LRT clients and HF is therefore a more
effective solution to long-term homelessness (e.g., Tsemberis, 1999; Tsemberis and
Eisenberg, 2000; Tsemberis et al., 2004; Stefancic and Tsemberis, 2007; Collins et
al., 2013); 2) HF decreases the use of emergency and inpatient services (more than
LTR/TAU) and is thus a cost-effective option (e.g., Gulcur et al., 2003; Gilmer et al.
2009; Larimer et al., 2009; Gilmer et al. 2010; Padgett et al., 2011; Srebnik et al.,
2013; Russolillo et al., 2014); 3) HF clients use alcohol and they have mental health
difficulties to the same (or lesser) degree than LRT clients (Tsemberis et al., 2003;
Tsemberis et al., 2004; Padgett et al., 2006; Robbins et al., 2009; Collins et al.,
2012a; b; Padgett et al., 2011); 4) permanent housing, client choice and self-deter-
mination decrease mental health symptoms and increase quality of life – HF thus
supports mental wellbeing better than LRT (e.g., Greenwood et al., 2005; Patterson,
Moniruzzaman et al., 2013); 5) social integration is an essential element in successful
housing, yet it cannot be expected to mean the same thing for everyone, or for HF
clients to be more integrated than people in general in urban life – social integration
is a multifaceted process, influenced by the neighbourhood, the form of housing
(the model), daily activities and the resident’s characteristics (Yanos et al., 2007;
Patterson et al., 2014); 6) the essential principle of HF – i.e., that adherence to
mental health treatment is not a requirement of obtaining housing – is well met in
practice, according to the accounts of residents (Robbins et al., 2009).
In this research orientation, the objectiveness of experiments and the practical
mission are combined to support the dissemination and development of the HF
model. The objective is to build up evidence for an evidence-based practice and,
through doing this, convince politicians, civil servants, managers, practitioners and
researchers worldwide that HF is a cost-effective way to tackle long-term home-
lessness and that individuals with major deficiencies in daily functioning can live in
scattered housing if sufficient support is available (e.g., Tsemberis, 1999; Tsemberis
and Eisenberg, 2000; Gulcur et al., 2003). In addition, the authors of literature within
this orientation advocate for support services based on voluntariness, client choice,
long-term support, and harm reduction and recovery (Greenwood et al., 2005;
Larimer et al., 2009; Padgett and Henwood, 2012).
A critical reading of the orientation’s publications requires special knowledge about
register-based designs, RCTs and quasi-experimental research designs. In
contrast, the political-practical arguments and objectives come across easily to a
wide range of audiences, as is evidenced through the circulation of these arguments
in other research orientations.
Tackling long-term homelessness means asking the question: which housing/
treatment model is the most (cost-)effective for those categorized as the ‘most
difficult to house’? The following literature orientation gives tools and guidelines to
plan and run such a housing project effectively.
Guidelines and Textbooks
Table 2. Guidelines and Textbooks
PUBLICATIONS (11) POLITICAL-PRACTICAL
Tsemberis and Asmussen, 1999;
Tsemberis, 2010a; 2010b;
McManus et al., 2011; Tsemberis and
De Decker, 2012; Bostad först som
Gaetz et al., 2013;
Goering and Tsemberis, 2014; Polvere
et al., 2014
1. Guidelines and exemplars
are needed in developing and
implementing HF in practice.
2. HF possesses the values,
ingredients and practical
means to tackle long-term
homelessness so it is worth
taking seriously and making
it known to a variety of
Model HF’s values,
practices into clear
ways of doing
Generate and distribute
knowledge about HF
and to enhance proper
ways of implementing it.
In the ‘guidelines and text books’ literature orientation we included HF textbooks,
book chapters and toolkits (11 publications). The publications included follow the
professional textbook tradition, presenting proper professional practices in an
educational and idealistic way. In addition, they are written in an introductory and
practical style, and HF is depicted as a successful intervention that transforms
long-term homeless with mental health and substance abuse difficulties into
responsible residents. The guidelines and textbooks are based on the practical/
personal knowledge of experts groups, researchers, practitioners and clients, yet
references to this knowledge are not always made in an exact and explicit way.
154 European Journal of Homelessness _ Volume 9, No. 1, June 2015
The textbooks and toolkits in this literature orientation offer practical guidelines to
putting PHF into practice, and they can be identified by the simplified and educa-
tional way in which they present PHF (Tsemberis and Assmussen, 1999; Lanzerotti,
2004; Tsemberis, 2010b; McManus, 2011; De Decker, 2012; Gaetz et al., 2013;
Polvere et al., 2014). Tsemberis and his co-authors have described the PHF model’s
core principles, implementation processes and current research evidence
(Tsemberis and Assmussen, 1999; Tsemberis, 2010a; b; Tsemberis and Henwood,
2011; Goering and Tsemberis, 2014). The guidelines and textbooks are addressed
to those who plan, establish, develop, provide, run and engage with HF – i.e., to the
actual ‘doers’ of HF projects. Book chapters (Tsemberis 2010b; Tsemberis and
Henwood, 2011; Goering and Tsemberis, 2014) comprise overall introductions to
HF’s background, principles, research evidence and successes. Book chapters are
aimed at a wide range of societal and scientific audiences and they are written in
more academic language than guidelines and textbooks. Yet they can be read as
‘advertising’ HF’s particularities and the advantages to ‘outsiders’ of the HF field
(e.g., Tsemberis and Henwood, 2011).
The orientation’s main political-practical arguments are that: 1) guidelines and
exemplars are needed in developing and implementing HF in practice; and 2) the
HF model contains the values, ingredients and practical means to tackle long-term
homelessness, so it is worth taking seriously and making it known to a variety of
audiences. The main objective is to model HF’s values, ingredients and practices
into clear ways of doing homelessness work. Another objective is to generate and
distribute knowledge about HF and to enhance proper ways of implementing it.
Tackling long-term homelessness requires making the best use of existing
knowledge about HF when planning and running local HF projects. HF research
evidence comes very much from demonstration projects that have strong evalua-
tion research components; these are presented next.
