The Community Practitioner

The Community Practitioner

Interview with Pathways to Housing founder: Sam Tsemberis
Written by Olya Glantsman

One of the best representations of community psychology in practice is the Pathways Housing First model, which is recognized by the United States Interagency Council on Homelessness (USICH), the Substance Abuse and Mental Health Services Administration (SAMHSA) and the U.S. Department of Veterans Affairs, among others, as the most effective approach to ending chronic homelessness for individuals with mental health and addiction issues. In 2014, its originator, Sam Tsemberis received an award for Distinguished Contribution to Practice in Community Psychology from the Society for Community Research and Action. This year, Sam is the recipient of the American Psychological Association’s award for Distinguished Contributions to Independent Practice. The story behind this extremely successful project offers community psychology practitioners the opportunity to see not only the intervention and results, but also the process behind them. The following interview with Dr. Tsemberis highlights some of his valuable insights as a visionary practitioner with respect to the intervention that has changed so many lives.

While doing my homework on the Pathways to Housing’s website, I came across a quote by Dr. Tsemberis: “Housing ends homelessness, it's that simple.” Many still do not see this “simple” truth as they discuss and implement policies surrounding homelessness. Many still believe that homelessness cannot be addressed unless we first address the ‘root causes’ which are considered to reside in the individual’s addiction, mental illness, or poor choices. So an obvious question for Sam was when did he realize this wasn’t so? What led him to believe that giving someone housing first, without any requirements for psychiatric treatment or sobriety would be helpful? The answer was definitely not right away. In fact, Sam told me that when he began working on the homelessness issue, he did not know that his project would develop the way it did. According to Dr. Tsemberis, when one enters a system of care and learns about the services for the homeless, one realizes that it is a service industry that is predicated on strongly held, erroneous assumptions that people with mental illness and substance abuse cannot function adequately without first addressing their clinical problems. Furthermore, most programs operate with the belief that a person’s diagnosis is correlated with inability to manage the ordinary demands of day-to-day life. Thus, individuals with a diagnosis of severe mental illness are often regarded as unable to manage something like housing; let alone an apartment of their own. Therefore, most programs for those who are homeless and have complex clinical problems require that participants first address their illness or drug and alcohol use in order to get ‘ready for housing.’  This is how programs for the homeless have operated for a very long time, and these demands for compliance with treatment or prolonged abstinence from drugs or alcohol in order to get a place to live were (and are) for many “too steep a climb” that puts housing out of reach. And so those who were most vulnerable and needed housing most, those with mental illness and substance abuse problems, remained homeless for years.

What Sam observed after working with this cohort for a while was that people were in fact much more capable than the first impression they give to the casual passerby. The person sitting motionless and seemingly helpless on a bench, her belongings in well-worn plastic bags placed nearby, is actually managing and juggling a number of decisions on a daily basis. People who are homeless need to keep track of the locations and hours of operation of soup kitchens and food pantries, they need to remember which churches, synagogues, and drop in centers offer a place to rest and an address where they can receive their monthly disability check, and on a nightly basis, they must find safe places to sleep without getting mugged or arrested. They know the terms and conditions of entry for clothing programs and shelters, and some know what to say to guarantee admission to detox or a hospital ward for a few weeks of respite from life on the streets. Many among the homeless are managing “an entire panoply of services” that would require a spreadsheet to keep track of. They have, what Sam calls “functional abilities” that guarantee their survival but all too often remain unseen by formal clinical assessments. Making this observation, he realized that even those people who may appear incapacitated by their symptoms are actually “managing a lot more than we give them credit for.” And this one realization, this one insight changes everything.

Knowing that a system needs to change and actually changing it are two different things, however. When asked what he wishes he knew going in, Sam says that he wishes he “would have asked people sooner what they wanted.” He notes that this delay had created a lot of “unnecessary hardship.” And even today there are still far too many people remaining homeless because programs do not recognize people’s strengths and insist that their participants must follow program rules especially with regard to first treating their mental illness or addiction.   

When Sam talks about the clients he has worked with over the years, it is impossible not to notice how much he cares, and going back to the original question of how did he know, he says “The people we were working with were literally homeless and because of the complexity of their problems–mental health, health, addiction–they were unwelcomed, basically locked out of just about every traditional service setting; with the exception of emergency rooms and jails. They were locked out of their housing and they were also locked out of traditional service settings. They lived among us in a state of internal exile.” He continues: “It was out of frustration, we needed to try something different.” It was this frustration born of “repeated failures” to try to get people into treatment and into existing housing programs that drove him to find something that worked. What it took, was first to stop assuming that “we knew best” and to stop believing that the failures of our ability to place people in existing housing programs was because the people we were serving were “hard to house” or  “not housing ready.” He began to have the kinds of conversations that invited clients to become the “architects of their own program.”

And it turns out “people were very articulate” about what they wanted. It turned out that what people wanted first and foremost was a place to live, a simple decent apartment, like the places they had lived in before they were homeless; a place where they can feel safe and secure and begin a way of life that was not only about surviving from one day to the next. 

