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by Katie Mackintosh
22 April 2013
Gimme Shelter

Gimme Shelter

Before he was provided with a home, Scott says he didn’t live, he existed.

“I was lying in a heap. All it revolved around is drugs and alcohol,” he recalls of his descent into homelessness.

Now, however, Scott is able to share his story from the comfort of his own home, thanks to his participation in an innovative pilot that has been developed by the charity Turning Point Scotland (TPS).

The pilot aims to break the cycle of chronic homelessness. Based on a model that originated in the US, ‘Housing First’ bypasses the more traditional approach of providing transitional housing to those with complex needs and instead, places eligible individuals directly into independent tenancies. To take part, they must be motivated and prepared to take support, which is available 24/7. However, unusually, participation in the programme is not dependent on abstinence and those who take part are aided by peer support workers who have their own experiences of substance misuse and/or homelessness.

Scott explains: “They come out to check my bills are paid, how I’m dealing with my house, am I OK? How my drug use or alcohol use is and they support me with all that...Basically, I know they are there to help me keep my tenancy as well because it is people who have actually been there. So they can understand where I’ve been and they can suggest things to me, things you don’t think about at the time.”

Scott is one of 22 individuals who were selected to take part in the Glasgow-based pilot and he is delighted with the results.

“This is the first tenancy I’ve ever had and I’m loving it so much. I can do what I want. I can invite who I want into the house. Just do my own thing, really,” he beams, adding that he now plans to go to college – something he admits that just two years ago, he never would have believed possible.

Ian Irvine, operations manager, Turning Point Scotland (TPS), is the person responsible for bringing the programme to Scotland. At the time, he says, there were concerns about the numbers of drug deaths and failed tenancies because of substance misuse in Glasgow, which led to the charity being consulted on possible ways forward.

Having read about the US programme and had his interest piqued, Irvine arranged to visit the project while on a family holiday in New York. What he saw there convinced him that it was worth trying in Scotland. And while he admits it took time, initially, to win some people over, he believes that the results show that the model is working.

“There was a reluctance from some housing agencies because people don’t have to stop using,” he explains.

“There is a basic assumption that people continue to use but, in the security that a home offers them, their recovery journey will at some point address their addiction. And, frankly, that clearly is what we’ve established in the last two and a bit years. Our success rate is incredibly high.”

Its early triumphs are particularly pleasing considering they deliberately targeted individuals who would “really test” the model, Emma Hamilton, Housing First, continues. 

“The pilot was aimed at the most chaotic people who typically didn’t engage with services, who had been around the block countless times and had always slipped through the net. We wanted to provide something new.”

Providing individuals with a tenancy of their own first won’t make their other problems disappear overnight, she stresses.

However, she argues that the pilot has shown that giving people a safe base to start to look at themselves and their recovery more objectively allows them the freedom and security to work at their own speed in their recovery journey to meet their recovery goals.

An interim independent evaluation of the pilot has been conducted by researchers at Heriot-Watt University, with a final report expected in the autumn. However, Dr Sarah Johnsen, Senior Research Fellow at the university’s Institute for Housing, Urban and Real Estate Research, says the preliminary findings are “really promising”.

The most notable finding is that almost all of the service users have maintained a tenancy to date, which, given that this is a group of individuals which has not traditionally coped well with mainstream services, Johnsen says that is a “massive achievement”. However, she adds that other positive outcomes include regaining contact with estranged family and friends, improvement in self-esteem, and re-engagement with education and training. Furthermore, a number have also reduced their substance misuse “quite considerably”, with a few achieving abstinence.

“For others, the pattern of substance misuse has fluctuated,” Johnsen acknowledges.

“But the overall trend has been a downward one and this should be viewed as a positive outcome given the highly damaging impact that substance misuse has on people’s lives.”

In exploring the reasons behind this success, Johnsen found that getting the staffing right and ensuring that they understand addiction and ‘get’ the philosophy of Housing First was key. 

“It is a very ‘sticky’ service. They keep persisting with service users, and that is quite a departure from traditional approaches. In many mainstream services, support is time limited so it will stop after, say, 6, or 12, or 18 months, or when someone disengages with services and stops attending appointments, and so on. With Housing First, that is not the case. Service users will have support for as long as they need it. The staff don’t write them off if they fail to attend appointments, they stick with them, and this is immensely important to the service users.”

Another point that came through strongly in the research was that service users said they felt like they could be totally honest with support staff for the first time.

“A lot of them have felt that they needed to lie about their addiction in order to access services for a long time. They don’t feel compelled to do that with this project. They can be completely honest about things like relapse, and the fact that they are able to do that is a real aid to their journey to recovery,” says Johnsen.

The inclusion of peer support workers with shared histories of homelessness and substance misuse also added value, she explains.

“What it does is it means service users don’t have this anxiety, justified or not, that they are going to be judged about their addiction or circumstances related to homelessness. So with that gone, they feel they can genuinely engage with staff and be honest about where they are at and how they are coping. It also gives them something to aspire to. They see their peer support worker in a job – healthy, well, succeeding – and it makes them think, ‘Perhaps there’s hope for me yet.’”

