Part G _ Reviews
Sam Tsemberis (2010)
Housing First: The Pathways Model to End
Homelessness for People with Mental Illness
and Addiction Manual
Minnesota: Hazelden, 244 pp. appr. €50
Housing First is the most discussed method in Europe in terms of combatting
homelessness. Within a relatively short period of time the concept has been widely
disseminated, but what is the Housing First model, exactly? A lot of questions have
been raised in recent years: what components and elements must be included in
this model? Who is the target group? Is Housing First a slogan, a philosophy, a
programme, a brand – or a policy? Many have looked forward to reading this book.
Homelessness is a widespread social problem, and the struggle is ongoing
throughout Europe to combat the problem. Conditions in various countries differ
widely, but many actors have realized that a new approach is necessary. In
Sweden, for example, an individual perspective dominated for a long time, and
homelessness has been mainly analysed and explained with reference to indi-
vidual factors such as substance abuse and dependence, mental disabilities or
other social problems; if these problems disappear then it should also be possible
to solve the problem of homelessness. Gradually, however, this explanation has
changed. To a large extent, a multifactorial explanatory model has been adopted
in its place, where structural factors like the structure of the housing market are
of vital importance. Other structural factors are exclusion from the housing
market, unemployment and discrimination. One of the fundamental ideas of the
Housing First model is to separate treatment from housing. This renders the
structural and individual factors visible, and it becomes clear that homelessness
is much more than just an individual problem.
The interest in evidence-based practice (EBP) has grown in our part of Europe. The
search for effective, well-researched methods is ongoing, and a method that has
proven to be efficient in randomized trials is difficult to dismiss; the Pathways
Housing First (PHF) programme is one such method, with well-established efficacy
in reducing homelessness for a particular group of individuals.
ISSN 2030-2762 / ISSN 2030- 3106 online
236 European Journal of Homelessness _ Volume 5, No. 2, Decembe r 2011
The author of this book, Sam Tsemberis, created the Pathways Housing First
model, which subsequently partly inspired the Housing First movement. Dr.
Tsemberis is Greek-born and holds a Ph.D. in clinical psychology. From his Greek
background he inherited certain values, including the belief that housing is a funda-
mental right for all people, including people with mental illness.. Tsemberis is based
in the Department of Psychiatry in Colombia University Medical Center, and is also
the lead trainer and consultant for the Pathways Housing First Training Institute.
Primarily, the book is to be characterized as a kind of manual; the first part
contains an introduction followed by eight chapters, while in the second part, the
Pathways Housing First Training Institute is introduced. The book also contains a
number of appendices.
One question often raised when discussing how to help homeless individuals is:
can people with both substance abuse and mental illness manage to live in their
own apartments, even with tailored support? Is it really possible? It required a lot
of courage to introduce this programme before research had proved its effective-
ness, and research has been crucial for the development of PHF as an evidence-
based programme. The book’s introduction describes the history of the programme
and the ideas on which PHF is based; each of the book’s chapters is then intro-
duced briefly so the reader knows what to expect, and at the end of this introduc-
tion a list of particularly relevant terms is provided.
Chapter 1 introduces the Pathways Housing First programme on recovery-oriented
service and its philosophical assumptions. Why does it work? By providing a home
for a person, the programme offers dignity and hope. For many clients, the result
is the beginning of a process of change. PHF offers an alternative to the previously
most common model used in the U.S and Europe – Continuum of Care (CC) or
Linear Residential Treatment (LRT). Within this model, the client gradually improves
their living situation; the steps or actions often begin through contact with an
outreach team, followed by stays in various types of shelter or transitional housing;
the last step is into permanent accommodation. ‘Gaining’ permanent housing is
frequently associated with meeting conditions such as participation in treatment
and demonstrating sobriety. For a client with a psychiatric disorder and substance
abuse dependence, the path to housing is often not straightforward; many fail and
fall into homelessness again. In the Continuum of Care the terms ‘treatment
resistant’ or ‘hard to house’ are used.