Table 3. Evaluation Reports
PUBLICATIONS (27) POLITICAL-PRACTICAL
Perlman and Parvensky, 2006;
Toronto Shelter Support…, 2007;
Pearson et al., 2007; Pearson et
al., 2009; Busch-Geertsema, 2010;
Goering et al., 2012; Johnsen and
Fitzpatrick, 2012; 2013;
Kristiansen and Espmarker, 2012;
Mental Health Commission…
2012 a, 2012b;
Stergiopoulos et al., 2012;
Benjaminsen, 2013a; Busch-
Geertsema, 2013; Fehér and
Johnsen and Fitzpatrick, 2013;
Nelson and Macnaughton et al.,
2013a; Ornelas, 2013;
Wewerinke et al., 2013; Aubry et
Busch-Geertsema, 2014; Currie et
al., 2014; Distasio et al., 2014;
Wewerinke et al., 2013; Goering et
al., 2014; Latimer et al., 2014;
Stergiopoulos et al., 2014
1. HF generates cost savings,
increases wellbeing and is an
effective route out of homelessness
2. In successful implementation of HF
it is crucial to have sustainable
resources and skilled practitioners
3. Scattered housing is to be preferred
4. Clients value HF principals,
scattered housing and long-term
support, and report their life
situation being improved
5. To achieve the best outcomes, HF
programmes should demonstrate
high fidelity to the core aspects of
the PHF model
6. HF can be effectively implemented
and disseminated in Canadian and
European cities of different size
and with different ‘ethno-racial’
and cultural composition
7. To overcome stigmatization,
social isolation, poverty and
unemployment, structural level
measures are needed
Document and display
the pivotal elements of
and thus to prove the
advantages of HF and
to promote its
Take a stance on the
issue of adapting and
disseminating HF in a
Call for national and
EU-level responsibility to
enhance and support HF
research and practice
Support the implemen-
tation of demonstration
projects by constructing
the success and
hindrance factors when
putting HF into practice
Evaluation reports typically involve qualitative data (or both qualitative and quantita-
tive), and carefully describe implementation processes, client characteristics and
housing stability rates. In addition, they assess changes in the wellbeing and life
situations of clients. This literature orientation is based on an evaluation research
tradition, although methodological commitments and decisions are not commonly
reflected in depth. Mostly methodological considerations are embedded in the final
reports (Busch-Geertsema, 2013; Goering et al., 2014). (Evaluation) research has
long been a crucial element in advocating for, and disseminating the concept of HF
in the US, Canada and most recently in Europe. As Greenwood, Stefancic et al.
(2013b, p. 310) state: “Many European HF initiatives are demonstration projects with
strong research or evaluation components that stakeholders hope will build a
strong European evidence base for HF.” There have been several (some remarkably
large-scale) HF projects, which have produced a major number of evaluation
reports). 27 reports were included in the ‘evaluation reports’ literature orientation.
156 European Journal of Homelessness _ Volume 9, No. 1, June 2015
The first three reports (Perlman and Parvensky, 2006; Toronto Shelter Support and
Housing Administration, 2007; Pearson et al., 2007) are evaluations of HF models
in the US and Canada.3 More recently, the world’s largest trial of HF – i.e., Canada’s
‘At Home / Chez Soi’ five-year (2009–2013) implementation and research project
with RCT and mixed-method research design – has made a significant contribution
to the HF literature.4 As stated by Goering and the team (2014, p.11): ‘At Home / Chez
Soi’ was designed to “help identify what works, at what cost, for whom, and in
which environments.” Evaluation was carried out by examining various aspects of
the lives of HF clients, such as housing stability, quality of life, community func-
tioning, recovery, employment, inclusion and costs. In addition, the researchers
conducted assessments of fidelity to the original PHF, documented the local imple-
mentation processes, and provided extensive training and technical assistance at
the sites (Nelson, Macnaughton et al., 2013a; Goering et al., 2014). The data used
includes both quantitative and qualitative components and thus facilitates a variety
of research publications from different research orientations (Goering et al., 2014).
A major boost to European HF projects and evaluation research has been ´Housing
First Europe’ (HFE, 2011-2013), funded by the European Commission. HFE was a
demonstration project, which promoted mutual learning across several European
cities that were implementing HF, and synthesized the findings of local evaluations
(Busch-Geertsema, 2011; 2013; Greenwood, Stefancic et al., 2013b).5 As stated in
the final report (Busch-Geertsema, 2013), European HF projects have been
3 Pearson and his colleagues (2007) conducted a multi-site, descriptive, implementation-outcome
evaluation of three HF sites that were: 1) Downtown Emergency Service Center, Seattle,
Washington, 2) Pathways to Housing, New York City, New York; and 3) Reaching Out and
Engaging to Achieve Consumer Health, San Diego, California. Perlman and Parvensky (2006,
p.1) carried out a “Cost Benefit Analysis focused on examining the actual health and emergency
service records of a sample of participants [N=19, number added by the authors] of the DHFC
(Denver Housing First Collaborative) for the 24-month period prior to entering the program and
the 24-month period after entering the program.”
4 Local de monstration projects of ‘At Home / Chez Soi’ in Vancouver, Winn ipeg, Toronto, Montréal
and Monc ton are documented i n several evaluation r eports (Aubr y et al., 2014; Currie et al., 20 14;
Distasio et al., 2014; Latimer et al., 2014; Stergiopoulos et al., 2014). The final evaluation report,
which summarizes the cross-setting implementation processes and general outcomes, was
conducted by Goering and the research team (Goering et al., 2014). ‘At Home / Chez Soi’
research was based on the following data types: a) interviews with clients at baseline and every
three months for up to two years of follow-up, b) information from the demonstration projects
(such as the n umber of clients and conduc ted service en counters), and c) natio nal and provincial
administrative data sources on the use of health and justice services before and after the
beginning of the study.
5 HFE comprised five ‘test site cities’ (Amsterdam, Budapest, Copenhagen, Glasgow and Lisbon)
and additional partners – i.e., ‘peer site cities’ (Dublin, Ghent, Gothenburg, Helsinki and Vienna)
(Socialstyrelsen/Housing First Europe). The final report summarizing the implementation
processes and outcomes was written by Busch-Geertsema (2013).
pioneering attempts to implement HF in an environment dominated either by the
LRT model or by emergency sheltering services. Only Copenhagen’s demonstra-
tion project was part of a national homelessness strategy to promote HF on a
national scale. Danish and Finnish endeavours to eliminate long-term homeless-
ness and to implement, study and stabilize HF at a national level have encouraged
literature and discussion on HF (Busch-Geertsema, 2010; Benjaminsen, 2013a; b).
None of the HFE test sites were an exact replica of the original PHF, although they
did follow the core ideas of PHF in many aspects. The ‘fidelity test’ was not
conducted and it was difficult to verify implementation of some of the principles in
practice (Busch-Geertsema, 2013). There was diversity between test sites in terms
of scale and implementation, data collection and evaluation methods. Administrative
data and interviews with the participants were important sources of information.
Both of these large-scale demonstration projects support and give grounds to
argue that HF can be successfully carried out outside the U.S context with signifi-
cant outcomes in housing sustainability and the well-being of clients.
The evaluation reports often end up with political-practical arguments that are
similar to those of the comparative studies, although the literature orientations differ
from each other in terms of research design and data types (evaluation reports are
mostly based on qualitative data and descriptive analysis). The main political-
practical arguments of the evaluation reports orientation are: 1) HF generates cost
savings, increases wellbeing and is an effective route out of homelessness (e.g.,
Perlman and Parvensky, 2006); 2) for successful implementation of HF, it is crucial
to have sustained and sufficient resources (e.g., affordable apartments) and skilled
practitioners (Busch-Geertsema, 2013; Goering et al., 2014); 3) scattered housing
is to be favoured as much as possible, yet other options are possible if they are in
line with client choice and expressed needs (Benjaminsen, 2013a); 4) clients value
HF principles, scattered housing and long-term support, and report their life
situation as being improved (Kristiansen and Espmarker, 2012; Benjaminsen, 2013a;
Johnsen and Fitzpatrick, 2012; 2013; Wewerinke et al., 2013); 5) to achieve the best
outcomes, HF programmes should demonstrate high fidelity to the core aspects of
the PHF model (Goering et al., 2014); 6) HF can be effectively implemented and
disseminated in Canadian and European cities of different size and with different
‘ethno-racial’ and cultural composition (Goering et al., 2014; Busch-Geertsema,
2013); 7) to overcome stigmatization, social isolation, poverty and unemployment,
structural level measures are needed (Busch-Geertsema, 2013).
