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Wednesday, January 7, 2009

sleeping on thin doors

Tonight is opening night of Three Hole Punch presents Flirty Laundry. We can't wait to see you there, so you better come. Yes, you.

One of my former patients came to visit the facility last week. I didn't recognize him he looked so good. He was a sick, very sick and depressed dying man the last time I had seen him. he loves his new place. He decorated it. He stopped drinking. He said he often has his homeless friends over for meals. He is getting a cat.

Yesterday the Globe reported that in the past year the number of homeless families in the city has increased by 22%. Today an article appeared in my homeless news feed that explained the proposal for dealing with this growing vulnerable population. The breakdown is that Boston is trying to adopt a Housing First policy in the hopes of decreasing the total number of homeless individuals but especially to decrease the total number of families who have no homes.

The main concept of Housing First as a social policy is that before an individual can deal with the issues that caused their homelessness he or she needs a roof overhead. According to Maslow's hierarchy of needs, the physiological needs of a human being must be met before safety, love, esteem or self actualization. Housing First brings to our attention that people can hardly be expected to be successful at meeting even the most basic of physiological needs (sleep, food, sex) without a consistent (and safe) shelter.

Housing First style programs exist in major cities all over the States though the concept is relatively new (1990s or so). If you google "housing first," and "boston," you can find statistics on how successful of a policy it is. This is particularly relevant if you know much about (or care about) the history of how homelessness as a social issues has previously been approached. The other major approach to dealing with chronic homelessness (by which I mean to exclude "newly" or transitionally homeless persons) is known as the Continuum of Care. Continuum of Care is still very much also in practice and it is the movement of the homeless through a system of "levels," which would ideally and ultimately lead them to an independent and permanent living situation. This is more in line with Maslow's familiar pyramid design. Get them into shelters so they can meet physiological needs (treat their physical and mental medical conditions so they become stable) and then they can look to achieve the rest of the steps on the way to safety and security.

Each policy has its place. And each one has weak spots. Housing First works well because obtaining a stable and safe dwelling place does in fact create an overall higher success rate for meeting physiological needs and then some. It is especially effective, I need to point out here, for families. However, for individual people who have spent years and years on the street in a community of other homeless people, an apartment can be an isolating and lonely experience. And many of them report that they still sleep outside or at least on the floor. A house doesn't replace a social network. And a house can't cure mental illness or addiction. On the street, someone who ODs may be taken to an ER by a buddy. Unfortunately I have had several former patients die from overdoses once they were housed.

Continuum of Care helps to prevent that scenario. People are placed in public shelters, and then agency shelters, then transitional housing, and then (ideally), their own place. The transitions from level to level help people to network and make the changes they need. For example, an alcoholic may only be accepted to certain programs based on how long he or she is able to document sobriety. This is meant to ensure that by the time this person gets their own housing they will be functional enough to deal with it. However, many individuals will never make it to the highest "level." It is difficult to find decent work while living in a shelter, even an agency shelter. It's difficult to stay sober or clean living amongst others with similar addictions. And constant rejection from employers or future landlords because of CORIs, lack of background information or just straight up bias can be damaging enough to the morale that people give up and end up on the streets again. Also, I suppose it bears saying that this strategy is not as effective for entire families.

I think Housing First policies are far more useful because they work for solo flyers and families. They create a safe and dedicated place where people can become successful on their own terms. However, in the future of homeless outreach I would like to see more strategies put into place to prepare individuals for "inside," life after years of rough living. They need a place to learn skills. Like how to balance a checkbook or budget a paycheck or shop for food for a week. I would like to see programs to enable much more follow up from case managers, mental health workers and occupational therapists. And I would like more attention paid to the fact that people form their own families in the street and that depression and lonesomeness are very real problems when suddenly everyone you love and know are far away.

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