PBS's series NOW had a segment on a housing first approach with a man named Footie who is chronically homeless and an alcoholic. He's clearly a late stage alcoholic, frequently has seizures and may have some cognitive impairment due to years of heavy drinking and seizures. (Streaming video of the entire episode is available at the link above.)The story made a pretty compelling case for this approach with this him, arguing that it was impossible to address his higher order needs when his physiological and safety needs were not being addressed. Footie was provided an apartment with no contingencies. The approach could make a lot of sense in many cases--the question is which cases and under what conditions?
I had several reactions to the segment. First, had Footie ever been provided with comprehensive treatment of and adequate dosage, duration? Why no contingencies? Maybe his housing shouldn't be contingent upon abstinence, but how about participation in treatment? If the fear is that this might be a set-up, how about reviewing it at monthly or quarterly intervals so that a bad week does not put him back on the street? Why not at least make it recovery-focused? If this approach is good for Footie and raises his functioning and quality of life to his potential, who's functioning and quality of life might be reduced to something below their potential? At Dawn Farm, we see some clients who would probably benefit greatly from a recovery-focused housing program that is not contingent upon abstinence. However, how many of clients who are currently in full recovery would have settled into an apartment like Footie's and never achieved stable recovery and a full, satisfying life? Many, I think.
UPDATE: This isn't to say it shouldn't be done, but rather how to go about it in a way that doesn't lower the bar for all homeless addicts and fail to address what caused their homelessness. Maybe one way to approach it is to ask, "Absent their addiction, would this person still be likely to be homeless?" In the case of Footie, the answer is "probably so". In the case of most of our homeless clients, the answer is "unlikely".
Of course, another big question is how to prioritize services in the context of scarce resources.
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In the 70s and 80s, old time programs like Sacred Heart offered "free" residential treatment up to 5 months for indigent patients. Sacred Heart had a deal with the state to provide food, housing and treatment in return for all of the patient's welfare benefits. So the net cost to the state was zero.
A lot of people got off the street and got clean and sober. Footie would have received more services for less money under this kind of model. I wish the various states would revisit this idea. It would save a lot of lives and save a lot of money.
I still see people who are clean and sober today from Sacred Heart. It was a time of miracles. The center still exists, but it's only a shadow of its former self.
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