HOUSING FIRST: A
MULTIFACETED EXPERIENCE
THE JOURNEY OF RECOVERY THROUGH
THE SUPPORT OF HOUSING FIRST
SIMON BLOMBERG
Degree Project in Social Psychiatry Malmö University 15 credits Faculty of Health and Society
HOUSING FIRST: A
MULTIFACETED EXPERIENCE
THE JOURNEY OF RECOVERY THROUGH
THE SUPPORT OF HOUSING FIRST
SIMON BLOMBERG
Blomberg, S. Housing First: A Multifaceted Experience - The Journey of Recovery Through the Support of Housing First. Degree project in Social
psychiatry. 15 credits. Malmö University: Faculty of Health and Society,
Department of Health and Society. 2020.
Bostad Först, en intervention som syftar till att lösa kronisk hemlöshet, har visat sig vara ett framgångsrikt och ekonomiskt hållbart alternativ under de senaste tre decennierna. Men i utvärderingarna nämns sällan erfarenheterna från boende inom Bostad Först och främst påverkan på deras återhämtningsprocess. Tidigare
forskning visar att erfarenheterna är mångfacetterade, i varierande grad beroende på ämne och att de ofta motsäger varandra. Detta gäller också för detta
forskningsprojekt. De olika upplevelserna berättar om en intervention med medkänsla, sociala interaktioner, en säker och stödjande miljö och en
utgångspunkt för förändring, men också en av osäkerhet, kampen mot att hålla sig nykter och hur svårt det är att gå från ett liv på gatorna. Så länge organisationer som utövar Bostad Först kontinuerligt undersöker behoven hos sina boende och ordnar sina servicelager i enlighet med dessa uppfyller interventionen till synes delar av en återhämtningsprocess.
Housing First, an intervention aimed at ending chronic homelessness, has shown itself to be a successful and financially viable alternative during the past three decades. But evaluations seldom mention the experiences from residents of Housing First and the impact it has on their process of recovery. Earlier research shows the experiences to be multifaceted, with varying degrees depending on topic and that they, more often than not, contradict one another. This holds true for this research project as well. The different experiences tell a story of residency of Housing First to be one of compassion, social interactions, a safe and
supportive environment and a starting point for change, but also one of insecurity, struggles with staying abstinent and how hard it is to transition from a life on the streets. As long as organizations practicing Housing First continually investigate their residential needs and ranson their service inventory accordingly, the
intervention seemingly fulfills the elements of recovery.
PREFACE
The most sincere of thanks to Isaac Karikari, PhD and Bret Weber, PhD at the University of North Dakota, USA, for inclusion and invaluable mentoring during the research project, and for the work of anonymization and providing the
research data. Without you this thesis would not have been possible.
Finally, special thanks to supervisor Oscar Andersson at Malmö University for thoughtful discussions and outstanding supervision during writing.
TABLE OF CONTENTS
ABSTRACT……….………...1
PREFACE………...2
1. INTRODUCTION...………...4
1.1 What is Housing First?……….4
1.2 The study site………... 4
1.3 Residents’ experiences……….5
1.3.1 Social relationships……….5
1.3.2 A safe and supportive environment……….6
1.3.3 Alcohol & Drug use………6
1.3.4 Reconquering and finding a way back…..………..6
1.3 Research question and aim………...7
1.4 Theoretical framework……….7 2. METHOD………....8 2.1 Data collection……….8 2.2 Analysis………....9 2.3 Ethical considerations……… 10 3. FINDINGS……… 11 3.1 Social relationships……… 11
3.2 A safe and supportive environment………....13 3.2.1 Transitioning…..………...15 3.3 Reconquering and finding a way back………...17 3.3.1 Movin on………....19 3.4 Drugs & Alcohol………....19 4. DISCUSSION………... 21
4.1 Method………... 21
4.2 Results………....22
4.2.1 The individual journey & recommendation for practice…………...23
4.3 Conclusion………..24 REFERENCES……….25
1. INTRODUCTION
To start this thesis off I will present the fundamental concept of the Housing First movement, the interventions cost-effectiveness as well as the Housing
First-project that was chosen for the study. Earlier research concerning residency at Housing First will also be presented followed by the study's aim and research question. Finally an emerging theory about the meaning of recovery and what it entails to be in recovery will be presented through compilation of a handful of research. This theory will be used later on to discuss if and how Housing First promotes the individual journey of recovery.
1.1 What is Housing First?
Ever since the work done by Dr. Tsemberis during the early 1990’s and the emergence of the Housing First movement the model of Housing First has continued to make ground as a good alternative for ending homelessness.
Contrary to the traditional staircase model of service for individuals experiencing homelessness, where the individuals access to housing is based on the level of abstinence from drugs and regular participation in treatment services (continuum of care), the Housing First model prioritize housing before treatment and sobriety and doesn’t hold the individual responsible for going through treatment or to stay completely sober to keep his or her housing (Home_EU 2020; The Homeless hub 2020). The individuals’ right to a home is the first and foremost goal and focus is centered around supporting residents in keeping their housing through various struggles with the help of employment services, medical care and housing support. How these services are arranged differs from project to project; some have the ability to have professionals on site the majority of the time during the week while some collaborate with local community providers to arrange treatment for residents. But at its core the values are the same: to alleviate a wide range of struggles connected to keeping one's housing.
The Housing First model has also emerged as a more cost effective solution in the long run compared to comparative housing services. During a study located in Maine performed by Thomas Chalmers McLaughlin (2011), costs related to emergency visits (which are already higher within a homeless population suffering from mental illness) for a total of 263 individuals, who had all been chronically homeless at least 6 months before moving in, decreased by
approximately $100,000 after individuals had been housed for 6 months. Other federal and state costs saw reductions as well during the same timeframe; cost for substance abuse treatment decreased by $60,000, incarceration costs reduced by $55,000, mental health costs reduced by $285,000 etc. After two years the costs were declining still. All these reductions in costs together with the increased cost of the actual housing still makes Housing First the most cost effective solution as of yet.
1.2 The study site
The project being studied is a permanent supportive housing-project located in an Upper Midwestern US state, and houses approximately 47 residents in 45
individual apartments. The front desk is manned at all times with the number of available staff and services declining during the later hours of the day, nights and
weekends. During weekdays on-site supportive services include employment services, healthcare and housing support along with external providers
intermittently visiting to provide services such as Social Security-support and STD-testing. The project also collaborates with the local Human Service Center for easier access and transition to mental health treatments for its residents, where group counseling and individual treatments are provided should the resident feel the need for mental health support. All the regular providers meet weekly to evaluate and discuss current residential needs, sharing necessary information and progress within their respective fields.
