Chapter 3: Housing First

There’s a guy I see every time I go to work. He sits on the sidewalk right next to the newsstand. Always in that same spot. His hair is dreadlocked and dirty and he’s often quietly muttering to himself. A few decades ago, if you would have asked a bunch of experts what they think this person needs – like, what is the best way to help him – the answers you would have gotten would be really different than the ones you’d get now. And that shift in thinking, it’s at least partly because of this guy — 

     Sam: Alright. Hey, Katie. Carla’s here. She’s got the microphone.

That’s Sam Tsemberis with producer Carla Green who we sent to record him.

     Carla: Okay, yeah. Just tell me what you had for breakfast this morning…

     Sam: Tell you what? 

     Carla: What you had… what you had for breakfast- 

     Sam: What I had for breakfast? This morning? So I’ve been eating bagels for breakfast for the last three days.

     Carla: Ok… I think, I think…

     Sam: So did I pass? I mean, is that ok? [LAUGHS] What if it was scrambled eggs – it’s like no! Is there a right answer? 

Sam is a psychologist, who, back in the 1980s was working with homeless people in New York City. And the ideas that came out of the work he was doing are pretty foundational to how people think about solving homelessness today. 

Back then, Sam’s typical day was spent driving around the streets of New York in a van with a nurse and a psychiatrist – essentially making sidewalk house calls to the city’s homeless.

     Sam: Two or three of us would be in the van with the driver and we would receive referrals. All kinds of people would call and say, I have… uh, I want to refer somebody to you. I saw them on the corner of 65th and Park, they’re ranting, and they don’t look well at all. And they’re standing out in the middle of the traffic trying to convert the drivers into some belief system.

The 1980s was really the beginning of homelessness as we now know it. Mainly because of rising income inequality and the dismantling of a lot of social programs like public housing. The crack epidemic and deinstitutionalization certainly didn’t help matters either. Anyway, homelessness was particularly exploding in New York. And there was a feeling that some of the people on the streets might be a danger to themselves or to others.

     Sam: And if they met that criteria, we would bring them to the hospital. Voluntarily, if we could accomplish that — persuade them to go. Or involuntarily, if necessary — we would call the police and they would be taken sometimes in handcuffs to the Bellevue psychiatric emergency room.

Sam thought there were times when involuntary commitment was necessary, but he was never completely comfortable with it. Sam had ended up in New York City for grad school where he’d gotten interested in the psychiatric survivors movement. The movement challenged the traditional paternalism of psychiatry and promoted the idea that patients should control their own care. This was the future Sam wanted. Which put him at odds, sometimes, with his co-workers. 

     Sam: We ended up in Grand Central Station one night. 

The team was responding to a call about a homeless person that they referred to as “the Catwoman.”

     Sam: …because she loved cats. And when she was outside, she’d have a cat sometimes with her. She always wore black, completely black outfits. And she was in the bathroom – the women’s bathroom – of Grand Central Station where she would stay. And she was like, “Leave me alone. I hate you people.” They thought, oh she’s in denial of her, you know, desperate situation. She’s not safe. So they bring her to the hospital. I was very upset by that.

This was not a situation Sam thought called for involuntary commitment and so he made an anonymous call to the legal aid program in the hospital. 

     Sam: I said, I just… I don’t want to say who I am. I just want to tell you about a situation that’s in the hospital right now. There’s this woman that was hospitalized involuntarily. I think she needs representation. She wants to be out of the hospital. 

This was an early sign that Sam was generally on team patient over team psychiatrist. Still, he worked like this for a couple more years. Driving around the city, checking in on people, sometimes taking people to Bellevue.

     Sam: We took about 300 people a year to Bellevue, like one a day, you know, on average. And at the end of the year, when I was doing follow-up studies like what happened to these people, many of them, like two-thirds, would simply be returning to the streets. And so there was like an awareness that whatever this is, whatever we’re trying to do with this population is not working. It’s not working. 

