Housing First and Harm Reduction: Stable Housing Without Preconditions
Traditional approaches to homelessness often required people to address substance use, mental health, and other issues before qualifying for housing. Housing First reverses this logic: provide stable housing first, then support people to address other challenges. This approach shares harm reduction's core philosophy of meeting people where they are rather than requiring them to meet preconditions. Understanding how Housing First works and its relationship to harm reduction illuminates an important application of harm reduction principles to housing policy.
The Housing First Philosophy
Housing is a basic need, not a reward. Housing First asserts that everyone deserves housing regardless of their circumstances. Housing isn't something to be earned through compliance with treatment requirements.
Stable housing supports other improvements. Research shows that having stable housing makes it easier—not harder—to address substance use, mental health, and other challenges. Instability undermines recovery.
Choice and autonomy are respected. Housing First respects individuals' choices about their own lives, including choices about substance use, treatment, and lifestyle. Support is offered but not mandated.
Services are separated from housing. In Housing First, housing is provided unconditionally. Services are offered and encouraged but not required as conditions of continued housing.
Contrasts with Traditional Approaches
Treatment first requires readiness. Traditional models required demonstrating "housing readiness" through sobriety, treatment compliance, or other achievements before qualifying for permanent housing.
Continuum models progress through stages. Traditional approaches moved people through emergency shelter, transitional housing, and finally permanent housing—with progression contingent on meeting requirements.
Abstinence requirements excluded many. Requiring abstinence from drugs or alcohol as condition of housing excluded those unable or unwilling to maintain abstinence, leaving them homeless.
Compliance requirements created barriers. Rules about guests, curfews, inspections, and behavior created barriers that caused people to leave or be evicted from housing programs.
Connection to Harm Reduction
Both meet people where they are. Like harm reduction, Housing First doesn't require people to change before receiving help. Both accept people as they are and work from there.
Both prioritize immediate wellbeing. Harm reduction prioritizes keeping people alive and healthy now; Housing First prioritizes housing people now. Neither waits for behavior change.
Both respect autonomy. Both approaches respect individuals' right to make their own choices, even choices others might disagree with, while offering support and information.
Housing First programs often incorporate harm reduction services. Many Housing First programs include harm reduction services for residents who use substances, integrating the approaches.
Evidence Base
Housing First achieves housing stability. Research consistently shows that Housing First programs achieve high housing retention rates—typically 80-90%—significantly better than traditional programs.
Cost-effectiveness is demonstrated. Studies show that Housing First reduces costs by decreasing emergency room visits, hospitalizations, incarceration, and shelter use that homelessness generates.
Health outcomes improve. Housed individuals show improvements in physical health, mental health, and quality of life compared to when they were homeless.
Substance use outcomes are mixed. Housing First doesn't necessarily reduce substance use more than other approaches, but it doesn't increase use either—while achieving much better housing outcomes.
Implementation Elements
Immediate access to housing is essential. Housing First programs should move people into permanent housing as quickly as possible, minimizing time in shelters or transitional settings.
Housing is scatter-site or project-based. Some programs place individuals in apartments scattered throughout the community; others provide dedicated buildings. Both models can work.
Support services are offered but not required. Intensive services are available and actively offered, but continued housing doesn't depend on accepting services.
Tenant rights are protected. Residents have standard tenant rights and can only be evicted for reasons that would apply to any tenant, not for substance use or service refusal.
Support intensity matches need. Services can be intensive (Assertive Community Treatment) or less intensive (Intensive Case Management) depending on individual needs.
Challenges in Implementation
Housing supply constrains programs. Housing First requires available housing. In tight markets with limited affordable housing, finding units is a major challenge.
Landlord relationships require cultivation. Convincing private landlords to rent to Housing First participants requires relationship building, guarantees, and responsive support when issues arise.
Staff may struggle with philosophy. Staff trained in traditional approaches may struggle to accept Housing First's tolerance of substance use and limited behavioral requirements.
Community opposition can arise. Neighbors may oppose Housing First facilities or scattered-site placements in their neighborhoods, creating NIMBY challenges.
Funding streams may impose requirements. Funding sources may impose requirements that conflict with Housing First principles, creating tension between philosophy and resources.
Populations Served
Chronically homeless individuals benefit most. Housing First was developed for and shows strongest effects with chronically homeless individuals with complex needs who cycle through streets, shelters, and institutions.
People with mental illness are well-served. Housing First works particularly well for people with serious mental illness who were previously considered unable to maintain housing.
Active substance users can succeed. Contrary to assumptions that people using substances can't maintain housing, Housing First demonstrates that they can when given opportunity and support.
Broader applications exist. While developed for chronically homeless populations, Housing First principles are increasingly applied to other populations including families and youth.
Addressing Substance Use in Housing First
Substance use is addressed, not ignored. Housing First doesn't ignore substance use—it offers support, treatment access, and harm reduction services while not making housing contingent on abstinence.
Harm reduction services support safety. Programs may provide naloxone, drug checking, safer use education, and other harm reduction supports to housed residents who use substances.
Treatment is available when wanted. Treatment for substance use disorder is available and offered, with timing determined by the individual's readiness rather than program requirements.
Housing itself may support recovery. Stable housing reduces stress and chaos that often accompany homelessness, potentially supporting recovery even without formal treatment.
System-Level Considerations
Housing First works best as system approach. Individual Housing First programs succeed best when they're part of coordinated systems that include prevention, emergency response, and housing pathways.
Coordination prevents bottlenecks. Without sufficient housing supply and coordinated entry, Housing First programs can become bottlenecked, serving few people while many wait.
Prevention addresses upstream factors. Housing First addresses existing homelessness; preventing homelessness in the first place requires addressing upstream factors like poverty and housing costs.
Adequate housing supply is fundamental. No approach to homelessness can succeed without adequate supply of affordable housing. Housing First doesn't substitute for housing policy.
Conclusion
Housing First represents harm reduction principles applied to homelessness—meeting people where they are, respecting autonomy, and providing basic needs without preconditions. Strong evidence supports its effectiveness at achieving housing stability and reducing costs, while demonstrating that people traditionally considered "unhoused-able" can succeed when given opportunity. Challenges of housing supply, implementation fidelity, and system coordination remain. Housing First doesn't solve homelessness by itself—that requires addressing housing affordability and other structural factors—but it demonstrates that harm reduction approaches can transform how we respond to some of society's most marginalized members.