All floors of the single building is reserved for residential apartments save for the ground floor, which is made up by an indoor gym, a communal room with a TV, videogames and other recreational activities. There is also a full-size industrial kitchen connected to a large seating area, mainly used by local church groups to prepare and serve dinner for the project's residents. Residents are free to come and go into the building and use communal spaces as they please at all hours and are allowed any amount of visitors, as long as the visitors keep to their hosts and don’t wander about the building. While alcohol is allowed it is required that intake take place within the residents apartments and not in the communal areas, and severe intoxication and aggressiveness towards others is reported as lease violations and in some cases to the local police department. Lease violations are issued for other reasons as well, such as destruction of property or general disturbance, and residents have a total of three “strikes” before being issued a notice of eviction.
1.3 Residents’ experiences
From an organizational standpoint Housing First may seem like a good fit. But what about the experience of the residents of Housing First, the individuals being provided for? After exploring a smaller sample of earlier research concerning the subject it becomes clear that a multitude of opinions and experiences emerge; both positive and negative (Bengtsson-Tops et al. 2014; Forenza et al. 2019; Huffman 2018; Kristiansen & Espmarker 2012; Raphael-Greenfield & Gutman 2015). In an attempt to make an overview of the different experiences a little easier I’m going to try to present the different voices of the residents in a thematic manner, which will also correlate with how the ‘Results’-section will be presented later on in this thesis. Some of the themes have been pre-contemplated and borrowed from the research reviewed, as most already were presented in a similar thematic manner.
1.3.1 Social relationships
As in most of lifes’ venues the topic of social relationships is something that is spoken about frequently in the experiences of Housing First. It is spoken about in the context of the relationships between residents and staff and is more often than not described as relationships founded by trust, support and ‘being seen for who one is’ or being seen as an individual (Kristiansen & Espmarker 2012). The relationships are described as more forgiving and nourishing than many other professional relationships within the healthcare system and residents seldom seem to want to speak ill of staff within the Housing First movement.
Private social relationships is also a topic that comes to light during past research, with descriptions of a sense of community and the comfort of spending time with others with the same type of experience of homelessness. It is also mentioned in
regards to regaining past relationships that may have been hindered by the lack of residency (Kristiansen & Espmarker 2012). Some residents describe regaining and being able to keep a close connection to lost family members; some even being able to formally be there as a grandparent after being able to restore relationships with long lost children after decades of disconnect.
Contrary to these findings social relationships can sometimes be the cause for tension. Some residents report feelings of being excluded, marginalized and being the victim of coercion and threats. The more aggravated incidents are generally presented as happening between residents and the residents’ opinions about other local residents and their contribution to recovery and society at large varies greatly (Huffman 2018). While some residents mention close and mutual friendships with others some talk about other residents causing issues and generally being a disturbance in their living situation.
1.3.2 A safe and supportive environment
Having a stable and reliable place to sleep, a shower, warmth and something to call your own is something most of us take for granted. But looking at past research these basic things are something that can bring an individual who has experienced prolonged periods of homelessness some temporary relief from an otherwise chaotic lifestyle; a moment of peace to get things together, make plans and set long-term goals (Bengtson-Tops et al. 2014). Residents report being comforted and feeling safe knowing their living spaces are considered their own,
their home, and not the staff's area of work and that it can be seen as a personal
retreat when the need arises . It’s considered a place for contemplation, for storing one’s personal belongings without risk of someone else stealing them and a space for recreation (Burns et al. 2020).
But support and a sense of safety does not only stem from the housing situation. The kind of social environment, with relationships built on trust and reliance and being seen as a person gives the residents a feeling of empowerment and
encourages personal development and exploration (Bengtsson-Tops et al. 2014). Residents also report finding a kind of support not really expected or previously experienced from social services where the staff's understanding, empathy and emotional investment are out of the ordinary.
1.3.3 Alcohol & Drug use
As substance abuse disorders are common among the homeless population it is not surprising to see the subject mentioned in relation to the experience of Housing First in one way or another. The rules and regulations regarding the subject vary greatly, as some projects keep to a strict “no-presence policy” with screenings when residents enter the premises while others are a little more lenient and let its inhabitants use legal drugs as long as it’s kept and consumed within the residents home (see for example Burns et al (2020) compared to the present study site). The social aspect also comes into play regarding drugs and alcohol, where residents express feelings of struggle staying abstinent because of others using in close vicinity, or being pressured to drink or use (Kristiansen & Espmarker 2014).
1.3.4 Reconquering and finding a way back
Throughout the stories being told by residents of Housing First some indicators can be seen that promote recovery and a way back to a functioning level of being.
Residents express that having a home, a reliable place of stay, and the supportive functioning of the Housing First staff makes them able to re engage with the surrounding community through employment, where further social and vocational opportunities may arise, or volunteering at local functions as a way of giving back to the community and to those less fortunate (Forenza et al. 2019). Staff are often reported as being helpful with difficult, but necessary, paperwork concerning social security or health insurance policies and are more often than not described as cornerstones through their journey of recovery and building a new independent self (Kristiansen & Espmarker 2014; Molin & Perdsjö 2014). Also being able to reconnect with family members and friends in a safe and stable environment reaffirms the process of recovery, as it may lead to a stronger sense of self through lost familial roles and connections.
1.3 Research question and aim
The opinions surrounding the Housing First intervention are many, ambiguous and contradictory, with a multitude of varying subjective experiences.
Furthermore, it is difficult to categorize participants in Housing First as a single homogeneous group, which is why each study targeting the experiences of living in a Housing First environment can be seen as representative of the organizational unit of the study exclusively. This makes it difficult to draw parallels between experiences among groups that may not be represented in previous research. The purpose of this study is thus to add to the collective research data the subjective experiences from another Housing First unit, this time from an Upper Midwestern US state, to increase the number of available data and to investigate possible further subjective experiences concerning Housing First residency.
Additionally, the research aims to investigate if living in Housing First promotes the individual's work towards recovery. And if so, in what ways does Housing First affect residents' sense of self? Does it contribute to the individual’s level of independence? What services being provided adds to the recovery process? If there are cases where Housing First does not promote recovery however, in what ways does it hinder the individual’s progress? And can Housing First transform to alleviate these cases?