The aim of the ‘evaluation reports’ orientation is to document and display the pivotal
elements of each individual demonstration project (and/or those of multi-site totali-
ties) and thus prove the advantages of HF and promote its development, funding
and research. The intent is to take a stance on the issue of adapting and dissemi-
nating HF in different contexts. The orientation calls for national and EU-level
158 European Journal of Homelessness _ Volume 9, No. 1, June 2015
responsibility to enhance and support HF research and practice. It also supports
the implementation of current and future demonstration projects by documenting
the factors leading to success and hindrance when putting HF into practice.
Hindrance factors include difficulties in getting proper apartments (delays in access
to housing), in integrating clients into society and in engaging them in meaningful
daily activities. Endeavours to quit substance abuse and scattered housing increase
the risk of isolation and loneliness (Busch-Geertsema, 2013; Johnsen and
Fitzpatrick, 2012; 2013). Having provided an apartment, the question of ‘what next?’
arises. Recently, social integration has become a strengthened theme in HF litera-
ture. The publications in this orientation make it possible to assess and discuss the
following: What is HF in different contexts? Who are HF clients? What are the
effects and client outcomes of HF? How are demonstration projects implemented
and what are the critical factors leading to success and hindrance? The knowledge
in this orientation is aimed at those who fund, plan, establish, develop, provide, run
and engage with HF projects.
The homelessness issue leads to questions of what works in what context and how
to balance PHF fidelity with adapting the initiative to local circumstances. These
issues are also central in the following literature orientation: ‘Commentaries’.
Table 4. Commentaries
PUBLICATIONS (32) POLITICAL-PRACTICAL
Fitzpatrick, 2004; Jensen, 2005;
Atherton and McNaughton-Nicholls, 2008;
Tainio and Fredriksson, 2009;
Housing-led Policy... , 2011; Busch-
Geertsema, 2011; Johnson, 2011;
Kettunen and Granfelt, 2011; Pleace,
Busch-Geertsema, 2012a, 2012b;
Hansen Löfstrand, 2012; Johnsen,
2012; Johnson, 2012;
Johnson et al., 2012;
Pleace and Bretherton 2012a; 2012b;
Raitakari and Juhila, 2012; Tsai and
Tsemberis, 2012; Tsemberis et al, 2012;
Benjaminsen 2013b; Culhane et al., 2013;
Kettunen, 2013; Knutagård and
Padgett, 2013, Pleace, 2013; Stefancic
et al., 2013;
Tsemberis, 2013; Cornes et al., 2014
1. More research is needed on
HF and other housing models
in a European context
2. Previous research evidence
on HF is not unquestionable
nor totally robust
3. HF has shown outstanding
outcomes on housing
sustainability but less
promising results concerning
recovery and social integration
4. There are many structural
and cultural constraints to
be taken into account when
transferring HF from one
locality to another
5. Most important is to hold on
to the PHF ethos, i.e. strong
housing rights, scattered
housing, off-site and intensive
support, client choice,
self-determination, a resilient
and compassionate attitude
6. HF is not an all-powerful
solution to long-term
homelessness and structural
changes are crucial in the
fight against poverty and
7. HF has lot to offer, but
critical thinking and research
Advance the academic
discussion and research
Make HF better known
to a variety of adminis-
The ‘Commentaries’ literature orientation covers texts that are not empirical studies,
reviews or text books. Thus, these texts do not include empirical data or any
systematic way of going through previous literature or presenting analysis. The
orientation includes a variety of text types, including debates, (critical) discussions,
policy reviews and descriptions of on-going HF projects. These texts are usually
quite short and they offer particular input into on-going (academic) discussions on
HF, relying on the author’s existing knowledge of the HF field. In the database, there
are 32 such publications in total. Texts in this orientation can be identified on the
160 European Journal of Homelessness _ Volume 9, No. 1, June 2015
one hand by arguments that call for ‘orthodoxy’ and on the other hand by arguments
that set forth the need to modify HF to different contexts. The texts can be either
positive towards or critical of HF.
The HF model is applied in different contexts and in many different ways. Unlike
the original PHF model, HF projects may include such elements as ‘light support’,
congregate or on-site housing (a well-know example of this is the Downtown
Emergency Service Center in Seattle), fixed-term housing, limited client choice, or
the use of social housing and existing support services (e.g., Tainio and Fredriksson,
2009; Johnson et al., 2012; Pleace, 2012a; Kettunen, 2013). Raitakari and Juhila
(2012) discuss the dilemmas embedded in both the LRT and HF models, while
Kettunen and Granfelt (2011) raise the issue of how demanding it is to do support
work by relying on the harm reduction principle. As HF has become more popular,
the risk has been highlighted of projects drifting away from the core elements of HF
and of the term ‘Housing First’ being used loosely (e.g., Pleace and Bretherton,
2013). As such, housing projects may be labelled as HF without major, transforma-
tive changes in the practitioners’ LRT-related patterns of thinking and acting (e.g.,
Knutagård and Kristiansen, 2013). Accordingly, there are great numbers of discus-
sion texts in HF literature that deal with the problem of ‘drifting away’ from PHF, and
how to apply HF and scale it to different contexts. The puzzling question is as to
what a HF project is and what is not (e.g., Hansen Löfstrand, 2012). As Tsemberis
(2013, p.236) asks: “which project components are flexible enough to be adapted
to new localities as well as serve new populations, and which components are core
principles that must remain constant?”
For example, in relation to scaling HF to different contexts, Atherton and
McNaughton-Nicholls (2008) state that client groups, national and local differences
in legislation, social and health services, and housing markets have a crucial impact
on the implementation and outcomes of HF (see also Johnson, 2011; Johnson et
al., 2012). Accordingly, it is important to scrutinize the local constraints and possi-
bilities of a particular HF project and evaluate its outcomes according to that
knowledge (e.g., Knutagård and Kristiansen, 2013). Atherton and McNaughton-
Nicholls (2008) conclude, as do many authors in the texts of other orientations, that
in order to adapt HF successfully to different societal contexts, we need more
European research on the success and hindrance factors in HF models.
