99% Invisible - Chapter 3: Housing First

Episode Date: December 9, 2020

In the 1980's, a psychologist named Sam Tsemberis was working with mentally ill homeless people on the streets of New York. Sometimes, when he thought it was necessary to keep someone safe, Sam would have people committed to a psychiatric hospital. But a few months later, he’d notice that person was back on the streets. Sam knew he needed to try something different. What he did changed everything about the way we think about solving homelessness. In this episode, what happens when you ask people what they need. Chapter 3: Housing First The way homelessness has exploded in California over the last decade, you’d think there was no system in place to address it. But there is one - it just wasn’t designed to help everyone. Katie Mingle’s According to Need is a documentary podcast in 5 chapters from 99% Invisible that asks: what are we doing to get people into housing?

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. All right, hey, Katie. Carlos here, she's got the microphone. That's Sam Semberis, with producer Carla Green, who we sent to record him. Okay, yeah, just tell me what you have for breakfast this morning. Tell you what? What you had for breakfast?

What I had for breakfast this morning. So I've been eating bagels for breakfast for the last three days. Okay, I think I know that. So did I pass? I mean, is that okay? What if it was scrambled eggs? It's like, no, is there a right answer? I just had a right answer. I just had an equation that...

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.

Two or three of us would be in the van with a driver, and we would receive referrals, all kinds of people would call and say, I have to, 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 up a Demick 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. 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, in voluntary commitment,

it was necessary, but he was never completely comfortable with it. Sam had ended up in New York City for grad school, where he got 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. 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 cat

woman. 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 a 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 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. I said, 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 a 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. 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 three. to need chapter three.

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 kind of, here's your diagnosis, and here's your prescription methodology, Sam wanted to try basically just asking people how he could help. We're gonna listen to our clients, and we're gonna really offer them the things they want

in the sequence they wanted. We were gonna 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 struggling with either 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. Like we're still homeless, but we could go there during the day and get shower and change

clothes and they buy a lunch. This is Alan. I'm just going to use his first name to protect his privacy. Alan 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 Alan was just 13, he ended up in Bridgewater State Hospital after getting into a fight. Bridgewater was an infamous prison slash hospital for the so-called criminally insane. Prison slash hospital was a prison period.

They just called it a hospital. That was a torture chamber. That's what it was. I turned 14 and wanted to sell. Alan 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. I got to a point where I wasn't taking no shit from nobody.

Oh yeah, I used to fight a lot. I do got a short temper when it comes to a bunch of bull crap. He would come into my office like, you're the dogs, if they ever do this to me, I'm gonna kill them, you know, like this. And I'm like, Alan, you can't actually say these things. It's a mental health program. Like, people are gonna come and lock you up,

you know, like, you gotta watch your language, you know. For Alan, 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 Alan and just about everyone else wanted. So, okay, people want housing. So there were any number of housing providers open 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. A kind of a quarantining to get people ready for housing and get them to get their life together so that they can get back into housing.

To say, the staircase felt frustratingly paternalistic. When he heard housing readiness, it sounded more like housing worthiness. You know, 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. 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 that 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. You know, the people we were going to house, when you met them, they didn't inspire confidence that it would all work out okay. 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. So you have to beat the streets and find the people that are willing to work with you. And what would you tell them about the clients?

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. Sam told us that the apartment says I was as soon as we get the leases. So we were sitting down there in choices one day and this young lady she was the

There's receptionist on a secretary or whatever And she got all the sweaty guys standing around her, you know at that factory see that we're watching this Fax machine for St. Lisa's out and we're standing there. Oh, there's my right there my He's coming out over there. That's my boy, you know Soon as we got the least we walk walked over to that apartment building 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 she owes.

I was so overwhelmed with joy. I didn't know how to act. This is Camaradine Smallwood. Indeed would be my middle initial. Smallwood is my last name. But I prefer to be called Kamar because that's my Muslim name, so that's who I am, so I love that name. Like Alan, Kamar 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. I slept all over the place.

I slept in the subway station in 42nd Street. Before you get to the end train, it used to be a new stand in the bathroom. And there was a lady that worked and cleaned the bathroom. And at night time, she would lock me in the bathroom so I would stand in and I would go to sleep. And then when she came in the morning to clean up, she opened it during, let me out.

I slept in a cardboard box under the FDR drive. I think that was. Finally, after years of homelessness, Kamara and her boyfriend, who was also homeless, were getting their own place. We had park a floors, central heating, central air conditioning. We had park a 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, just cross the street, go over there and have a cook out. We had a night, we live right on a central park west 100th, 10th street. Beautiful. Nice over there. Do you remember like trying to kind of set it up and decorate it and just feeling like? 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.