1.4 Theoretical framework
While being on the streets for a considerable amount of time without a home, employment and nourishing social life in itself might take a toll on an individuals physical and mental health, the underlying reason for ending up in chronic homelessness may still be present and untreated even after being housed through Housing First. After finally having been housed with all the basics of living covered, the journey of recovery can begin. But what does recovery mean? Getting back to full health and to a functional state of being after being the victim of illness, does that mean that one has recovered? Or is it a state of being, a perspective one chooses after a crisis or severe illness, when the dust has settled? Recovery can be seen as a highly individual process where two journeys can be regarded as very similar or alike, but never exactly the same. The process should take into account the individuals hope, dreams, personal goals and fundamental right for choice, which is to be a leading star for services to work towards (Onken et al. 2007; Deegan 1995). Compared to a more traditional line of service where
interventions and treatments are centered around illness reduction and symptom awareness and prevention, recovery should be based on and maintain the
individual's strengths and options for self-care in hope of nourishing independence (Slade 2009). Recovery should not be seen as a linear course with hallmarks for if and when the individual reaches certain goals or steps (Tondora & Davidson 2006), as it is a highly individual process, and can contain momentary setbacks as well as periods of rapid progression. While individuals in recovery can be
regarded as less progressive, it should not mean that mental health services are free to take the reins along with all the responsibility for all outpatient situations, but respect the individuals right to make his or her own decisions, as well as occasional mistakes as a learning opportunity (Slade 2009). The environment surrounding the individual should promote choice, even if arbitrary (Onken et al. 2007). To have people around that have gone through similar experiences of recovery as role models, either as recruited staff of general community members, can instil hope in individuals that are going through moments of doubt in their own recovery process (Davidson et al. 1999). The value of social relationships in the process of recovery should also not be undervalued, where social
environments opens possibilities for the individual to give and receive advice for self-care to manage symptoms to others and express mutual understanding in one’s situation, further instilling the feeling of not being alone (Topor et al. 2011). Further, relationships to professionals that benefit the recovery process are those that are founded on trust, collaboration and reciprocity where the professional approach does not follow the ordinary power dynamics of user < professional (a.a.)
2. METHOD
I will now present the methodical steps that were used to conduct the study. First the methods used to collect data will be presented, with in-depth descriptions about how the interviews were conducted and how the questions were structured. Next the part of analysis will be explained, where my main focus is distributed since I did not personally collect the present data used for this study (even though I collected data for the overarching study at a later stage). Finally the ethical considerations that were formulated will be presented in two parts, since the studies have been approved by both an US institutional review board and the ethics committee at my own university.
2.1 Data collection
As the present research data originates from a wider, mixed-method and ongoing study and hasn’t been gathered personally by the writer (me) of this thesis, the data collection and the steps therein will be described partly as was told by the original researchers at the writers (my) recruitment into the project, and partly how the data was collected during the writers (my) personal attendance during later interviews (not present in this study). The procedures were continually discussed throughout the writer's inclusion.
Research data was collected through qualitative, semi-structured interviews with Housing First residents at the site of study. The approach was chosen as it was believed to illicit personal accounts and experiences concerning residency at
Housing First in addition to heavily focusing on the residents' experiences in favor of organizational purposes for services and treatment (Bryman 2012 p. 399-401). Further, the choice for semi-structured interviews were made because the
overarching study included a wide range of topics while encouraging responders to talk freely and in a more natural manner about the different topics and
experiences therein (Bryman 2012 p. 469-7470). Recruitment was done in part through a “snowballing”-method, where key individuals were initially recruited and later asked to spread the word about the study (Bryman 2012), and also through the researchers being present on site in public areas personally informing the residents about the research project. Prospective recruits were then available to ask further questions about the study and schedule an appropriate time for
interviews should the resident feel the need to plan ahead. Among the 47 residents at the study site, about half were asked to participate in the interviews. Participant selection was distributed as evenly as possible between gender, age and ethnicity in order to collect as nuanced and truthful answers as possible.
The interviews, lasting a minimum amount of 45 minutes, were presented to recruits as the first interview of a larger set, recurring periodically (on a yearly basis) in order to study the Housing First-projects progress and the effect of Permanent Supportive Housing on the community at large as well as its residents over a longer period of time. Interviews were conducted at the study site in a conference room adjacent to the public area as to not make residents feel closed in or unfamiliar with the interview space at large, while also respecting the residents private space by not requiring the residents personal apartment. Questions were structured in such a way as to facilitate more rich and nuanced answers. For example, when asked about any improvements in mental health care since moving into the Housing First-project, introducing questions such as “Have you had any
improvements in mental health care since moving in at [Housing First-project]?”
were asked, and if so, follow-up questions such as “In what ways?” or “Can you
tell me more about that?” would follow (Bryman 2012). In the events that a topic
didn’t find a fluid flow, restructuring would occur in styles of “Let’s move on to a
different topic, if that’s okay with you?” and so on. Interview questions were also
assessed as time went by, with additional questions being added if a certain theme would emerge that the interviewers had not expected. For example, the theme of having to cling to the shadows (which is elaborated under subtopic 3.2 A safe and
supportive environment) was mentioned by a number of responders in the early
stages of interviews and led to the interviewers expanding the questionnaire to be able to investigate the topic more thoroughly. The same would go for topics that found no real foothold or real relevance to the study.
Recruits were also given the opportunity to answer the questions in written form instead of doing a verbal, recorded interview. No one chose this option and
instead opted for a session with the researchers or not participating at all. After the interview sessions the recorded audio was sent to an experienced transcriber for transcription.
2.2 Analysis
Since the site of study was the writers (my) current field placement for ten weeks during bachelor studies abroad, in preparation for analysis and to minimize personal bias, interviews were anonymized by the initial researchers by request from the writer (me). The interviews were also asked to be picked at random, as to
further anonymize the responders. Out of the total number of interviews, six were selected and sent over to the writer (me).