PHF started as an alternative to this model, finding that housing is fundamental to
survival and to meeting the basic human needs of refuge and safety. The principles
of Housing First are: housing as a basic human right; respect, warmth and compas-
sion for all clients; a commitment to work with clients as long as they need it;
scatted-site housing; independent apartments; the separation of housing and
Part G _ Reviews
services; consumer choice and self-determination; a recovery orientation; and
harm reduction. The emphasis is on values and the attitudes towards clients.
Chapter 1 goes on to describe these principles in detail.
Chapter 2 covers the initial steps involved in PHF. The target group and require-
ments for joining the programme are described; the client must be long-term
homeless, have a severe mental illness, and show interest in taking part in the
programme – maybe not initially but over time. The client must also fulfil two core
requirements: first, payment of rent – thirty percent of the “monthly income”
should go to rent; and secondly, weekly visits by PHF team member. The chapter
points out that engagement is one of the most important phases of the PHF
programme and first impressions of the programme are very important. Four
principles are emphasized as being behind the success of the programme:
accepting the client’s priority for housing; providing a flexible service; removing
obstacles whenever possible; and taking responsibility for follow-up. While the
general philosophy in working with homeless people is to tell the clients what they
need to do, PHF, in contrast, involves continually asking: “How can I help?”, and
then listening to the answer.
Chapter 3 is about housing and housing support services. The desire for a regular
dwelling is at the top of almost all clients’ priority lists. Approximately 95% have a
preference for a private apartment within the community. This chapter explains
what might be involved in the process of finding the right apartment for the client.
One client said: “I walked around for years without a single key: a key to a car, a key
to a house, a key to anything… I do not think people understand what a key typifies.
It is something that belongs to you. It is something huge” (p.57). Various aspects of
housing are described in the chapter. Difficulties like loneliness are discussed, as
well as questions about having pets. The importance of relationships with landlords
is highlighted, and many practical issues such us handling keys and plumbing
problems are raised. Challenges like health and safety issues, and relationships
with family and children are also discussed briefly, as well as what happens when
clients fail; team members understand that relapses are part of mental illness and
addiction, and sometimes relocation is necessary. The home visit is described in
this chapter as serving many purposes that fall into two areas: housing related
issues and human clinical issues. Home visits provide an opportunity for staff to
get an idea of, and observe the kind of assistance the client requires to maintain
their apartment in the best way. The following is an insightful quote from a staff
member in this regard: “The home visit is the heart and soul of the work we do,
because I think that’s ultimately where you want the change to happen, you know,
in the person’s environment” (p.48).
238 European Journal of Homelessness _ Volume 5, No. 2, Decembe r 2011
Chapter 4 describes the two types of teams that provide treatment and support
services within the Pathways Housing First model. By using the Assertive
Community Treatment (ACT) and the Intensive Case Management (ICM), the same
staff can conduct outreach and provide support for clients living on the street,
assist them in finding and moving into apartments, and then continue to provide
treatment and support until the client graduates from the programme. The ACT
serves people with severe psychiatric disabilities and the ICM serves people with
more moderate disabilities. One of the main challenges is to recruit and train staff
members, and to ensure that they share the human and social justice values on
which the programme is based. In this chapter, information is provided about
practical tools that can be used in daily work, such as the WRAP (Wellness Recover y
Action Plan), which is based on the client’s strength, needs, interests and goals.
Chapters 5 and 6 are about the two models (ACT) and (ICM) used in the context of
the PHF model. These chapters are a detailed manual and explanation of how the
models can best be used in the PHF framework.