Pleace (2011) also sets forth cautionary arguments concerning the translation of
HF to different contexts, in particular the ‘drifting away’ phenomenon and about
the term ‘Housing First’ being used in a loose way. It is also likely that for some
clients, better outcomes can be achieved using models other than HF (see also
Culhane et al., 2013), and there is a risk of HF dominating the social discussion
on homelessness, which may lead to an overemphasis on the vulnerabilities and
troubles of particular individuals instead of an emphasis on the structural and
societal barriers that sustain long-term homelessness in Western societies
(Pleace, 2011). In addition, Johnson and his co-writers (2012) bring up the possi-
bility that, in political-practical discussions, the research evidence of HF may be
interpreted in a simplified and overly positive way, thus setting too high expecta-
tions on it. It should not be forgotten that setting up a proper HF project requires
major and sustained resources.
Some of the publications in this literature orientation present endeavours to promote
HF as a national-level policy (e.g., Fitzpatrick, 2004; Tainio and Fredriksson, 2009;
Benjaminsen, 2013b; Culhane et al., 2013) while others introduce and summarize
on-going demonstration projects (Busch-Geertsema, 2011; 2012a; b). Yet there are
also articles that reflect more critically on translating HF to local contexts and on
its potentials and constraints (Pleace, 2011; Hansen Löfstrand, 2012; Johnsen,
2012; Knutagård and Kristiansen, 2013).
From the publications in this orientation, the following main political-practical
arguments can be summarized: 1) more research is needed on HF and other
housing models in a European context (e.g., Atherton and McNaughton-Nicholls,
2008; Tainio and Fredriksson, 2009; Tsai and Rosenheck, 2012); 2) previous
research evidence on HF is not absolute nor should it automatically be considered
robust (Johnson et al., 2012); 3) HF has led to outstanding outcomes in terms of
housing sustainability but has shown less promising results in terms of recovery
and social integration (Pleace, 2011; Johnson et al., 2012); 4) there are many struc-
tural and cultural constraints to be taken into account when transferring HF from
one locality to another (Knutagård and Kristiansen, 2013); 5) the most important
thing is to hold on to the PHF ethos – i.e., strong housing rights, scattered housing,
off-site and intensive support, client choice, self-determination, and a resilient and
compassionate attitude; 6) HF is not an all-powerful solution to long-term home-
lessness, and structural changes are crucial in the fight against poverty and
marginalization; 7) HF has lot to offer, but critical thinking and research are essential
(Padgett, 2013; Pleace, 2013; Pleace and Bretherton, 2013).
The objective of the orientation is to advance academic discussion and research
on HF. Texts are meaningful in making HF better known to a variety of administra-
tive, professional and academic audiences. They are based on previous research
and discussion papers, yet references to these are often made in implicit ways.
Previous research is made much more explicit in the ‘reviews’ orientation that is
162 European Journal of Homelessness _ Volume 9, No. 1, June 2015
Table 5. Reviews
PUBLICATIONS (6) POLITICAL-PRACTICAL ARGUMENTS OBJECTIVES
Johnsen and Teixeira, 2010;
Nelson, 2010; Pleace, 2012;
Rook, 2012; Groton, 2013;
Raitakari and Juhila, 2014
1. It is essential to gather, compare and
critically evaluate the existing research
evidence of different housing models and
to make informed choices concerning
homeless peoples’ services
2. Present research evidence is incomplete
and, in part, not robust enough methodologi-
cally; yet the evidence supports adapting and
implementing HF in different contexts
3. It is essential to do more research on
housing models and also to develop the
methodology of such research
Develop existing HF
Provide bases for
making in homeless-
ness services and
For the ‘reviews’ orientation, we included articles and reports that are based purely
on previous HF publications and that summarize existing HF knowledge and
research evidence. The publications commonly map and categorize previous HF
literature, summarize and assess the existing research evidence and/or conceptu-
alize different approaches to HF research and practice. Johnsen and Teixeira’s
review (2010) provides an overview of research and (critical) discussions related to
the LRT model, and it contrasts this with research on the HF model. They state here,
as do many other contributors, that departures from the original PHF model make
it difficult to draw firm conclusions regarding the effectiveness of different HF
projects, yet the existing literature does identify a number of key outcomes and
advantages. These results are summarized in the review and the authors conclude
with recommendations on how to strengthen (evaluation) research on different
housing models (Johnsen and Teixeira, 2010). Nelson (2010) analyses the historical
shifts in housing approaches (from institutions to housing to homes) for people with
a serious mental illness. He describes HF under the ‘supported housing’ approach
and argues that a shift to that approach represents a transformative change in
mental health policy and practice.
In a review report, Pleace (2012) makes an interesting grouping of different kinds of
HF applications. There are housing projects, which are very much exact replicas of
PHF. In addition, some housing projects can be defined as Communal Housing First
(CHF), as they are based on congregate housing and on-site support. By Housing
First ‘Light’ Services, Pleace (2012) refers to living in ordinary apartments and
receiving less intensive floating support. This classification extends the ‘bounda-
ries’ of the concept of HF, yet also makes it clearer what the original PHF is and
what the different ways of mixing it with other housing models are.
Groton’s quite recent article (2013) scrutinizes studies that compare the effective-
ness of various HF programmes with the effectiveness of LRT programmes – i.e.,
studies included in the ‘comparative studies’ orientation. Client outcomes related
to housing retention, substance use and mental health are compared. The article
concludes that, while HF provides strong promise, existing studies contain meth-
odological deficiencies and, thus, a reserved attitude towards HF should be main-
tained. Waegemakers-Schiff and Rook (2012) include a much more comprehensive
range of HF literature in their review report than Groton (2013), but the authors,
similarly, seek and critically evaluate evidence on HF. They (2012, p.17) come to the
following conclusion: “given the paucity of highly controlled outcome studies, we
examined the process whereby HF had so rapidly become accepted as a ‘best
practice’. Declaring the Housing first model a best practice appears to be a political
decision rather than a scientific research decision.”
The political-practical arguments of the ‘reviews’ literature orientation are the
following: 1) it is essential to gather, compare and critically evaluate the existing
research evidence of different housing models and to make informed choices
concerning services for homeless people (Johnsen and Teixeira, 2010); 2) existing
research evidence is incomplete and, in part, not sufficiently robust methodologi-
cally, but it supports adapting and implementing HF in different contexts
(Waegemakers-Schiff and Rook 2012; Groton, 2013); 3) it is essential to do more
research on housing models and also to develop the methodology of such research
(e.g., Johnsen and Teixeira, 2010; Groton, 2013). The objectives of this literature
orientation are to develop existing HF research and to provide bases for informed
decision-making in homelessness services and policies. These objectives are also
essential in the following, and sixth, research orientation: ‘implementation and
164 European Journal of Homelessness _ Volume 9, No. 1, June 2015
Implementation and Outcome Studies
Table 6. Implementation and Outcome Studies
PUBLICATIONS (28) POLITICAL-PRACTICAL
Felton, 2003; Falvo, 2009; Pearson et al.,
2009; van Wormer and van Wormer 2009:
Stergiopoulos et al., 2010; McNaughton
and Atherton, 2011;
Wideman, 2011; Collins et al., 2012;
Goldbloom and Bradley, 2012;
Zabkiewicz et al., 2012;
Bean et al., 2013;
Clifasefi et al., 2013; Gilmer et al., 2013;
Greenwood and Stefancic et al., 2013a;
Greenwood and Stefancic , et al.,
2013b ; Keller et al., 2013;
Macnaughton et al., 2013; Nelson et al.,
2013; Palepu et al., 2013;
Watson et al., 2013; Davidson et al., 2014;
Gilmer et al., 2014; Granelli et al., 2014;
Henwood and Matejkowski et al., 2014;
Henwood and Melekis et al. 2014;
Nelson et al., 2014; Stergiopoulos et al.,
2014; West et al., 2014
1. Describing and exploring
programme implementation is
central to a better under-
standing of the critical
ingredients and practices that
help clients to achieve positive
outcomes and life changes
2. High fidelity to PHF
associates with better
housing stability and quality
of life outcomes
3. The combination of research,
and advocacy will foster new
programmes in the future
that will continue to expand
the use of PHF with new
client groups and localities
4. Especially important in
successful implementation is
the recruiting of staff whose
technical and interpersonal
skills, and personal values are
congruent with the HF model
Document and display
the implementation of
Study the relations
contexts, fidelity and
outcomes – and thus to
credibility of the HF
The publications within this literature orientation are academic, empirical research
articles based on implementation-outcome research. They describe and scrutinize
a particular HF project (or HF projects) in its (or their) own right – the HF project is
not compared to other housing models or evaluated in such a context. Both qualita-
tive and quantitative data, such as interviews, surveys and documents are used.