Analysis was done through a thematic approach. Thematic analysis mainly focuses on topics that emerge from the data through repetition, metaphors, analogies and transitions, but also from differences and outliers that may contradict what has been said earlier in the data (Ryan & Bernard 2003). The process involves reading and rereading the data thoroughly several times to get an overarching perspective, all the while taking notes as themes appear in the data (Bryman 2012). Consequently, interviews were read thoroughly several times with initial notes and margin marks which would lay the groundwork for the following coding process (Creswell 2013). Repetition and common use of words or expressions in the interviews were identified and compared with the whole, where similar patterns and experiences were loosely linked together to broaden their meaning (Bryman 2012). If, for example, a significant number of residents responded similarly to a singular or set of questions, notes would be made to analyze this further. Outliers and contradicting statements were also identified and noted to broaden the experiences and stories shared by residents. When this step no longer generated further substantial notes, the interviews along with notes were then carried over to QSR International’s Nvivo 12 for coding. With the help of the application interviews and notes could be scrutinized more thoroughly and wider connections could be made throughout the interviews, where subthemes and wider themes emerged and could be arranged as seen fit (Ryan & Bernard 2003). For example, experiences related to healthcare was initially noted as just healthcare, which at the later stages was split into sub themes like mental healthcare and
physical healthcare (along with similar sibling topics), but also came to have an
overarching theme itself. The codes were then investigated separately and
experiences were looked at one by one which made similarities and outliers stand out further, and intersecting codes were made visible. The sub-theme for code 3.2
A safe and supportive environment for example started intersecting with codes
from 3.1 Social relationships in cases where experiences expressed parts of both themes. Codes were then weighted as to which way the code weighed heaviest thematically, and was ordered under the appropriate sub-theme. Finally, notes for especially significant and expressive accounts were taken and subsequently picked for presentation in this thesis.
2.3 Ethical considerations
The study was believed to contribute to the general body of knowledge on interventions and measures designed to effectively address homelessness, specifically, the use of supportive housing models such as Housing First. The research was believed to include minimal risk during participation and was approved by the initial researchers institutional review board. Recruits were informed about risks, such as uncomfortable feelings and experiences being identifiable by context. Information about the study and the risks were provided by pre-approved consent forms from the researchers institutional review board, and the aforementioned was used to collect consent from participants (Bryman 2012 p. 140). The same information was also verbally discussed before the interviews and careful consideration was taken to clarify the voluntary aspect of participation. Contact information to research staff was also distributed should the
participant choose to withdraw from the research project at a later date, add information or to ask additional questions.
Since the interviews had been done internationally and not in the writer’s country of origin, ethical considerations were also sent to the writer’s own university for approval. These considerations specifically remarked the anonymization of the interviews and the material being sent over, as well as ethical consideration that had taken place during interviews. No additional risks were believed to be included in this part of the study and was believed to contribute to the general body of knowledge concerning the experience of living in Housing First. Considering the small sample of participants, names and genders of individual respondents were withdrawn from the results to decrease identifiability by context (Bryman 2012 p.136).
3. FINDINGS
Even though similarities can be found and themes emerge among the experiences of residents at the Housing First-project some stories shed light on different aspects of the experiences while others outright contradict them. There are also some outliers among the experiences, which will also be presented due to their unique and contributing aspects to the themes at large.
3.1 Social relationships
Mentions of social relationships and its impact on the quality and experience of housing is frequently discussed during the interviews. Residents report having deep and long lasting relationships with other residents, where some relationships are founded long before being housed at the Housing First-project. One resident, who even has a sibling living within the same Housing First-project, explains:
“And the people within these walls, almost every single one of them, I have love for all these people. I don't like alcoholism and I don't like addiction but… [...] These people that are here, most of these people that are here, I've been around for 10 to 12 years. Yeah. I have a lot of love... And my little [sibling] lives a door down from me.”
Just an all around social atmosphere can also be beneficial. For one resident, even though services are provided at the Housing First-project, just having people nearby to talk with or just spending time with others, inside or outside, makes a difference to everyday life. The community room, which houses a selection of activities meant to foster social interaction, or visiting neighbours makes it possible to interact with others in a variety of ways.
“Interviewer: What kind of services do you... like what is it about living here that helps you not drink so much?
Resident: Just like, simple chit-chatting with people downstairs. Going outside for walks. Going to play in the garden.
Interviewer: The social atmosphere?
Resident: Yeah. Watching TV. Playing the Wii. Visiting, you know, certain people that I talk to around here. Talking to staff.”
The relationships to staff are also reported as being crucial to the quality of
housing at the Housing First-project. A majority of residents express gratitude and positive remarks about staff and the services being provided, where a sense of support and understanding makes itself apparent. Understanding and supportive relationships contribute to a sense of comfort and being able to let one's guard down, and when staff show compassion and care for residents it can really make a difference:
“I just, the atmosphere, I mean the people around here, they're... [...] I feel, you know, I feel at ease. I don't feel like I have to be on guard 24 hours a day and that's huge. It's almost like they go out of their way to try to help us. It's really cool.”
While most residents describe the social atmosphere and the connections within the project to be one of reprociation, understanding and generally pleasant in nature, some residents share another perspective. Contrary to the above
experiences, some residents report incidents of physical violence, racism, threats and altercations. These incidents affect the residents’ sense of security and add to a sense of instability of an otherwise stable environment. On the topic of feelings of insecurity and physical violence, either to oneself or others being the victim of physical violence, a resident shares an incident. The resident heard another resident out in the hallway, seemingly being the victim of physical violence, and went out to record the incident for proof keeping and ended up being the victim instead:
“The reason why I was recording is because I thought [Resident] was getting beat up out in the hallway. Then I ended up getting attacked. Then they didn't even do anything about it. It just makes me feel not safe.”
As the city where the Housing First-project is situated belongs on the smaller side of US cities, it’s not without understanding that many of the individuals that come to live in the building may have a history from the streets. As residents start moving into the Housing First-project and the apartments start filling up, past disputes or disagreements that may or may not have been settled may rise up again. One resident (albeit briefly) mentions this during an interview:
“Interviewer: So how do people get along at [Housing First-project]? Resident: Not too good.
Interviewer: Not too good? Resident: I don't think.
Interviewer: Uh-huh. You've mentioned you've had fights with some people here?
Resident: Oh yeah
Interviewer: People you knew at the Mission earlier?
Resident: Yeah but, yeah, we get along good now. It was alcoholic related.”
Even though the argument may have been settled, a number of residents report knowing each other from before moving into the Housing First-project. For some
residents this results in close and long-lasting relationships, while for others it may result in old disputes finding their way back.