We was living there and we was doing well, but we just couldn't let go of any drugs. Yeah, we was running out, going around and going to buy drugs and coming back. I don't know if anybody's seen us go buy drugs and then come back because all I know is that they kept saying we were doing a lot of running out and they're not having it. A few months into their stay, Kamar and her partner got kicked out of their building. I felt really bad. I felt like that. 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 coworkers, police, case workers. It didn't take much, you know, like for him to get very upset. He had a very low threshold for disappointment. And he would threaten people, like, and he was very, very good at threats. I mean, they 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, Alan 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. 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. 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 I'm 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 Alan 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. 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 just like trying to hold on to people and here I'm telling him like 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. He did it. Look, I saw it in his face. That's what made me that 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 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 Camor, Pathway's 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 Kamar got out of the program, Pathways helped her get a second place. This time she decorated. Putting 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 new stand on my way to work. Here's the criteria. No matter what the person looks like, if you see they're able to survive on the street

by virtue of their survival on the street on 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. Yeah because like I see the same people every day when I go to work and they're sitting in the same spot. And so in my mind they exist. Yes, yes, yes, yes. But of course they don't. Of course.

They have to eat. They have to go to the bathroom. They have to be safe. They have probably a monthly benefit check that they're getting in some church post off his 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 being housed. It's not necessary. Everyone is ready. But a lot of people just couldn't believe it. In fact, some people thought it was unethical to the clients themselves. Like giving them their own place was setting them up to fail. So we had to do a randomized control 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. And then we just coined toss, housing first, treatment is usual. Treatment is usual was a 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. And 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 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. Days homeless for the control group, you know, was a slope down and they had reduced it by about 40 percent. And days homeless on housing first went all the way down to like 3 percent. 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. People thought New York is very, very well subsidized in terms of services. It's kind of a blue liberal progressive place and it's unique in the country.

And no other place could do what you do in New York. The water comes from the Hudson. Everyone's drinking the same water. It could be that. It could be anything. It could be the bagels. Yeah, it could be the same water, could be that. Could be anything. It could be the bagels. Yeah, 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, Komara talks about Sam as if he's only a smidge below a law. No, really. I give all glory to a law and then when I step down from that, I give Sam his props. I never heard any clients complain about Sam. We always talk 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 know I heard about him, but I never met him. I said, wow, you shouldn't met Sam. Well, that's not anything bad. No, that's not anything bad.

But if you wanna talk about what's the worst thing, that's the worst, because 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 Kumar both said things didn't run as smoothly. 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. Well, obviously not. Right?

I mean, the program is all over the world, so it's not so 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 Colhane. Dennis Colhane had identified that for the population that we were housing, the housing first population that 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 the most vulnerable, because they were dealing with a lot of extra challenges, like mental illness, addiction,

or physical disabilities. They also happened to be the people who are 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 Cullhane 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. 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 launch 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 firstee the applications are. Sam Simberis 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 Camar were ready, even though they had stumbled a little at first.

After Camar 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. And Sam says to me, Alan, what planet are you that you wake up on? He says this is everyday stuff.

He says people, they make errors. And 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 Tilecia 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. Thank you. Coming up on the next episode of According to Need, 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? And are you like... Are you able to see where she would have ended up on that list?

No. The list. I mean, I, that, today I even saw someone, hey, I don't know how they prioritize the list. I don't know how they're pulling people from the list. When you're looking at that list all day every day, you kind of, you become really familiar with where people are, what they rank, and it's just like mesmerizing in a sense. 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. Because there's so much structural racism, it is much easier to become homeless if you're black. 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 Tilecia 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 Pollock, Emmett Fitzgerald, Delaney Hall, Christopher Johnson, Joe Rosenberg, and Roman Mars. Jacob Winnick was our sound engineer, fat checking by Amy Gaines, beautiful music by the beautiful Sean Raell, branding and design by muchmore.io. Kurt Colstead was our digital director, additional support from Sofia Klatsker, Vivian Leigh, and Chris Baroube.

Special thanks to Philip Mangano, Hillary Melton, and all the people who spoke to me for this series, as well as Marie Sol Medina-Kedena, Johanna Zorn, and Chelsea Miller. According to Need is a project of 99% invisible, which is a founding proud member of Radio Topia from PRX, a network of independent listener-supported, artist-owned podcasts. Radio Tepio from PRX.