Research articles that deal with the following were included in this orientation: a)
the outcomes and success/hindrance factors of a particular HF project (e.g.,
McNaughton and Atherton, 2011; Bean et al., 2013; Nelson et al., 2014); b) the
implementation of a particular HF project (or HF projects) and its (or their) fidelity
to the original PHF (Greenwood, Stefancic et al., 2013b; Nelson, Macnaughton et
al., 2013b; Nelson et al., 2014); and c) a description of a particular research design
used in HF research (Zabkiewicz, 2012). There are 28 publications in literature
orientation ‘implementation and outcome studies’ and it is a rapidly expanding
area. This kind of research has been generated by HF demonstration and research
projects in particular (see the section ‘evaluation reports’) and these two literature
orientations are therefore very closely related.
For example, with regard to the outcomes of a particular HF project, Clifasefi and
his co-writers (2013, p.291) state that “[m]onths of project-based HF exposure – not
prior criminal histories – predicted significant decreases in jail days and bookings
from the two years prior and subsequent to participants’ move into HF.” Similarly,
Collins, Malone and Larimer (2012) conducted a quantitative secondary study to
shed light on the potential mechanisms associated with improved alcohol-use
outcomes following engagement in a HF project. The study utilizes data gathered
in a HF context. It is common for implementation and outcome studies to be based
on data gathered in large-scale and multi-site comparative (and/or evaluative case
study) HF research projects (e.g., Palepu et al., 2013a; b). In such studies, a
particular research question, preliminary observation or theme, which has come up
in the original ‘host’ study, is analysed in more detail. For example, Henwood,
Matejkowski et al. (2014) focused especially on quality of life and community inte-
gration outcomes, which are the rising themes in current HF research.
Some studies depict and reflect on the implementation of HF per se (e.g., Henwood,
Melekis et al., 2014). For example, Greenwood, Stefancic et al. (2013a) tell the ‘triumph
story’ of HF moving from exile to mainstream. The article explains how research was
used to persuade key stakeholders to support funding for and dissemination of HF.
It also presents strategies to maximize social change impact, as well as the key
challenges that were faced along the way to triumph. Van Wormer and van Wormer
(2009) describe the policy shift from a sobriety-first requirement to a Housing First
philosophy in the US through a case study from Portland. Felton (2003) describes
and analyses the implementation – both barriers and facilitators – of a particular HF
project as understood by stakeholders in the change. As she concludes (2003, p.321):
“The narrative method reveals on-going concern with interagency relations and,
possibly, ambivalence about the values and assumptions of the new practice, and
thus offers a richer and more content-based picture of the change process.” Nelson,
Macnaughton et al. (2013b) describe the planning process of the ‘At Home / Chez
Soi’ demonstration project and the challenges associated with it.
Other publications investigate the relationship between the implementation and
outcomes of housing projects and their fidelity to PHF (e.g.. Davidson et al., 2014;
Gilmer et al., 2014). The need to examine the fidelity of a particular HF project to the
original PHF arises from the dilemma of PHF being a flexible model for dissemination
in different locations, yet being on the other hand a clearly articulated procedure with
its own premises, practices, ‘rules’ and values (Stefancic, Tsemberis et al., 2013; Gilmer
et al., 2014). In addition, outcomes are seen as being bound to implementation
166 European Journal of Homelessness _ Volume 9, No. 1, June 2015
processes. If there are major differences and flaws in implementation between HF
projects, it makes it difficult to compare the results and argue for the ‘evidence base’
of HF (Watson, Wagner and Rivers, 2013). Watson, Wagner and Rivers (2013, p.169)
define the following six critical ingredients of a successful HF project: 1) a low-threshold
admissions policy, 2) harm reduction, 3) eviction prevention, 4) reduced service require-
ments, 5) the separation of housing and services and 6) consumer education.
Greenwood and co-authors (2013b) describe and evaluate the fidelity to the PHF
model of HF initiatives in six European countries (Finland, France, Ireland, the
Netherlands, Portugal and Scotland) and they examine the larger social and
historical factors that may foster or impede model fidelity. Key stakeholders repre-
senting six European HF initiatives completed semi-structured phone interviews.
Greenwood, Stefancic et al. (2013b, p.307) summarize implementation challenges
as involving “skepticism and resistance from existing services, availability of afford-
able private-market housing, and moral judgments about worthiness for housing.”
The ‘At Home / Chez Soi’ demonstration project’s fidelity, and the factors facilitating
or hindering its implementation, were assessed in a large qualitative study using
key stakeholders as informants (Nelson, Macnaughton et al., 2013b). Both studies
(Greenwood, Stefancic et al., 2013b; Nelson, Macnaughton et al., 2013b; Nelson et.
al, 2014) find that, although local context meant the need for unique adaptations of
HF, the principles of the model provided the foundation for a common approach
across sites and nations.
The main objective of the literature in this orientation is to document and display the
implementation of HF projects and to study the relations between planning, imple-
mentation, local contexts, fidelity and outcomes – and thus to strengthen the under-
standing and credibility of the HF initiatives. The publications are research articles
and are addressed primarily to academic readers. They include the following political-
practical arguments: 1) describing and exploring programme implementation is
central to a better understanding of the critical ingredients and practices that help
clients to achieve positive outcomes and life changes (Davidson et al., 2014); 2) high
fidelity to PHF is associated with better housing stability and quality of life outcomes;
3) the combination of research, ‘evidence-based’ practices and advocacy will foster
new programmes in the future that will continue to expand the use of PHF with new
client groups and localities (Greenwood, Stefancic et al., 2013b); 4) especially
important in successful implementation is the recruiting of staff whose technical and
interpersonal skills, and personal values are congruent with the HF model (Nelson,
Macnaughton et al., 2013b; Nelson et Al., 2014). In this literature orientation, looking
at how to tackle long-term homelessness comes back to the question of how to
implement a housing project that is sufficiently in line with PHF principles yet fits well
in the local context, in order to produce outcomes as remarkable as those reported
from the original PHF model (see section on ‘comparative studies’).