3.2 A safe and supportive environment
While different things can be said about the Housing First-project in general, a theme of the project, services being provided and staff acting as a safe structure and a support in a wide variety of ways clearly emerges from the interviews. Fundamental, basic things that most people may take for granted can incite feelings of safety and comfort to ones everyday life. On the topic of how the Housing First project may have changed the residents' situation in everyday life compared to living on the street, one resident shares how worries regarding hygiene and clean clothes is a thing of the past:
“Interviewer: So overall, it sounds like but I don't, I don't want to answer for you, but has your life been better [since moving in]?
Resident: It has been better.
Interviewer: Can, can you tell me more about that?
Resident: Um, it's been better because, you know, I don't have to worry about eating. I don't have to worry about not showering. I don't have to worry about clean clothes. You know? I don't have to worry about it. Interviewer: You can take a daily shower here.
Resident: Yeah.
Interviewer BW: You can do laundry here.
Resident: I don't have to worry about, you know, staying up all night watching, you know, to make sure nobody's going to attack.”
In regards to safety and keeping your things (and most importantly yourself) safe from others wanting to do you or your property harm, as mentioned in the quote above, another resident shares a similar experience. At the study site all visitors have to show their ID and state their reason for visiting before being allowed entry into the building, which brings questions from some visitors and residents. This resident, however, shares a different perspective:
“[...] And also when you're in a safe environment like this, where you have to use your ID to get in, that right there alone keeps a lot of people from coming here. So, it kind of, a lot of the rules here, a lot of people think are harsh but I call them safety nets. [...] A lot of them keep me from having to like worry about people that are shady or people that might be using to come here, because they won't want to give their ID.”
When asked about matters concerning Medicare and Social Security a majority of residents report that navigating through formal paperwork and procedures and getting in touch with the right people to get covered can be a daunting thing when you don’t know where to start, and asking for help might not always be so easy. One resident talks about the experience of starting out getting access to services, and how transitioning from a life of doing it on one's own compares to getting support. The resident went to the designated case manager at a local healthcare provider, one the resident had visited many times before, and was enlightened to the fact that such support was provided at the Housing First-project:
“Interviewer: [...] So you've mentioned services, that you can access services here. Is it easier to access services now that you're here than before you moved here? And has that been a good thing?
Resident: Yeah there's just some confusion though because see, I'm just so used to doing things on my own. That I go do it myself and then I didn't realize that we could have the help here too. So like the people over there at [local healthcare provider] like, "You know you could do that at your building?". I'm like, "Oh, I didn't know that."”
The resident continues later on during the interview, talking about having been taken off Medicaid and Social Security and expressing the need for support in traversing the paperwork. The resident shares about the struggles of getting re-covered and how the services being provided at the Housing First project helps alleviate this struggle:
“Interviewer: You don't have Medicaid right now?
Resident: Or Social Security. I just got taken off Social Security because I don't, I need help with my paperwork.
Interviewer: Uh-huh. Is there anyone here who can help you?
Resident: They're actually starting to help me now because I'm actually just now finding out, like, how much they can help.
Interviewer: Okay.
Resident: Because I do need help.”
Another resident shares a similar story. Shortly after being housed at the project this resident was diagnosed with a severe chronic condition, which led to regular follow-ups with the visiting doctor that comes around to provide advanced healthcare for residents. Without the intervention and services being provided by the Housing First-project; the support being provided to get covered by insurance, reminders for appointments with the doctor and consecutive check-ups and the professional approach by the doctor the resident did not feel the outcome had been the same:
“Interviewer: [...] Since you've been living here, has the healthcare situation improved for you? Do you get better healthcare now? Resident: I see the doctor here, yeah. She's pretty good. She's pretty good. You know, she's very thorough. If I need to go get an ultrasound or she wants to check my, see if my liver's coming back or if it's staying the same, you know, she sends me to [local healthcare provider] to go get, you know. Then she gets the results and tells me all about it.
Interviewer: And do you have insurance now? Resident: Yeah. They got me insurance.
Interviewer: So you didn't have insurance before? Resident: No.
Interviewer: So when you were first diagnosed, not much follow-up? Now you get care?
Resident: Yeah
Interviewer: And is that, has that improved your life? Resident: Yes it has. It really has.
Resident : Because it makes me feel better knowing that they are taking care of me and you know, if I do this, because if I do this and I do that you know, I could get better. It'll heal. I'll live longer. But if I didn't have no insurance, I would probably have just kept going the way I was.”
While being under the influence, lashing out and saying or doing inappropriate things that you don’t really mean and regret later on aren’t especially uncommon. In the life of addiction these occurrences are even less uncommon. Treating individuals struggling with addiction can therefore be a balancing act of understanding and correcting behaviour. A resident shares an experience that, albeit not telling a tale of security, speaks of the understanding and support coming from staff at the project. While intoxicated, the resident had made
threatening remarks about a staff member which ended up getting reported to staff as aggressive behaviour. In and of itself the incident could very well have ended up being reported to police as terrorizing (according to the resident) and could have ended very differently had the staff not acted in such an understanding manner:
“I went up in the elevator and I was drinking and I said, "I'm gonna stab that b-i-t-c-h" and was talking about [staff member], the gal that works here. A tenant that was upstairs, in the elevator, came back down and told them. That's terrorizing. I could've either got thrown into jail, because that was a lease violation. I've had three of them already. But [building manager] understands that, you know, it's all addiction. I don't act like that when I'm sober.
Interviewer: Huh. Resident IV: Nope.
Interviewer: So, you said it could have been terrorizing Resident: It could have!
Interviewer: She didn't call the police or anything?
Resident: Well no, she just didn't pursue it. She just wrote me up for it. I had to speak to [building manager].”
3.2.1 Transitioning
Out on the street you might have nothing more besides the clothes on your back and a small bag with some personal belongings. Moving into a Housing
First-project then provides you with all the basics: a roof, warmth, shower, furniture, food and some extra luxuries like a TV or a radio. With all these fundamentals of living covered, you don’t have to fend for yourself as much anymore and can pursue a recovery process in a different state of being. One resident shares an experience from having just moved into the Housing
First-project, and how laziness, a bit more money on hand and staying abstinent became a thing:
“Interviewer: Did you have a hard time adjusting when you first started living indoors here?
Resident: I got lazy.
Interviewer: What do you mean? Resident: I got everything, you know? Interviewer: Uh-huh.