This is According to Need, Chapter 3.

After a couple years of this routine – taking people to Bellevue, seeing them bounce back onto the streets, Sam decided to try something new. Instead of dragging people off to the hospital or a kind of here’s-your-diagnosis-and-here’s-your-prescription methodology, Sam wanted to try basically just asking people how he could help. 

     Sam: We’re going to listen to our clients and we’re going to really offer them the things they want in the sequence they want it. We were going to facilitate it.

Sam hired a new team, some of whom had personal lived experience with homelessness. And they opened a drop-in center for people who were either struggling with mental illness or addiction, or both. They named the center Choices Unlimited, although mostly people just called it Choices. Choices wanted to give people a place to come and rest, take a shower, and then start to think about a plan. 

     Allen: Like, we still out. We’re still homeless. But we could go there during the day and get shower and change clothes and they buy you lunch.

This is Allen. I’m just going to use his first name to protect his privacy. Allen was one of the first clients at Choices. He’d grown up in Boston and had made his way to New York in the early 80s. By the time he ended up at the Choices drop-in center, he’d already had a bunch of interactions with the kind of psychiatry that Sam was hoping to move away from. When Allen was just 13, he ended up in Bridgewater State Hospital after getting into a fight. Bridgewater was an infamous prison/hospital for the so-called “criminally insane.” 

     Allen: Prison/hospital – it was a prison period. They just called that a hospital. That was a torture chamber. That’s what it was. I turned 14 in one of those cells.

Allen told me that abuse from his mother and mistreatment from all kinds of authority figures had left him full of rage that he couldn’t always control.

     Allen: I got to a point where I wasn’t taking no [BLEEP] from nobody. Oh, yeah, I used to, I used to fight a lot. I do got a short temper when it comes to a bunch of bullcrap. 

     Sam: He would come into my office like, “Hey, if they ever do this to me, I’m going to kill them!” And I’m like, “Allen, you can’t actually say these things. It’s a mental health program! People are going to come and lock you up, you know. You’ve gotta watch your language, you know.” 

For Allen, it was anger. But all the clients at Choices were dealing with some kind of mental health issue. Things like bipolar disorder and schizophrenia. 

These clients didn’t trust the choices other people made for them, but maybe they would trust their own. Sam’s job was just to help make it happen.

You want a drug rehab program? We’ll help you find one and enroll. You want to get on meds? We’ll get you connected to the right doctors. You want housing? Cool. We can help with that too.

Except housing, it turned out, was tricky. It was also what Allen and just about everyone else wanted. 

     Sam: So, ok. People want housing. So, there were any number of housing providers opened for business at that time. 

The system for getting into housing at that time in the 1980s and 90s was designed as a sort of staircase. You started at the bottom in shelter and then if you fulfilled certain requirements like getting sober or taking your meds, you graduated to something sort of like a dormitory. From there you might go to a shared apartment with a few other people. The final, final step, at the very top of the staircase, might be your own apartment in a building with other formerly homeless people. But it was hard to get there. 

The idea behind the staircase was something people called ‘housing readiness.’ 

     Sam: A kind of a quarantining to get people ready for housing. And get them to get their life together so they can get back into housing.

To Sam, the staircase felt frustratingly paternalistic. When he heard housing readiness, it sounded more like housing worthiness. 

     Sam: You know, the… the kind of “improve the poor” attitude. 

The staff at Choices helped the clients apply for these programs. But inevitably the housing providers would end up asking things like “How long have you been clean and sober?” and “If you have a mental illness, what sort of treatment are you doing?”, “What medications are you taking?”, etc. 

     Sam: And so when these kinds of questions came up, our applicants repeatedly failed the housing interviews. We could not persuade housing providers to take anybody. We were failing miserably. 

It’s sort of a problem when you start a program called Choices Unlimited, only to find the choices are, in fact, quite limited.