An interesting observation is that the term ‘fidelity’ is increasingly used and circu-
lated in the most recent HF literature; fidelity is to be defined, assessed, measured
and put into practice. The next, quite marginal (at this time) literature orientation
concerns the development of fidelity and outcome tests. The viewpoint shifts from
implementation of HF projects to developing reliable research instruments and data
to assess fidelity.
Development of Scales and Fidelity Tests
Table 7. Development of Scales and Fidelity Tests
PUBLICATIONS (6) POLITICAL-PRACTICAL ARGUMENTS OBJECTIVES
Clifasefi et al., 2011; Raphael-
Greenfield, 2012; Gilmer et al.,
2013; Stefancic et al., 2013;
Watson et al., 2013;
Adair et al., 2014
1. The fidelity scale is to be used as a
guide in programme development
and training, and as a research tool
2. It is necessary for researchers, policy
makers and practitioners to have
tools for measuring the extent to
which a housing model is imple-
mented according to PHF principals
3. Fidelity tests help to assess the
relations between model ingredients,
implementation and outcomes
4. Point 3 promotes a broader
understanding of how to facilitate
stable housing and recovery from
homelessness and other adversities
at a grass roots level
Provide a tool to define
and measure in a reliable
way the elements and
practices of particular
of more consistent and
accurate replicas of PHF
The research articles in this literature orientation describe and make explicit the
making of a measuring tool. The aim is to develop a tool to define and measure in a
reliable way the elements and practices of particular HF initiatives, and through this
to enhance dissemination of more consistent and accurate replicas of PHF. Authors
make use of mostly qualitative data produced during the development process, such
as interviews and focus groups of wide range of stakeholders. This orientation is quite
new and marginal within the HF research field and it contains six publications.
Debates surrounding the implementation, outcomes and dissemination of HF have
prompted the creation of ‘fidelity tests’, which measure the fidelity of housing
projects to the PHF model along both structural and philosophical dimensions
(Johnsen and Teixeira, 2010). As Watson, Orwat et al. (2013, p.1) argue, “[a] lack of
clear fidelity guidelines has resulted in inconsistent implementation.” They continue
(2013, p.3) to say that “[n]o fidelity instrument had been created at the time we
168 European Journal of Homelessness _ Volume 9, No. 1, June 2015
started development of the HFM (Housing First Model) Fidelity Index.” This research
orientation includes descriptions of creating and validating fidelity measuring tools,
and texts that address use of the Observer-Rated Housing Quality Scale (Adair et
al., 2014) as well as use of the Executive Function Performance Test to assess
executive and community functioning among homeless persons with substance
use disorders (Raphael-Greenfield, 2012).
Gilmer, Stefancic et al. (2013) describe the development and validation of the HF
fidelity survey; the 46-item survey was created to measure fidelity across five
domains: housing process and structure, the separation of housing and services,
service philosophy, service array and team structure. The staff and clients of 93
supported-housing programmes in California validated the survey. Similarly,
Stefancic, Tsemberis et al. (2013) conducted a study to develop and test a PHF
fidelity scale. In the article they (2013, p.241) describe the process of making the
scale and summarize it in the following way: “The PHF model’s guiding principles
and prospective ingredients were identified through reviews of PHF literature and
relevant fidelity scales, interviews with PHF administrators and a survey adminis-
tered to HF providers. An expert panel developed the items into a fidelity scale,
which was field-tested as part of two large-scale research initiatives in California
and Canada.” Watson, Orwat et al. (2013, p.3) argue that they have conducted “a
bottom-up approach to the development of the index that sought to identify and
operationalize the critical elements of the HFM that differentiate it from the absti-
nence-based approach”. They come up with a five-dimensional index (staff, client
enrolment, flexible policies, low demand, and intensive case management and
housing arrangements) by which to assess and measure project implementation.
The texts are written primarily for researchers, funders, planners and those running
HF projects. The following political-practical arguments are contained in the
articles: 1) the fidelity scale is to be used as a guide in programme development
and training, and as a research tool (Stefancic, Tsemberis et al., 2013); 2) it is
necessary for researchers, policy-makers and practitioners to have tools for
measuring the extent to which a housing model is implemented according to PHF
principals and procedures; 3) fidelity tests help to assess the relationships between
model ingredients, implementation and outcomes, and, thus, they 4) promote a
broader understanding of how to facilitate stable housing and recovery from home-
lessness and other adverse situations at a grass roots level. Next we will turn to the
research orientation that examines the grass roots level of HF – i.e., the joint
encounters and experiences of practitioners and clients.
Experiences and Interaction Studies
Table 8. Experiences and Interaction Studies
PUBLICATIONS (22) POLITICAL-PRACTICAL
Yanos et al., 2004; Padgett, 2007;
Padgett et. al., 2008; Burlingham et al.,
2010; Collins et al., 2012;
Padgett and Henwood, 2012; Piat et al.
2012; Stefancic et al., 2012; Granfelt
2013a; 2013b; Haahtela 2013;
Henwood et al., 2013; Polvere et al., 2013;
Tiderington et al., 2013; Austin et al., 2014;
Balogi and Fehér 2014; Henwood and
Padgett et al., 2014;
Juhila et al. 2014; Kirst et al., 2014;
Ornelas et al., 2014; Zerger and
Pridham et al., 2014a; Zerger and
Pridham et al., 2014b
1. It is important to study HF as
the local, mutual and
of clients and practitioners
2. Stakeholders construct and
realize HF ‘in-action’ and in
3. The extent to which
tions and ideals are able to
make social changes are
dependent on the transfer
processes at the micro-level
4. HF is to be understood and
studied as societal, local,
interactional and situational
social practice and experience
macro-level ways of
thinking and policies are
and in personal
Make visible the
current politics, policies
and everyday practices,
and by doing this to
inform the development
of HF initiatives and
support work more
The ‘experiences and interaction studies’ literature orientation involves qualitative
methods and data. We included research articles in this orientation that focus on
everyday interactional practices and the experiences of clients, practitioners and
policy-makers in HF contexts. The purpose of these studies is to scrutinize how
macro-level ways of thinking and policies (e.g., recovery and harm reduction) are
transferred to and understood in micro-level practices and in personal experiences.
The research agenda is to make visible the relations between current politics, policies
and everyday practices, and by doing this to inform the development of HF initiatives
and support work more generally (Juhila et al., 2014). Only after a housing model has
been planned and implemented can its micro-level practices be studied – i.e., as a
joint endeavour accomplished in practitioner–client interaction, producing and being
affected by particular experiences and emotions. Thus, it is not surprising that the
‘experiences and interaction studies’ orientation is quite recent, though rapidly
expanding and strengthening (22 publications). It overlaps with the qualitative evalu-
ation reports, which are based on stakeholders’ accounts (e.g., Johnsen and
Fitzpatrick, 2012; 2013; Kristiansen and Espmarker, 2012; Piat et al., 2012; Polvere et
al., 2013; Balogi and Fehér, 2014), and as this orientation is a rapidly growing one, the
publications included in this review likely do not cover this research field properly.