Resident: It's just like anybody, you know, if you are given an abode and you take it... Listen, okay, so really? Really? I didn't have cable but I have a TV to watch. No matter what was on. You know it didn't matter. Interviewer: You get a little money, you can buy something to drink and come here and watch TV.
Resident: Yeah.
Interviewer: You got lazy, you said?
Resident: But see then I get on to the point where I make a little bit more, you know? I mean I worked a little bit, pick up a few days here, a few extra jobs. And more money. And at least I haven't stepped out into the drug thing, you know? I don't want to do that.”
Transitioning from a life on the street, where one always has to keep a watchful eye out for protection, to one living in an apartment in a surveyed building is a struggle mentioned by a few of the residents. Not only concerning getting lazy and bored, but also where experiences of struggling with being housed emerges. One resident, in addition to mentioning feeling spoiled by the services and support being given by the Housing Support-project, speaks of thinking about the past and the feeling of being more free sleeping outside; even if not too far from the
premises:
Interviewer: So you've been in well coming up on almost a year, huh? Resident: Uh-huh. But it's still, I don't know, sometimes I still sleep outside, you know? I don't know, I just feel free out there, you know? But then I know I'm safe in here, you know, because they have all these cameras. I just feel safe. Like sometimes I'd start thinking about living outside, living out there 5 years and how I survived and all this, and I just sleep outside.
Interviewer: When you sleep outside now, where do you go? Resident: I go, I just go behind where the cameras are. Interviewer BW: Yeah?
(both laugh)
Resident: I don't go far. Just right where the cameras are.
A third experience about the transition moving into the Housing First project comes from another resident. For this resident, having been on the streets for a prolonged period of time, the hard part about moving in was the compassion; that people would inquire about the residents health and general wellbeing. After some time of struggle and adjusting, the resident felt at ease and started reaching out to neighbours and getting some friends.
“Interviewer: When you first moved in, did you have trouble adjusting to living here?
Resident: A little bit, yeah. It was a little overwhelming. It was kind of like culture shock in a way.
Interviewer: Yeah! Tell me about that. That's amazing.
Resident VI: I don't know. It was like strange that like people would check. [...] It was shocking. Like it was... I remember when they gave me my keys when I first moved in and I like started bawling right in front of them. It was like so... I don't know, just so emotional because I had been through quite a bit on the streets and whatever. But more so to answer
your question it was just, there was kind of a little rough adjusting but you know, I got through it. I made some friends. I made some, my neighbors are pretty good friends, so yeah. Some good people here.”
3.3 Reconquering and finding a way back
Having been on the street without a home for an extended period of time; losing touch with family or friends, not having a place of work, no reliable income; most residents did not enter the housing first-project with much to spare - be it socially, physically or financially. Through the journey of recovery, individuals often report finding that things that have been lost can be regained, which might further fuel the strive for continuing the journey. In the interviews with residents, a theme such as this becomes apparent as well. When asked about psychiatric medication, one resident shares being prescribed antidepressants and medication for anxiety, but since being housed not feeling the need for them as much anymore due to practical circumstances:
“Interviewer 1: So for the depression, do you have any medication? Resident: I'm on a different one for that now. But I explained to the doctor last Thursday that I don't feel that I need them anymore. Interviewer 1: Oh.
Interviewer 2: That's good news too!
Resident: I know, it's been a real big change. Interviewer 2: Living here?
Resident: Yes. It's been a real, it's been different... because I was so used to the streets.“
Some residents also talk about vocational habits and the value of having employment to keep the mind busy from distracting and sometimes intrusive thoughts. As well as assisting with employment services, the program director had, at an earlier stage of the project, started an employment initiative through the local Housing business, which made it easier for residents to apply for entry level work. One resident, who had acquired employment through this service, shares about the value of employment and its power to occupy the mind in favor of thoughts about addiction and as self-care for anxiety disorders:
“I've been here for a year and I've only relapsed twice since I've been here. It was during a time period when there were problems in my
relationship that I went back to addiction. But I know today that being an addict is not what I want. Now that I'm here, [program director] has also started a work program for us, through housing, and so I'm getting to work part-time - it's just temporary - but I'm getting to work part-time about 20 hours, 25 hours a week. That helps a lot because it gives me something to do. I have something to occupy my mind. And if you don't think about doing addiction, or about it, it keeps my mind occupied from even thinking about just everyday things that, you know, because I'm an over-thinker and I suffer from depression. I also am, I have anxiety. I have social anxiety and I have separation anxiety. So working keeps my mind occupied. And too I get to see the result of my work. I get to see the difference in it.”
The feeling of giving back, of entering the social machine through employment and fulfilling a societal role is mentioned specifically by another resident as well. This resident reported having had rough experiences with society at large at an earlier point in life, which transformed into a very skeptical view on the societal machine. At a more recent stage the resident had overcome the skepticism and come to a point where giving back and being a productive member of society had more of a focus.
“Resident: I definitely want to be a more productive member of society. Interviewer: Since you've been living here?
Resident: Yeah. Work's kind of coming along so but I've got kind of a, I've got a pretty bad work history so just trying to overcome that and just basically surviving. Well not surviving but you know, just getting along.”
Another resident speaks of the importance of having people around for distraction and at the same time of the value of being able to spend some time in solitude if prefered. This residents finds solace on the ground floor of the Housing
First-project, in the community room, with a lot of activities and opportunities for residents and staff to get together and spend some quality time. But it also brings peace to know that once the resident enters his or her home, no one comes knocking on the door wanting to share a drink or two as a way to pass time.
“ I'm drinking to feel better, I'm drinking because I'm blah blah, you know? Now that there's so much to do around here, there's always somebody downstairs, there's meals every day, there's [community group] meetings, there's TV down here. The [other housing facility] was, I stepped outside and it was so depressing looking out there. All that everybody wanted to do when they knocked on my door was get drunk. Here, nobody knocks on my door.”
Having a reliable place to call “home” extends to other venues in life than just warmth, safety and being able to store your personal belongings. Residents share experiences of more easily getting in touch with and meeting people from past relationships due to having a reliable place of stay, both for themselves and the occasional visitor. One resident shares a story about being able to spend time with family during the holidays, and how living at the Housing First-project has made it possible to transform the relationship:
“Interviewer: You mentioned your daughter, does she come visit or does she live here with you?
