Homelessness, Mental Health, and Housing First

Current Research and Action by Interest Group Members


Community psychologists have contributed to the understanding of and solutions to the problem of homelessness dating back to the early work of Dr. Beth Shinn and Dr. Paul Toro in the 1990s. Much of this work focused on homeless people with mental illness and homeless women with families. In the wake of deinstitutionalization of long-stay psychiatric hospitals and the advent of neo-liberal policies that eroded affordable housing, the number of homeless people with mental illness and mother-headed homeless families has increased since the 1980s.

Ground-breaking research published in the American Journal of Community Psychology by Kuhn and Culhane (1998) identified a typology of homeless persons. They found that there is relatively small sub-group of the homeless population who are chronically or episodically homeless. This sub-group is more likely to have serious mental illness and to be high users of other services, the so-called Million Dollar Murray phenomenon made popular by Malcolm Gladwell in an article in the New Yorker. This original research was replicated by Dr. Tim Aubry and colleagues (2013) with single adults in Canada and with families who are homeless in research by Culhane and colleagues (2007). Chronically and episodically homeless persons have become the focus of community interventions because they account for such high levels of shelter days and service use.

For more information on homelessness, visit the Homeless Hub website, the largest compendium of information about homelessness anywhere in the world.


From Residential Treatment to Supported Housing to Housing First

Housing for people with mental illness has been based on a residential continuum or staircase model, in which consumers must work their way through a number of settings before they obtain independent housing. They start in highly structured, highly staffed until they “graduate” to less structured more independent housing.


Dr. Paul Carling (1995) challenged the staircase model with an approach to housing people with serious mental illness that he called “supported housing.” In contrast to a residential continuum approach that emphasizes “readiness” for housing as judged by professionals, support housing is a consumer-driven approach in which people with mental health issues “choose, get, and keep” the housing that they want.

In the late 1990s, Dr. Sam Tsemberis, a clinical-community psychologist took the supported housing approach one step further in applying it to people with serious mental illness who are chronically or episodically homeless in New York City. The Pathways to Housing program in New York has become widely known as the Housing First approach. Housing First is based on a number of community psychology principles, including: (1) consumer choice, control, and empowerment, (2) the separation of housing and treatment, (3) a focus on the individual’s strengths and potential for recovery, and (4) community integration into typical community settings (Tsemberis, 2010). In Housing First, rent supplements that enable participants to obtained scattered-site housing is linked with Assertive Community Treatment (ACT) or Intensive Case Management (ICM).

In a comparative evaluation of the Pathways Housing First program and the residential continuum, Tsemberis and Eisenberg (2000) found that participants in the Pathways program achieved housing stability at much higher rates than those in the residential continuum. Moreover, Stefancic and Tsemberis (2007) replicated these findings in suburban community in New York. Subsequently, Tsemberis teamed up with other colleagues to conduct a randomized controlled trial of Housing First and found both superior housing stability and reduced costs for the Housing First group compared with a group receiving treatment as usual (Gulcur, Stefancic, Shinn, Tsemberis, & Fischer, 2003).

Housing First is a transformational approach in community mental health. First, it transforms the role of the participant in Housing First from one of a client to a citizen. Second, it is a consumer-driven approach. Third, it challenges the status quo of the shelter system and residential continuum and replaces it with permanent housing. For more information on Housing First, there are several resources below that you can use to learn about Housing First. Based on its successes, Housing First has been embraced as a model for ending homelessness and has led to the creation of 10-year plans to end homelessness.

Dr. Tsemberis won the SCRA Award for Distinguished Contributions to Practice in Community Psychology in 2014 and the APA Award for Distinguished Contributions to Independent Practice. 


Housing First and Canada’s At Home / Chez Soi Research Demonstration Project

One criticism of evidence-based practices is that they often rely heavily on research that has been done by its founders. In 2008, the Mental Health Commission of Canada mounted the largest randomized controlled trial of a social intervention in Canadian history. This work followed the introduction of Housing First in the province of Alberta, see the Calgary Homeless Foundation and Alberta’s Seven Cities Network.