And so once again, Sam started thinking about doing something new. Something that at the time, barely anyone had actually tried before. He wanted to try moving homeless people with significant mental health issues straight from the streets into their own apartments. Just regular apartments that they would find for folks on the private market. 

This approach would come to be known as Housing First. But back then it was just a wild idea they were trying out.

     Sam: You know, the people we were going to house, when you met them, they didn’t inspire confidence that it would all work out ok. 

Sam and his colleagues secured money from the state office of mental health services to pay for this experiment, enough for 50 apartments plus case management services. And they started a new nonprofit to handle all this new work called Pathways to Housing.  

One of the first things they had to do was reach out to landlords.

Sam: So you have to, you know, beat the streets and find the people that are willing to work with you.

     Katie: And what would you tell them about the clients?

     Sam: We would tell them as little as possible.

Sam said they would tell people basically, “we’re working with low-income clients, helping them find housing” but not, “we’re working with formerly homeless, severely mentally ill clients who are also struggling with addiction.” 

They also had people on staff whose specific job it was to communicate with landlords. And it helped, Sam said, that they were always able to guarantee the rent would be paid.

Pathways’ clients would have to put 30% of their incomes toward rent, but the rest would be covered. For most clients, the 30% came out of some kind of benefit check they were eligible to receive from the government. The hope was that Pathways would continue to provide this subsidy for the rest of these clients’ lives if they needed it. Although, at the beginning, Sam said no one had any idea whether this experiment would last.

     Allen: Sam told us that the apartment was ours as soon as we get the leases. So we were sitting down there in Choices one day. And this young lady, she was the receptionist or the secretary or whatever. She’s got all those sweaty guys standing around her, you know, at that fax machine. And we’re watching this fax machine push the leases out. And we’re standing there like, “Oh, there’s mine! Mines comin’ out over there, that one’s mine!” Soon as we got the lease, we walk over to that apartment building and to Alex – he was the super. And we show him that lease and he knows everything’s legitimate. Then he give us the keys and point to the apartment. That’s yours. 

     Qamar: I was so overwhelmed with joy, I didn’t know how to act. 

This is Qamar D. Smallwood.

     Qamar: And D would be my middle initial and Smallwood is my last name. But I prefer to be called Qamar because that’s my Muslim name. So that’s who I am so, I love that name.

Like Allen, Qamar was one of the first people to get housing through the Pathways program. For the last several years, she’d been sleeping wherever she could.

     Qamar: I slept all over the place. I slept in the subway station on 42nd Street. Before you get to the N Train, there used to be a newsstand and a bathroom. And there was a lady that worked and cleaned the bathrooms. And at nighttime, she would lock me in the bathroom so I would stay in there and I would go to sleep. And then when she came in the morning to clean up, she opened the door and let me out. I slept in a cardboard box under the FDR Drive, I think that was.

Finally, after years of homelessness, Qamar and her boyfriend – who was also homeless – were getting their own place. 

     Qamar: We had parquet floors, central heating, central air conditioning. We had two bedrooms. And it was only me and him. If you wanted to go to the park, you just crossed the street, go over there and have a cookout. We lived on Central Park West 110th Street. Beautiful, nice over there. 

     Katie: Do you remember, like, trying to kind of set it up and decorate it and just feeling like..?

     Qamar: I wasn’t even thinking about decoration. I was just so glad I wasn’t in the street. 

But that beautiful place by the park, it didn’t last that long.

     Qamar: We was living there and we was doing well, but we just couldn’t let go of the drugs. Yeah, we was running out, going around the corner, buying drugs and comin’ back. Now, I don’t know if anybody’s seen us go buy drugs, then come back, because all I know is that they kept saying we’re doing a lot of running in and out. And they not having it. 

A few months into their stay, Qamar and her partner got kicked out of their building.

     Qamar: I felt really bad. I felt like I wish I could get off these drugs.