Another “exciting” aspect of the study is that it is “challenging a number of received wisdoms” and showing “quite convincingly” that people with active addictions can be supported to acquire and sustain a tenancy, she adds.

“I’ve been doing research on homelessness and related forms of exclusion for about 12 or 13 years now and it is very clear from all the work I’ve done that this is a client group that is very often failed by mainstream services – so that they end up in that cycle of going in and out of hostels, on and off the street, in and out of various institutions. They often fall into a ‘too hard basket’ that mainstream services struggle to know what to do with. They are the people who keep getting evicted, they are the people who cause a disproportionate amount of conflict in services because their lives are so chaotic. But there is a growing body of evidence that shows that Housing First does actually work for this group. It is not going to be a panacea, and I would underline that quite strongly – it doesn’t work for everyone. But the evidence convincingly shows that it can provide a solution for some, and that is really exciting given that we have not done well by this group, historically.”

Sam Tsemberis, the charismatic founder and CEO of Pathways to Housing in New York and originator of the Housing First model, shares his “excitement” that the programme has crossed the Atlantic and that more people are getting help. While Glasgow was the first city in the UK to pilot the model, other sites have since been established and the Glasgow pilot is also one of the sites selected for a European project to test and evaluate Housing First initiatives in five major European cities. Tsemberis is glad to see it expanding, and recognises the “surprise and joy” and “shared exuberance” as the new projects realise they may be on to something.

When Pathways to Housing was established in 1992, Tsemberis had been working as a psychologist at the famous Bellevue Hospital, and he recalls the “frustration and helplessness” that he and his colleagues felt when programmes that were supposedly designed to help those living on the streets to find a home would reject those who would show up visibly mentally ill and addicted.

“They wanted someone who had a history of mental ill health and addiction, not a current practice of that. So it was impossible, really, to get people qualified. Because people weren’t that motivated to stay sober when they were on the street. They were knocking themselves out just to fall asleep. It was a part of them coping, in a way.”

As was the case in Glasgow, Tsemberis says some initially questioned whether people who had survived, in some cases for years, on the streets, would manage an apartment of their own. However, he explains why these individuals should not be underestimated:

“It turns out that they have already been managing. They know which church offers the meals. They know where it is safe to sleep without getting arrested. They know where they can keep their stuff and who they can trust to watch it for them while they go off to the loo for a few minutes. The survival skills of people on the street are remarkable.

“Now that is not immediately obvious to the passer by – they see someone in a bundle with all their stuff with them. But really, that they are out there, is a testament to how resilient and how resourceful they are, because they are surviving where most of us couldn’t. So if then you take this kind of person, who initially for us looked sort of sad and helpless, and they are in an apartment and suddenly they don’t have to leave their stuff and go three blocks down to go to the bathroom, they just get off the couch and go round the corner to their own bathroom, like everybody else. Life became so much easier for them and they were able to manage the apartment situation very, very easily; it was life made easy, not life made difficult.”

It is a multi-dimensional programme, but Tsemberis says the key to its success is listening and offering housing and support on people’s own terms.

“What we were prepared to do was offer anything that they wanted. If they had wanted haircuts first, that is what we would have been doing. We would have gone to the barber’s shop with them. We would have been prepared to treat them first. We would have been prepared to do sobriety first. We would have done employment, family reconnection, podiatry – we were not committed to a specific sequence. What we were committed to is helping the person make the decision and help them to realise the goal that they had set for themselves.”

This turned the treatment system on its head, he says: “The usual approach people experience when they were seeking a service was they meet a psychiatrist or a social worker who immediately starts to tell them what they need to do to get better. And here they were meeting the same type of people who were saying to them, ‘How can I help you? What is important to you?’ And it builds in people a sense of confidence and mastery that they can do things on their own. People with mental ill health and addiction are not endlessly helpless and in need of services. They are people who can, with the right support, start to do a lot on their own.”

And the results speak for themselves. In its first year, Tsemberis says that around 85 per cent of those they housed remained housed by the end of the year, and it is a retention rate that, 20 years later, they are still maintaining.

In Scotland, the three-year pilot officially runs until September this year. However, Irvine is keen to see it continue and expand and is confident that a number of other local authorities can be persuaded to come on board – sharing that another pilot will be in place in Renfrewshire later this year, while others such as East Dunbartonshire and South Lanarkshire have also indicated an interest. He also expresses his conviction that the model is transferable to other groups experiencing homelessness, including those with mental ill-health, families, people leaving prison, and even veterans.

While they remain wary of challenges such as the recent changes to housing benefits and proposed benefit sanctions and the impact these could have on the individuals they are working with, Irvine maintains that through the pilot they have established, Housing First is a model of housing support that is appropriate for Scotland.

“I can definitely see the potential,” he says.

“It is like dropping a stone in the water and watching the ripples. It is expanding all the time.”

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