170 European Journal of Homelessness _ Volume 9, No. 1, June 2015
Researchers within this orientation analyse the realization of HF initiatives in terms of
practitioner–client interaction and from the viewpoints and experiences of practitioners
(e.g., Collins et al., 2012a; b; Granfelt, 2013a; b; Haahtela, 2013; Henwood, Padgett et al.,
2014), clients (Collins et al., 2012a; b; Granfelt, 2013a; b; Haahtela, 2013; Kirst et al., 2014)
and civil servants (Johnsen and Teixeira, 2012). There are also texts that more generally
map the experience of transferring from homelessness to having an apartment, being at
home and experiencing ‘ontological security’ (Padgett, 2007; Henwood, Hsu et al., 2013).
Kirst and her colleagues (2014) use clients’ narratives of ‘hopes for recovery’ and see
housing as a pivotal condition in creating hope for future recovery. Yet, they mention (as
do the other researchers, including Johnsen and Fitzpatrick (2012; 2013) and Granfelt
(2013b)) that there are risks such as isolation, boredom, poverty and insecurity, which
might temper the success of independent living and recovery. Accordingly, housing is
essential but is not on its own a sufficient resource for living in the community and for
recovery. Burlingham et al.’s (2010) phenomenological study analyses accounts of
women with alcohol issues who become homeless, and examines how personal life
histories explain decisions to stay or leave (HF) housing.
Granfelt (2013a; b) has developed the concept of ‘housing social work’. This working
method comprises the following dimensions: interactional skills (particular skills involved
in negotiating with, for example, tenants, neighbours, social housing authorities and other
stakeholders); ‘therapeutic’ skills for genuine and empathic presence in support work;
and the ability to set boundaries and to support (often severely traumatized) persons in
converting apartments into secure homes (rather than a distressing trap). Tiderington et
al.’s (2013) ethnographic study, based on observations and interviews, explores how the
principle of harm reduction is interpreted as an element that enhances trust in a practi-
tioner–client relationship. The article is a good example of the mission of this literature
orientation to make sense of how HF principals and procedures are talked into being and
understood in everyday encounters with clients and practitioners.
The common political-practical arguments set forth in the publications within this
orientation are: 1) it is important to study HF as the local, mutual and interactional
accomplishment of clients and practitioners; 2) stakeholders construct and realise
HF ‘in-action’ and in particular settings; 3) the extent to which macro-level concep-
tualizations and ideals are able to make social changes are dependent on the
transfer processes at the micro-level; 4) HF is to be understood and studied as a
societal, local, interactional and situational social practice and experience; accord-
ingly, the essential question in the fight against homelessness is: how is HF (to be)
accomplished as an everyday practice, and how is it conceptualized and experi-
enced by different stakeholders?
Next we turn to the final literature orientation, which approaches HF as an exemplar
of Western thinking and is ready to question it.
Critical Social Science
Table 9. Critical Social Science
PUBLICATIONS (6) POLITICAL-PRACTICAL
Kertesz et al., 2009; Kertesz
and Winer, 2009; Willse, 2010;
Stanhope and Dunn, 2011;
Hansen Löfstrand and Juhila,
1. HF is based on liberal values and
2. Alliance between HF research and
politics is strong, yet not unproblematic
3. We need to be cautious about the
ways research results and political-
practical arguments are used in
homelessness policy and in making
decisions about housing, health and
4. HF research and practice is a
creation of our time and it must be
both questioned and promoted
To question common
expectations and values
To open up our minds
to doing things
differently, in a new way
This literature orientation approaches HF as a case exemplar, which informs us
about our time and Western thinking patterns. The research articles included draw
from the critical research tradition that questions and deconstructs our common
ways of thinking and acting as citizens in Western societies. By doing this, the aim
is to open up our minds to doing things differently, in a new way. All articles have
strong theoretical frameworks and most of them are based on and scrutinise
previous HF writings and documents. Texts are written for academic and profes-
sional audiences and for those interested in questioning common premises, norms,
expectations and values.
This research orientation is at the margin of the HF literature with only six publica-
tions. These texts critically scrutinise the presumptions of HF, including intertwined
practices of evidence-based research and evidence-based policy (Stanhope and
Dunn, 2011), (restricted) client choice (Hansen Löfstrand and Juhila, 2012) and
support for liberal economics and individualized interpretations of social problems
Willse (2010) shows how HF leans on and is in line with liberal thinking – how it takes
as self-evident the primacy of economics. Homeless persons are not housed for
ethical reasons but for economic ones. HF is not advocated by using an ethical-
humanistic argument but by using economic arguments. Accordingly, HF is not
targeted at changing society or dismantling the inequalities that are causing and
maintaining long-term homelessness in the first place. This makes it ver y understand-
able that, although HF is shown to be successful in securing sustained housing, the
total number of homeless people may not decrease (or it even may increase) in
172 European Journal of Homelessness _ Volume 9, No. 1, June 2015
Western societies due to, for example, high unemployment rates. Hansen Löfstrand
and Juhila (2012) analyse the consumer discourse in Tsemberis’ (2010) textbook:
‘Housing First’. They discuss how on the one hand, the textbook emphasises client
choice and self-determination, yet on the other hand, in the HF model (as in the
society as a whole) the client’s choices are limited and restricted. The client is
expected to make the ‘right choices’ and if he/she does not comply, the possibilities
for making choices become scarcer. Accordingly, HF does not totally solve the
question of what happens to those who are not able to, or do not want to, conform
to ‘normal’ life and to its demanding expectations and rules of acting.
Stanhope and Dunn (2011) outline HF’s assumptions about (scientific) knowledge,
and power and influence on political decision-making. HF research is depicted as
an apparatus for making policies and advocating ‘what works’ initiatives. As
Stanhope and Dunn (2011, p.276) argue, “[f]or EBPol’s (Evidence Based Policy)
proponents, the search for ‘what works’ is guided by survey research, experimental
and quasi-experimental designs, cost-benefit analysis and system analysis.” HF
offers the possibility for reflection on the relationship between knowledge claims,
research and policy, and on the place that values have in this bigger picture. There
is the risk that the triumph of the ‘evidence base’ simplifies the understanding of
decision-making, which in real life involves moral issues, conflicting interests and
difficult negotiations of power. Also, Kertesz, Crouch et al. (2009) warn about the
risks associated with the close alliance of HF research and policy-making; there is
a possibility that policy actors overreach, interpret the research findings too posi-
tively and place exaggerated expectations on HF initiatives. There is no quick, easy
or inexpensive fix for social problems or ethical injustices.