Allen had problems too, not with his apartment. Allen’s problem was always his anger. He got in fights with everyone. With co-workers, police, caseworkers… 

     Sam: It didn’t take much, you know, for him to get very upset. He had a very low threshold for disappointment and he would threaten people and he was very, very good at threats. I mean, there were not like, “I’ll kill you.” Like, they were very specific to the person. You know, like he knew how to read people’s vulnerabilities in a way, it was kind of uncanny. 

At some point, Allen had threatened so many people at Pathways that the program director told Sam, he’d get kicked out if he did it one more time. Sam’s experiment was being tested. 

     Sam: You know, it’s not like this thing solves your problems of loneliness, of poverty, of addiction, of mental illness, of disconnection from your family. It’s not like a panacea. The whole point of doing Housing First is you can actually start to deal with these other things which are much more profound and much more difficult. And, you know, at least it gives you a shot at having those conversations. Because if people are on the street, you’re never going to be able to have those conversations because it’s all about where am I going to sleep and what am I going to eat, and you know, like, am I safe. 

Sam is fond of saying Housing First does not mean housing only and Pathways’ clients had access to all kinds of support like therapy and drug treatment. And in general, Sam just tried really hard not to give up on folks. When Allen was on the verge of getting kicked out of the program for threatening people, Sam took him out to dinner to make one last appeal.

     Sam: And we were at a Chinese restaurant and I had to kind of convey this news to him that if he threatened anyone else on the staff that that would be it, we couldn’t work with him anymore. And when I started telling him about it, I started to cry because I… because I’d spent years, like, trying to hold on to people and here I’m telling him I have to go. And when he saw me crying, his response was, I had no idea it meant that much to you. I’m not going to do that anymore.

     Allen: He did it. Look, I saw it in his face. That’s what made me… I’ll tell you the truth, that’s what really made me really stop, stop, stop. Because I did see that. You know, this guy right here, he’s really trying to protect me because he didn’t have to do that. That’s what I told myself. And that’s when I started chilling out a bit.

As for Qamar, Pathways encouraged her to go to rehab before she tried again with housing. Which, I have to say, I found sort of surprising at first. I thought it was always Housing First, then treatment. But when I asked Sam about it, he said no, not necessarily. The goal was always for their clients to get better, healthier. They never would have made housing contingent on rehab, but that doesn’t mean they wouldn’t have encouraged someone to try it before moving back into an apartment. When Qamar got out of the program, Pathways helped her get a second place. This time she decorated. 

     Qamar: Puttin’ hanging things on the wall. I painted my bedroom. Yeah. 

That first year, Sam told me he thinks probably 20% of the clients bounced out of their place at least once and had to be rehoused. That was just the cost of doing business.  

But even though people had plenty of challenges to address, Sam increasingly believed that there were very few people who weren’t ready for housing. That included people yelling on the corner, people who smell so bad on the train that everyone moves away… And yeah, the guy I see every day by the newsstand on my way to work. 

     Sam: Here’s the criteria. No matter what the person looks like, if you see they are able to survive on the street – by virtue of their survival on the street in that tent or in that park and as smelly and as awful as they look – if they’re surviving on the street, they can definitely survive in an apartment. 

     Katie: Yeah because, like, I see the same people every day when I go to work and they’re sitting in the same spot. So in my mind, they exist in that spot.

     Sam: Yes, yes, yes, yes. 

     Katie: But of course they don’t. 

     Sam: Of course. 

     Katie: They have to- 

     Sam: Eat. They have to go to the bathroom. They have to be safe. They probably have a monthly benefit check that they’re getting in some church post office box, who knows what. 

Sam does concede that there are some people who may need more of an institutional setting. But, they’re often the same people who haven’t been able to take care of their own basic needs while living on the street. Every year Pathways took on more clients who were given permanent subsidized housing and supportive services. And they started making presentations to their colleagues at conferences. Like look, this whole concept of housing readiness – that people need to be sober or mentally fit before getting housed – it’s not necessary. Everyone is ready.   