Led by Dr. Paula Goering, the At Home / Chez Soi research team included Dr. Tsemberis, Dr. Aubry, and Dr. Geoff Nelson, all community psychologists. Participants in the At Home / Chez Soi project were randomly assigned to Housing First or treatment as usual in five Canadian cities. All participants in Housing First received a rent supplement so that they could obtain housing of their choice from the local rental market. Moreover, they paid no more than 30% of their income on housing, and rented living units as regular tenants in buildings in which no more than 20% of residents were known to have a mental illness (Goering et al., 2011). Nested within each of these two experimental conditions were two groups of clients: those with high needs, who received support from Assertive Community Treatment (ACT) teams in Housing First, and those with moderate needs, who received support from Intensive Case Management (ICM) programs in Housing First (Tsemberis, 2010). Both ACT and ICM provide support services, but differ in how services are provided. ACT offers services that are provided by a team that includes specialists; has a low staff to client ratio (1:10); and operates 24/7. In contrast, ICM provides services through a case manager who often “brokers” services with other agencies; has a slightly higher staff to client ratio (1:15-20); and operates 12/7 (Nelson et al., 2012). Additionally, sites had the option of developing a “third arm,” or a Housing First intervention condition that was adapted to local conditions and needs, and all sites developed a third arm. More than 2,000 clients were enrolled in the study.

The research found that the programs demonstrated a high level of fidelity to the Housing First model, both initially (Nelson et al., 2013) and after one year of operation (Macnaughton et al., 2015). Moreover, fidelity was significantly and directly associated with positive outcomes, including housing stability, quality of life, and community functioning (Goering et al., 2015). After one and two years, Housing First participants showed significantly more positive outcomes than participants in treatment as usual on measures of housing stability, both in the ACT (Aubry et al., 2015; Aubry et al., 2016) and ICM (Stergiopoulos et al., 2015) programs. For more information on this project, please consult the following sources.


Housing First Programs and Research Around the World

Conceived in New York City, Housing First is now having far reaching application (Padgett, Henwood, & Tsemberis, 2016). Europe, which hosted the first  International Housing First conference in Lisbon in 2013 and the second in Ireland in 2016, has seen Housing First grow by leaps and bounds in a short period of time. For example, France has just completed a four-city randomized controlled trial of Housing First based on Canada’s At Home / Chez Soi project (Tinland et al., 2013); a three-city randomized controlled trial of Housing First is being conducted in Spain (Bernad, Yuncal, & Panadero, 2016); Portugal is researching and expanding Housing First (Ornelas, Martins, Zilhāo, & Duarte, 2014); Italy has developed a network of Housing First programs (Console, Cortese, Molinari, & Zenarolla, 2016); and a multi-national Housing First fidelity study is underway. In Australia, rigorous research on Housing First programs is being conducted (Whittaker et al., 2015). The adoption of Housing First internationally has been influenced by research conducted in the US and Canada and integrated knowledge transfer activities provided by Dr. Sam Tsemberis and others. For more about Housing First across the world, please consult the following sources.


Family Homelessness

thumb_Shinn_Beth_2014_1024.jpgDr. Beth Shinn, a community psychologist who does research on homelessness, won the SCRA Award for Distinguished Contributions to Theory and Research in Community Psychology in 1996 and the SCRA Seymour Sarason award in 2013.

Dr. Shinn has made contributions to ending family homelessness (Shinn, Rog, & Culhane, 2005). She conducted a randomized controlled trial of Family Critical Time Intervention (Shinn, Samuels, Fischer, Thomkins, & Fowler, 2015). This intervention combines housing with time-limited intensive case management. The researchers found that over a two-year period that Family Critical Time Intervention led to a greater reduction in internalizing and externalizing problems for pre-school children and externalizing problems for adolescents relative to families in the treatment as usual condition. The intervention also led to significant reductions in school-related problems for elementary school-aged children and adolescents relative to treatment as usual.

In a much larger randomized controlled trial conducted at 12 sites in the United States, she and collaborators (Gubits et al., 2015, 2016; Shinn, Brown, Wood, and Gubits, 2016) compared three different types of housing interventions with treatment as usual: permanent housing subsidies, community-base rapid re-housing, and project-based transitional housing. Over a 37-month period, the permanent housing subsidies intervention led to better housing stability outcomes and ending homelessness relative to the other interventions. The permanent housing subsidies intervention also led to better outcomes in adult well-being, child well-being, parental self-sufficiency, and family preservation.