The Pathways to Housing organization was initially funded by government supported housing grants that would pay for both the rent and the treatment services. These grants did not specify the sequence of housing and services and Sam and his team simply reversed the traditional order; they did the opposite from what others receiving the same grants were doing. Most importantly, he says, it was about giving people chances – not just one chance at a new life but second, third, and fourth. “We were not going to operate a program that was going to discharge people for relapsing.  Relapsing is part of recovery,” he says. “Where are people who were out on the streets when we met them going to go? We are the program of last resort.” So to him, it’s not just about the second chance. “The second chance,” he says, “is just the beginning. People need many, many chances.” It is “a journey, and it is a different journey with each individual.” Importantly, while it doesn’t always go smoothly or work right away, it remains a program that recognizes that a great deal can be learned from making mistakes and allows program participants the ‘dignity of failure.” Consumer choice and self-determination have been the cornerstone of the program’s philosophy.  Making your own decision and charting the course of your life is “what recovery is all about” and “learning from the failures is as important as learning from success.”  

One of the key reasons that Housing First is so widely disseminated today is because of the impressive research record it has established over the years. This practice of evaluating the effectiveness of the program is part and parcel of what Sam calls the ‘practice-research’ tradition of community-clinical psychology. From the very first year that Pathways was in operation the program was collecting outcome data. The results were remarkable. After the first year, 84 percent of the Pathways Housing First participants were still housed in their apartments compared to 40 percent for the ‘treatment then housing group.’  "That was a huge wakeup call," Tsemberis says. "It was like, 'Hey, we're on to something here because nobody's getting an 84-percent outcome on this population with anything."  Today Pathways Housing First is listed in the SAMHSA National Registry of Evidence Based Programs.

Upon reflection, he says he is glad he didn’t know how difficult operating such a program would be - people don’t always succeed in the first apartment, they may be relocated, there are crises, innumerable house calls, problems with neighbors, family members, landlord, etc. “I didn’t know enough to be afraid to try it, to give people a chance. I’m glad I didn’t know that.” He continues, “I think if I had been too risk-aversive… I would have never had the courage to go ahead with it.” This insight is particularly poignant. How many times have practitioners, such as Sam, given up on a project because of fear of challenge or failure? Many have felt it, and it bears hearing that even those who have seen success still work through that discomfort. “Being a little bit optimistic, helped a great deal” he notes, “Sometimes, you have to take a leap of faith and assume that the best is possible.”

Leaps of faith rarely happen in a vacuum. Dr. Tsemberis says that there have been others who inspired and supported him in the process. Asked to name them, he laughs and asks how much time we have. After listing a few colleagues like psychologists Bill Anthony, Mikal Cohen, and Rachel Efron, he talks about consumer champions like Howie the Harp, Ed Rooney and Hilary Melton and the many remarkable people he has worked with over the years, both colleagues and clients.  He says wisdom and inspiration come from unexpected places. He credits his “long list of accumulated wisdom” to the “sum of the interactions with very wise people” he was fortunate to encounter through his life. What is most important, Sam notes, is trying to maintain an open mind, having openness to a life-long learning, and to continue exposing oneself to new ideas. According to Sam, “every person that you work with has the capacity of teaching you something new.” When he was younger, he tells me, he was a bit more hierarchically minded and expected important learning to come from “socially sanctioned teachers.” Over the years, he came to a realization that you never really know where the wisdom will come from and that great learning can come from all kinds of people. To him, “wisdom is not a monopoly of those in traditional position of authority” and comes from the experience of engaging with others and sharing of knowledge. The key is, that one has to listen to be able to “receive learning when it is available to you and allow yourself to be changed by the new learning.”

Shared knowledge implies ways to influence the future. What other basic human rights, in addition to housing, could we be working on in the future using the Housing First model? “America,” Tsemberis says, “is unique that it doesn’t recognize health or education as a human right. Young people are graduating college with enormous debt.  Right now the largest national debt is college loans.” He continues: “How will someone graduating today be free to take risks or experiment with new and untested ideas when they are in tremendous debt and must hold on to steady work because they cannot afford to do otherwise?”  To Sam, offering housing as a basic human right is an essential component of the program and a key message about how we regard housing as a society.  Especially for people who are so poor that they are homeless housing should not be something that must be earned. The participants do not have to jump through hoops to get it. To him, this is not a clinical matter it is about social justice. “Who deserves housing?” he asks. “Why should people who are homeless have to earn it?”

He then tells me a bit about his own background. Sam was born in a village in Greece. From his growing up there he retained a “sense of community and belonging.” In the village, he tells me, it is “unthinkable that one of your own is on the street.” His voice becomes even more passionate: “You will do whatever you can to house that person.” He asks me where I was born and raised, and after I tell him Ukraine, he asks whether it was the same way in my country. We then talk about what he calls “the fabric of connectedness” and “inclusiveness,” and the result of those ideals: intolerability of social problems such as homelessness. “Ultimately,” he says: “If the general public came to believe that homelessness was unacceptable – we would no longer have homelessness.” To solve homelessness, people need to perceive as “intolerable the idea that our fellow citizens are on the street.” In sum, this wisdom can be applied to a myriad of other social issues. And thus, it is up to each and every one of us to affect change, to make injustice intolerable and it is our collective responsibility to help those who need help in the ways they need it rather than how we believe they should receive it. And often, success results from being open to learning and taking chances, and begins simply with asking and truly hearing the answers.