Resident: No. She comes to visit. She lives with my mom but it's been really nice. That's the nice thing about living here. Is that I finally have a place and now I'm, I'm actually getting a relationship with my mom and my daughter, a POSITIVE one. That's the cool thing about this, all this. Like we had Thanksgiving. My mom cooked and she brought the food over, and we like ate here and stuff like that. It was nice.
Interviewer: Why do you think living here has helped that happen? Resident: I think it gives my mom and my daughter a sense that I'm okay. You know now? Whereas before they were worried about me all the time. They still worry about me but I know I feel like they know that I'm okay.”
Something that arose in the early stages of the interviews, and that came as a surprise to the interviewers, were experiences of having to cling to the shadows, to make oneself invisible and the need to marginalize oneself in comparison to others when traversing through general society. This led to the interviewers expanding their questionnaire guidelines, and when asked about this experience, one resident familiarised with the topic. But even though the feeling of having to hide had been present earlier, since being housed, the feelings had changed due to having a new social position in life.
“Interviewer: Do you still feel the need to be invisible?
Resident: No. I actually feel better about myself. Like I have a place I can go. I can hold my head up high. Have I made the best decisions? Not all the time. But, you know, I still have, I still have shelter. I still have food. I still have all the basics. So I definitely, it definitely makes you feel better. Or at least myself.”
3.3.1 Movin on
While most of the interviews are centered around residents' past and current experiences and the disparities between the two, some of the residents also talk about the subject of what comes next and their long-term plans going forward. All of the residents agree, in one form or another, that the project fulfills their basic needs of shelter and security, but some also see it as an opportunity and a good starting point to start anew. One resident shares plans of the future; of getting a home of one’s own, making sense of all that has happened and contributing through lived experiences:
“Resident: Well I've been watching these videos on like these people who are doing tiny houses.
Interviewer: Yeah?
Resident: I would like to live on my land and have a tiny house. Interviewer: Yeah.
Resident: Off grid.
Interviewer: Yeah. But with TV and wifi! (laughter)
Resident: Well because you gotta make videos! That's what I really want to do. I want to make videos. I want to make videos on addiction and meth prevention and basically be like my stories to the world.”
Plans for the future generally include things like these: finding one’s own home, settling down, finding a partner and an enjoyable and fulfilling vocation.
Residents speak of staying abstinent long enough through the support from substance abuse treatment and the services provided at the project to progress in their recovery enough to have safe employment to be able to move into the commercial housing market.
3.4 Drugs & Alcohol
As with many of the past research concerning Housing First, the subject of drugs and alcohol makes its appearance in these interviews as well. While trying to recover from any type of addiction and staying abstinent, easy access to
substances and having people around that uses drugs and alcohol is reported to be something of a hindrance for some in their recovering journey. As the research
site is amongst those that allow alcohol to be brought into the building, that fact becomes even more apparent. One resident shares an experience of trying to stay abstinent, but how the projects’ leniency towards the use of alcohol affects that struggle:
“Resident: It's like consuming my mind right now. [...] It's something I'm going through right now. I'm trying to quit drinking but it's kind of hard. Interviewer: And moving in here, did that make that any easier or harder? Or did it change it at all?
Resident: I want to say it would be easier but it's not. It's harder because there's a lot of people drinking.”
A similar experience is shared by another resident. This resident recalls earlier experiences of the project, a time where abstinence wasn’t as respected among a certain group of residents and saying “No” to being offered alcohol might usher a negative response. Things changed after a few evictions, and the atmosphere went elsewhere:
“[...] In the beginning when I first got here, people were. It was extremely upsetting. Because I would say no and they wouldn't respect that.
Interviewer: It seems pretty mellow around here these days but back then, it had a party atmosphere?
Resident: It did. It was pretty rough. I don't really... Interviewer: How long did that last?
Resident: It maybe lasted maybe 4, 5 months? Interviewer: Yeah?
Resident: It was pretty rough. Interviewer: How did that change?
Resident: I don't know... one, a couple people got evicted and then now everybody that's evicted is partying over at the Townsquare again. So everybody that's in here now, leaves and goes there.”
Another resident shares an experience of abstinence in relation to keeping the provided apartment. As using and getting out of control might lead to a lease violation, of which residents have three before a notice of eviction, the fear of losing residency keeps the abstinence in control. Staying away from drugs makes it easier to keep residency, and while keeping residency it is easier to make changes in life, compared to living on the streets.
“Interviewer: Does living here and having a place to sleep, a place to go crash, does that help you walk away from it?
Resident: Oh yeah, most definitely. Because I don't want to lose this place, you know? It's like a second chance. So it's... yeah basically I'm trying to keep this place. I mean, it's really nice. They definitely care. So it's uh, yeah it's definitely easier when you have a place to stay instead of like being on the streets, I'd just keep going, survival mode. Like keep trying to find something, keep going. You know? Stay alert. Stay awake.”
The resident continues, elaborating on the comparison between using on the street and the need to stay awake and alert, and using while being housed in a safe and comfortable environment.
“Resident: I feel like for me a lot of it, I have to be comfortable where I'm at.
Interviewer: Right.
Resident: Like on the streets I'm not comfortable. Interviewer: Right.
Resident: So I'll try to like stay up so I can stay alert, stay focused. Interviewer: Oh and using helps you stay awake to stay alert because it's dangerous living outside?
Resident: yeah. Exactly.
Interviewer: Wow. Okay. I hadn't thought of it that way.
Resident: To where, like here it's, I try to keep it like a safe zone. I don't really try to invite a whole lot of that in.”
Using while on the streets can be seen as a way of survival, to keep awake and alert when and if dangers come around. Being housed, having a safe and secure apartment with surveillance and staff just around the corner, many of those dangers are taken away, and gives place for relaxation, rest and recovery.
4. DISCUSSION
I will now finally discuss the benefits and shortcomings of the methods that were used for the study, as well as a brief discussion concerning the findings.
Additionally, I will discuss recommendations for future practice with the individuality of the recovery process in mind, and end with a concluding statement.
4.1 Method
The methods used for the study (semi-structured interviews & thematic analysis) has been in line with general qualitative research (Bryman 2012; Creswell 2013; Ryan & Bernard 2003) and has been a contributing factor in the results. By following set and tried instructions for qualitative research design, abstraction of the meanings of statements and experiences shared could be made more
methodically and could be explored and analysed in a deeper fashion than had they been interpreted at face value. Without the work of having to collect data and transcribing the interviews, which had all been done in the earlier overarching study, more time could be spent on analysis, which contributed to a more in-depth analysis and presentation of the material. But even though the methods utilised for the study has yielded good and insightful results, much can be said about the limitations of the way the study was constructed.
