US Foreword — Creating a Common Language

The “Housing First” movement, like most social movements, grew out of a sense on the part of many that something in society was fundamentally wrong. In Massachusetts, I witnessed the late 1980s and early 1990s from the views of those in the trenches responding to unaccompanied adult homelessness. One had to be particularly insensitive, or wholly blinded by the conviction that they were involved in some noble mission to shelter the poor, to not understand that something had gone fundamentally wrong. Homelessness represents the failure of multiple systems of care, especially those systems meant to serve people whose lives had been impacted by serious behavioral illnesses and disorders.

For me, working those days at Boston Intake, the Newton Overflow Shelter, and eventually Father Bill’s Place in Quincy, Massachusetts, it was a shocking revelation to see the number of people with serious mental illness simply cut adrift. How does one explain the frustration of trying to have a person in the midst of a psychotic episode evaluated, only to be told from the clinician at emergency services that you would have to transport the client to a hospital or a police station because the clinician did not feel safe coming to your shelter?

During those times, people with serious mental illness were being directly discharged to homeless shelters. There were few opportunities for residential programs, and often the subtle or sometimes explicit message was that the person was not “housing ready” or even program ready. They were seen as noncompliant clients. It was painfully apparent that such “clients” would never improve their wellbeing if the system was built around clinicians sitting in clinics waiting for these people to show up and say they needed help.

Over time, this realization grew among many of us serving homeless individuals. We asked: “What if we tried using our various housing resources to house them?” This idea was not grasped by all; there was hardly universal acceptance for such a concept. Those who opposed it felt that these individuals were not capable of sustaining housing. Some argued that an urban shelter was the best you could ever expect for this population. Some even promoted the idea that shelters should be considered an acceptable urban housing niche. Fortunately, a critical mass of homeless providers did not share this view.

Yet, once committed to the cause, then what? How should we reach out, approach homeless individuals and serve them in such settings? What expectations should we place on such tenants? Out of this questioning, our own particular form of “low-threshold” housing grew into place. The Massachusetts Housing& Shelter Alliance (MHSA) advocated for and began an effort to shape a statewide movement to make Housing First a reality in the Commonwealth. MHSA’s founding Executive Director Philip Mangano’s early advocacy for the conversion of resources toward housing and services emerged as the national vision of Housing First. Not only would housing result in a reduction of costly emergency and acute resources across systems of care, it would actually improve peoples’ chances for recovery. Over the past ten years, MHSA, with the vital work of agencies across the Commonwealth, is proud to have been a part of housing nearly 2000 people who were chronically homeless. The claims of cost savings have been substantiated by a number of different studies (Byrne and Smart, 2017; Wright et al., 2016; Buchanan et al., 2009; Larimer et al., 2009).

But, this is not the whole story of how such an approach came to be. The emergence of any great innovation has a complex causal structure. From my perspective, the low-threshold approach to housing would never have emerged in Massachusetts without the long practice of clinicians committed to providing outreach to the very population described above. The core wisdom of accepting people where they are, without judging or pigeonholing them, grew from the work of clinicians engaged with the Department of Mental Health (DMH) Homeless Outreach Team in Boston, or the work of Projects for Assistance in Transition from Homelessness (PATH) Counselors across the Commonwealth, which proved that one could connect, communicate and inspire people to seek the resources they needed.

My own perspective on the possibilities of low-threshold housing was often reinforced by outreach counselors sharing their personal experiences with me. They, too, seemed to know that the conventional and institutional approaches had failed. I think it was their approach, honed in the urban streets and alleys, under bridges, and in the forests of our rural areas, that shaped housin