The traditional approach to homeless services has operated on a "treatment first" or "housing readiness" model: people experiencing homelessness must demonstrate sobriety, treatment compliance, or other behavioral criteria before accessing stable housing. The logic is intuitive, ensure stability before providing the benefit. The evidence does not support it.
Housing First, developed as a clinical program in the 1990s, reverses the sequence: stable housing is provided first, without preconditions, and wraparound services are offered (but not required) after housing is secured. The reasoning is that the conditions necessary for addressing behavioral health, substance use, and other challenges, safety, predictability, privacy, basic physiological needs met, can only be created by stable housing, not as a prerequisite for it.
The evidence
The At Home/Chez Soi study, a randomized controlled trial conducted across five Canadian cities, is the most rigorous evaluation of Housing First to date. It found that Housing First participants were stably housed significantly more of the time than those receiving treatment as usual. Community functioning improved. There was no evidence that providing housing without preconditions increased substance use or reduced treatment engagement. Mental health outcomes improved modestly.
The economic evidence is also favorable. Emergency room visits, hospitalizations, and incarceration are all expensive. Studies consistently find that Housing First programs produce cost savings in these domains that partially or fully offset the cost of housing provision. The argument that society cannot afford to house people experiencing homelessness underestimates the cost of not doing so.