But a lot of people just couldn’t believe it, in fact, some even thought it was unethical to the clients themselves. Like giving people their own place was setting them up to fail.   

     Sam: So we had to do a randomized controlled trial.

This time, they ran the study as a real clinical trial with a control group and a treatment group. They enrolled 225 people, all who had a psychiatric diagnosis of severe mental illness. And although it wasn’t a requirement, most of the participants also had a history of abusing drugs or alcohol.

     Sam: And then we just coin toss: Housing First, treatment-as-usual.

Treatment-as-usual was the staircase approach I talked about earlier. In which you have to be housing ready, i.e. sober, to start the program. And if you relapse at any point, you were out.

The data took a few years to gather because the whole point was watching people over time. It was finally published in 2004 and the results were pretty astonishing. In the treatment-as-usual group, only 34% of the people in the study still had housing after two years. But in the Pathways group, 80% did. 

Sam’s favorite graph to come out of the study – the one he actually taped to his door – was the one that showed how much time, over the course of the study, each group had spent being homeless.

     Sam: Days homeless for the control group… you know, it was a slope down and they had reduced it by about 40%. And days homeless on Housing First went all the way down to like 3%. Like, right along the baseline like a snake. It was beautiful. It was beautiful.

But even after the results were published, there were still doubters.

     Sam: People thought New York is very, very well subsidized in terms of services. It’s kind of a, you know, blue liberal progressive place. It’s unique in the country and no other place could do what you do in New York. The water comes from the Hudson, you know… everyone’s drinking the same water, it could be that. You know, could be anything – 

     Katie: [LAUGHS] Could be the bagels…

     Sam: Could be the bagels! Exactly.

There was also a theory that maybe it only worked because of Sam’s singular dedication to the work. And this theory, I have to admit, seemed kind of legit to me. I mean, Qamar talks about Sam as if he’s only a smidge below Allah. No, really.

     Qamar: By his permission, I give all glory to Allah. And then when I step down from that, I give Sam his props. I never heard any clients complain about Sam. We always talking about, “Well, Sam got a plan. What we gonna do? Yeah, Sam got a plan.” The only thing I heard was I asked my coworkers now and I said, “You know Sam?” And they were like, “Oh I heard about him, but I never met him.” I said, “Wow, you should’ve met Sam.” 

     Katie: [LAUGHS] Well, that’s not anything bad.

     Qamar: No, that’s not anything bad. But if you wanna talk about what’s the worst thing, that’s the worst. Cause I’m like, if you don’t know Sam, you don’t know what you’re missing. 

So basically, the worst thing about Sam is the idea of not having a Sam, and when Sam backed up from the day-to-day operations at Pathways New York, to bring the Housing First model to other places, Allen and Qamar both said things didn’t run as smoothly.

     Allen: Matter of fact, I really didn’t care for Pathways as much once Sam wasn’t, like, you know, when he was doing bigger things.

But Sam gets kind of sassy if you suggest the Pathways model can’t be replicated without him. 

     Sam: Well, obviously not, right? I mean, I mean, the program is all over the world, so it’s not that hard to replicate, after all.

Sass notwithstanding, Sam is right. Since he first ran that program in New York, the model has spread far and wide. 

Sam had proved Housing First could work. But what really helped the model spread was some convincing research by a guy named Dennis Culhane. 

     Sam: Dennis Culhane had identified that for the population that we were housing – the Housing First population, the most vulnerable – was costing taxpayers a fortune. 

What Sam means is it was costing taxpayers a fortune to allow these folks to stay homeless. The people that Sam had been working with – who were often talked about as being ‘the most vulnerable’ because they were dealing with a lot of extra challenges like mental health, addiction, or physical disabilities – they also happened to be the people who were the most likely to stay in shelters for long periods of time, like years, and rack up visits to emergency rooms and detox centers and jails. For this particular group, studies by Dennis Culhane and others were finding that it might actually be cheaper to do something than to do nothing. And the idea of cost savings made the Housing First concept appealing to a whole new group of people- 

Sam: From different points of view and different value-orientations.