First and foremost, the study sample represents interviews with six individuals living at a single permanent supportive housing facility, in part due to the timeframe of the research project (10 weeks) and in part because of the
academical level of the writer (bachelor). Despite the nature of qualitative studies and their case for homogeneity and generalization not being the goal of research
(Bryman 2012 p. 406), care should be taken not to interpret these results as general for Housing First or for the whatever group the individuals might be regarded to represent by any means. The results can be valuable for getting an overview of different experiences coming from residents at Housing First, but they do not represent all of the experiences that Housing First residents possess. Second, the study sample is a part of an ongoing and larger study, studying the effect Housing First has on the local community and its residents. Interviews were set to have a wide scope of study and result in a wide array of elements, such as healthcare, interaction with police, services being provided and reasons for being the victim of chronic homelessness. Therefore the interviews included a large range of material that did not pertain to the questions studied in this thesis due to changes of subject during the interviews, where further questions aimed at
specific experiences might have revealed additional perspectives and insights. The study would have benefited from being a separate study, directing the aim more carefully.
Third, the study sample can be regarded as second hand analysis (Bryman 2012 p. 586-587). While the interviews were being conducted by experienced researchers (philosophical doctorates) and yielded satisfying results, the writer (I) was present neither for the interviews themselves, nor took part in transcribing any of the audio material. Responders' physical expressions and tone of voice were
consequently not part of analysis, where only text versions remained. If this fact would affect analysis in a significant way remains to be discussed, but it should at least be mentioned and noted.
Fourth and final, the writer (me), is the sole interpreter of the study sample, which can bring into question the interpretation of the results. Studies generally increase their reliability if being discussed among a few researchers, where different perspectives can be discussed, collide and viewed (Bryman 2012 p. 390-393), but in the case of this study, this is my own personal interpretation of the material provided. I would also have liked the opportunity for respondent validation
(Bryman 2012; Creswell 2013) (though Creswell uses the term member checking), but due to the distance between myself and the responders along with the state of the world at the current moment in time (Covid-19 pandemic), this was
unfortunately not an option. I have tried to alleviate this fact by including as much of the interview material as possible through the use of the quotes throughout the thesis, so that you, the reader, can confirm or deny if my interpretations are true and within reason.
4.2 Results
As can be seen among the findings from earlier research the opinions and experiences vary greatly and can more often than not contradict each other (Bengtsson-Tops et al 2014; Forenza et al. 2019; Huffman 2018; Kristiansen & Espmarker 2012; Raphael-Greenfield & Gutman 2015). This holds true for this research project as well. Throughout the interviews and following analysis it is clear that the experiences from residents living at the present Housing
First-project contain a large number of multifaceted views. It is therefore hard and inefficient to apply the perspective of residents of Housing First as a homogenous
group who all apply for the same needs and services when the goals and fundamentals are at such varying stages.
Concerning recovery the intervention of Housing First covers most of the
constituents that make up a recovery process. Following the elements of recovery by Onken et al (2007) the support from Housing First and connected services can help the individual find coping skills for mental health issues through treatment, giving an opportunity for healing to take place. Employment services can increase the individual’s sense of meaning and purpose by finding places for fulfilling work opportunities and contribute to distractions of the mind, shifting the focus from thoughts of addiction and self harm. Social circumstance that comes with living close to others going through a similar journey can bring the individual hope and a sense of potentiality by seeing others achieve goals and
accomplishments that one might find insurmountable in the current situation. It can also foster social relationships, another crucial part of recovery (Topor et al. 2011), both through the proximity to others who have been through similar things, but also through having a safe place of stay for friends and family to visit.
Services and the closeness to others can also shed light on different options for recovery that the individual might not have been aware of. Lastly, what
contributes most is the availability of different options for recovery, and that the individual’s sense of agency is valued above all during the process of recovery.
4.2.1 The individual journey & recommendation for practice
Considering the individuality of recovery and the wide variety of needs and services that must be in place for treatment to be as effective as possible, along with the fact that each research project pertains specifically to the experiences of the site in question, it’s hard to recommend specific services for general Housing First practice across the board. For organizations wanting to serve a lot of
different residential needs it can lead to a lot of time and resources spent on services not being utilized, resulting in financial ineffectiveness or losses. I will therefore stay away from recommending specific services targeting general practice and leave that topic to those more knowledgeable.
What I recommend is similar to what Bengtsson-Tops et al (2014) concludes: that organizations and services working with residents of Housing First investigate their internal needs and ranson their inventory targeting those needs specifically. My meaning is that staff and services should continually communicate with residents in order to explore their individual goals, narratives, personal strengths and service requirements in order to be able to support their residents, not residents of Housing First in general, in order to address the present residents needs and avoiding labeling residents as non-compliant when offered services currently on hand (Slade 2009; Deegan 2007). This could be done by holding regular meetings with staff and residents where questions and ideas are shared for improving or restructuring services, akin to innovative forms of collaborations mentioned by Amering & Schmolke (2009), as well as appointing resident-lead committés who act as spokespersons for residents at professional meetings in order to promote engagement. Recruitment of staff with lived experience would also help bridge the gap between professionals and residents, sharing personal expertise and acting as a beacon of hope through the role of peer supports (Davidson et al. 1999). These steps would put the residents in the front-seat of knowledge, meaning the organization would take a less dominating role by
empowering residents and not taking a “we know what’s best”-type of stance, while also respecting the individual's right for choice and personhood. After all, in the words of William A. Anthony (2014): “people with severe mental illnesses are people”.
4.3 Conclusion
Even though the intervention of Housing First seemingly fulfills most of the elements of recovery, some changes could be made to advance Housing First practice on the individual level. Through the work of this research project along with earlier research, it becomes clear that the subjective experiences of residency within Housing First are multifaceted, at varying degrees and sometimes
contradictory. Additionally, the requirement of services seems to be different among residents. Using the perspective of residents of Housing First as a
homogenous group who all require the same services therefore seems ineffective to be able to support the process of recovery. In order to provide the highest level of support, Housing First organizations should continually investigate the needs of residents and ranson their inventory accordingly to meet the requirements at hand in favor of aiming to provide service to Housing First residents en masse.