Chapter 7 briefly describes a number of evidence-based practice and clinical
interventions. In order to be able to offer the clients the necessary support, other
methods and models than the ACT and the ICM may be used. All of the models
mentioned are based on the same client-driven and human values principles that
are fundamental to the PHF programme. Harm reduction is an important component
of the PHF programme, where the aim is to reduce the negative effects of abuse
and dependence; “The goal in harm reduction is to help the client live a better life,
but is not a permanent solution. Harm reduction is about observing and celebrating
small positive steps and it requires an individualized approach.” Engagement in
treatment is the primary goal of PHF, but staff members do not insist on treatment,
nor do they challenge a client’s point of view. Most PHF clients have dual problems
with mental illness and substance abuse. Integrated dual disorders treatment
(IDDT) is described as the most effective approach to addressing these problems,
while two other well known models are also mentioned in this chapter: the Stages
of Change, and Motivational Interviewing (MI). Chapter 8 is about how to adapt the
PHF programme to ‘your’ community.
The Housing First model has been highlighted as a big success, but it has also been
questioned and criticized. The main issue has been: what is Housing First? The
extremely positive outcomes demonstrated in randomized studies raise questions:
does this positive effect apply to all Housing First programmes? Which compo-
nents or elements should be included in order to achieve such good results? What
groups should be targeted? These questions are not all answered in this book; the
book obviously only deals with the Pathways Housing First programme, and it is
Part G _ Reviews
clear that the target group for the programme is long-term homeless people with
severe mental illness and addiction problems. The book is neither a research report
nor a book on theory, but a manual for a specific programme in the U.S.
In the EU there is an ambition to broaden the term Housing First. The final report
from the European Consensus Conference on Homelessness 2010 suggested the
term ‘Housing Led’, to describe all policy approaches that identify the provision of
stable housing with security of tenure as the initial step in solving homelessness.
“How can I help?” is the main question in the book. Suddenly the perspective is
changed; the client is the expert and the staff assists him/her to achieve the goals.
The programme Pathways Housing First must adapt to the client’s needs and not
the other way round, where the client is supposed to fit into the programme. “How
can I help?” The question is asked again and again. Its strength is in this sentence,
and this particular feeling permeates the entire book; it arouses a desire to partici-
pate in a process of change and provides an excellent description of how such work
can be carried out.
The Housing First programme has sometimes been criticized for being a Housing
Only solution, in that housing will be offered without the individualized support that
is necessary and that also requires a lot of resources. The book shows that tailored
support is crucial for success in the Pathways Housing First programme. Above all,
it is the client’s objectives that guide the entire programme. PHF is impressively
structured and systematized with a number of tools. There is a variety of methods
and programmes mentioned, as well as practical guidelines and checklists on how
the planning can be done with the client in a structured way, and how objectives
are then followed up. However, the most radical aspect of the approach is, as
previously mentioned, that the client’s perspective is the fundamental value that
influences every measure taken. The discussion in the book about ‘failures’ is a
good illustration of these values. It is a fact that clients sometimes relapse and that
relocations are necessary; up to 30% of clients move from their first home, and a
number move two or three times. In these cases, it is vital to have a non-judgmental
attitude and to realize that those who suffer most are the clients; it is essential to
ask continually: “How can I help?”
The fact that this book is written in the U.S. influences its approach. In European
countries, a more moderate mode of expression is generally used, and words like
‘success’ may be considered shallow. However, the book is refreshingly positive.
Anyone who expected a book on theory or a research study might be disappointed;
the analysis has already been done, and the Housing First model is the only solution
to end homelessness. Will this book really make a difference in the fight against
homelessness? Yes; adapted to the situation in different countries it can be an
important source of knowledge and inspiration. Research, evaluation and follow-up
240 European Journal of Homelessness _ Volume 5, No. 2, December 2011
are needed in the European context; a variety of measures are required for different
target groups, and knowledge has to be increased with regard to those differences.
This book is, however, of undoubted use for many categories of staff and researchers
because the necessary components of PHF are well-described. The book can also
play an important role in changing attitudes towards homeless people and the
homelessness problem in general. The biggest challenge for European countries
is to achieve a real change of perspective and to adopt the conviction that ending
homelessness is possible.
Annika Remaeus and Ann Jönsson
The National Board of Health and Welfare, Stockholm, Sweden.