Publications in this literature orientation present three pivotal political-practical
arguments, which are: 1) HF is based on liberal values and premises; 2) alliance
between HF research and politics is strong, yet not unproblematic; 3) we need to
be cautious about the ways in which research results and political-practical
arguments are used in homelessness policy and in making decisions about housing,
health and social services – HF research and practice is a creation of our time and
it must be both questioned and promoted.
Conclusions and Discussion
In this article, we have introduced and mapped out nine different literature orienta-
tions, which approach HF from different genres and research designs, pursue
different audiences and set forth a variety of political-practical arguments. The
teasing out of the political-practical arguments made it clear that the majority of HF
research is practice-oriented and motivated by promoting the HF model at interna-
tional, national and local levels. The analysis also shows how contributors within
different literature orientations end up with quite similar political-practical
arguments, such as: HF generates cost savings, increases wellbeing and is an
effective route out of homelessness; high fidelity to PHF is associated with better
housing stability and quality of life outcomes; and there are many structural and
cultural constraints to be taken into account when transferring HF from one locality
to another. Although there are doubtful and questioning voices in the HF literature,
there is considerable agreement that HF is a promising, (cost-)effective and client-
friendly housing solution for long-term homeless people with special needs and
barriers in life. However, analytical and questioning arguments are crucial and
valuable in further developing HF discussions, research and practice. It is essential
to evaluate existing HF literature critically and, most importantly, to develop the
conceptual-theoretical frameworks, methodological grounds and methods
employed within each orientation.
It can be concluded that HF research has both expanded and developed enor-
mously in the last few years; HF literature has grown quantitatively, new orientations
have appeared and traditional ones have been made more solid. New texts have
been published since our literature search, from which we include some examples
in this conclusion section (and which are not included in the database). Yet research
is never completed; new questions are asked, new directions and critical stances
taken. This is how research orientations develop and go from exile to mainstream
or in the opposite direction (see for HF research’s future directions Nelson and
MacLeod in progress). The main body of HF literature consists of: quantitative
comparisons between the HF and LRT/TAU models (Nelson, Patterson et al., 2015);
evaluations of HF demonstration projects and national strategies and descriptions
of their implementation processes (Nelson, Macnaughton et al., 2015; Macnaughton
et al., 2015; Pleace et al., 2015); and discussions on the transferability of PHF to
different contexts and societies.
Theoretically oriented research has a valuable role in deconstructing taken-for-
granted HF discourses and thereby advancing societal thinking (and endeavours).
For example, HF provides many possibilities to study current macro-level discourses
and ideals (and their realization in practice), such as, for example, responsibiliza-
tion, consumerism and deinstitutionalization. Thus, there is much potential within
the (critical) social sciences for HF research and practice. There are also increasing
numbers of qualitative studies on the experiences of clients, practitioners and and
other stakeholders on everyday HF practices (e.g. Aubry et al. 2015). This line of
research is particularly valuable in unpacking the dilemmas of translating abstract
principles (like choice, harm reduction, integration, resilience and recovery) into
everyday practices and interactions between the clients and practitioners who
apply these principles (Raitakari et al., 2015). There is much untapped potential for
174 European Journal of Homelessness _ Volume 9, No. 1, June 2015
research on experiences and micro-level interaction. For example, outcome evalu-
ations and qualitative studies on HF are usually done separately rather than being
integrated. However, there is a call for mixed method approaches that integrate
qualitative and quantitative approaches (and current research is going to this
direction) as well as macro-micro level analyses. In addition, there is a need for
innovative research projects that concentrate solely on grass roots level HF experi-
ences and practices.
Another rising direction for research lies in comparing different ways of putting HF
into practice – i.e., scattered and congregate housing sites and the variety of ways
to provide support services (e.g. Stergiopoulos et al., 2015; Whittaker et al. 2015).
There is also a call for long-term follow-up studies, as most studies follow clients
for only one or two years at most (Nelson and MacLeod in progress). Greater
attention should be devoted to examining the variety of ways in which support can
be offered (e.g., informal and formal; peer- and professionally driven; intensive and
less intensive; short- and long-term; practical and therapeutic).
The development of fidelity tests is also an interesting future direction for HF
research, yet this should also be approached with caution. This direction has major
advantages since fidelity has been shown to be critically important for successful
client outcomes. However, there is a risk that we start to rely on fidelity tests too
much, as they can only inform us about the realities of housing projects from a
narrow, specific point of view. There is also the dilemma that while effective profes-
sional support work requires (ethical) guidelines and procedures, it also requires
autonomy, discretion and the ability not to go by the book. In addition, fidelity tests
do not tell us how HF is actually put into practice in situ.
Since HF is not implemented in a vacuum, it is also vital to examine further what
contemporary policy trends in relation to public services (such as active and
responsible citizenship discourse) mean for the implementation of HF in different
contexts and for the life conditions of the people with severe mental and substance
abuse difficulties. When value for money and demonstrable client outcomes are
increasingly emphasized in society, this might bring undesirable consequences for
homelessness services, such as ‘creaming’ and tightening eligibility criteria. That
is why research on client selection processes as well as ‘client failures’ is topical.
As stated in the HF literature, a minority of clients cannot yet be helped or housed
through HF; they are important for research, as there are valuable lessons to be
learned from them and their situations, although they are hard to reach. Eligibility
criteria, and failures and successes should be studied, for example in regard to
differences among long-term homeless people. Are some client groups more
vulnerable (women, former prisoners, young people, immigrants), and do they
become dropouts from the HF models more easily and, if so, for what reasons?
Alasuutari (2009, p.70) uses the concept ‘domestication’ in examining how “supra-
national policy models are introduced within a nation-state.” He claims that the
actual implementation of new models at a national level is always culturally bound
and the result of compromise between different stakeholders. The concept of
domestication might be useful in analysing how HF models are applied in different
countries and in more local contexts (municipalities or service providers with
certain histories and cultures of working with homelessness). How the culturally
strong LRT approach is present and mixed in the ideas of HF in local homelessness
work practices should be studied more closely, even though the HF model is widely
accepted as the new approach to be applied. When analysing the possibly mixed
housing practices, the starting point should not be that the practices are divided
into ‘bad’ (old) and ‘good’ (new). Mixed models might include innovative practices
to tackle long-term homelessness.
As a final remark, we conclude that the HF literature seems to be a rather internal
research field in the sense that the publications refer to each other a lot. However,
there is range of research conducted in other fields, especially in mental health
studies, that might produce new insights for both HF research and practice, and
support the research findings presented in the HF field. For instance, research done
on deinstitutionalization and home-based services includes many relevant themes
for HF, among others – scattered housing, community integration and support work
based on home visiting or floating support. Also, literature related to recovery and
citizenship (in mental health and substance abuse studies) and desistance (in
criminal studies) would probably be useful. Some social work studies also come
very close to the topics dealt with in HF research (e.g., topics related to client
choice, involvement and participation). Without doubt, HF research would also have
a lot to offer these other research fields. Research develops through reciprocal,
respectful dialogues between different disciplines and through innovative crossing
of the boundaries of research fields.
Acknowledgements: The article was conducted in the research project “Long-term
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