When Sam says different value-orientations, he means basically, Republicans. Some very notable ones ended up embracing the Housing First model. One of the first was George W. Bush who helped launched several Housing First-style programs across the country.

Fast forward a few more years, and HUD, which gives a lot of money to nonprofits that work with the homeless – they’re actually evaluating grant applications on how “Housing-First-y” the applications are. 

Sam Tsemberis and his colleagues and all the clients at Pathways – they had flipped the script completely. And these days, most people at HUD, Ben Carson notwithstanding, don’t talk about folks being housing ready anymore. Now there’s an understanding: people were always ready to be housed.

Allen and Qamar were ready, even though they had stumbled a little at first. After Qamar got her second place and went through rehab, she never relapsed and she never had another bout of homelessness. She recently reunited with some family – something that she says wouldn’t have been possible without the stability of housing. And Allen’s doing well too. He’s still in housing, and he still talks to Sam. Just the other day, he called him ranting and raving about a receptionist at his doctor’s office who had made some kind of trivial error.

     Allen: And Sam says to me, “Allen, what planet are you… Did you wake up on?” He says this is everyday stuff, he says people, they… they make errors. He’s right about that though, yeah.

The clients at Pathways taught the world that everyone was ready for a house, but what happens when there isn’t enough funding for all the people in need of a home? Well, a system is created to sort out who needs it the most. A list of people ranked according to need. This was the list Tulicia Lee had ended up on, but she never got anything from it. On the next episode of According to Need, we’ll finally understand why. 

After the break, a preview.

[BREAK]

Coming up on the next episode of According to Need…

     Katie: Everyone’s always referring to “the List,” right? Yeah, it feels a little bit like the Wizard of Oz. Like, there’s someone behind this curtain that’s sort of like doing some stuff that I can’t figure out who it is. And so… I guess my first question is like are you the Wizard? Is this Oz? 

     Katie: And are you like… are you able to see where she would have ended up on that list?

     Elsa: No.

     Rashana: The list! I mean, today I even told someone, “Hey, I don’t know how they prioritize the list. I don’t know how they’re pulling people from the list.”

     Lakeshia: When you’re looking at that list all day, every day, you kinda… you become really familiar with where people are, what they rank. And it’s just like mesmerizing in a sense.

     Julie: Everybody has their own opinion about who should be prioritized, who shouldn’t. And then you hear a lot of conversation about who’s deserving, who’s not deserving. So that’s where you hear about the list. And the list is long right now. 

     Margot: Because there’s so much structural racism, it is much easier to become homeless if you’re Black.

     Sam: We are still talking about homelessness like it’s about the people on the street today. It’s unbelievable to me. 

The mysterious list, how it works, and where Tulicia ended up on it – all of that is coming up, on According to Need.

This chapter of According to Need was produced by me, Katie Mingle, with associate producer Abby Madan and managing editor Whitney Henry-Lester. Roman Mars was the executive producer. Invaluable editing from Lisa Pollak, Emmett FitzGerald, Delaney Hall, Christopher Johnson, Joe Rosenberg, and Roman Mars. Jacob Winik was our sound engineer. Fact checking by Amy Gaines. Beautiful music by the beautiful Sean Real. Branding and Design by MUCHMORE.io. Kurt Kohlstedt was our digital director. Additional support from Sofia Klatzker, Vivian Le and Chris Berube.

Special thanks to Philip Mangano, Hillary Melton, and all the people who spoke to me for this series as well as Marisol Medina-Cadena, Johanna Zorn, and Chelsea Miller.

According to Need is a project of 99% Invisible, which is a founding, proud member of Radiotopia from PRX, a network of independent, listener-supported, artist-owned podcasts.