Participants in the Housing First program were able to obtain and maintain independent housing without compromising psychiatric or substance abuse symptoms.

The literature on homeless adults with severe mental illness is generally silent on a critical issue surrounding service delivery—the contrast between housing first and treatment first program philosophies. This study draws on data from a longitudinal experiment contrasting a housing first program (which offers immediate permanent housing without requiring treatment compliance or abstinence) and treatment first (standard care) programs for 225 adults who were homeless with mental illness in New York City. After 48 months, results showed no significant group differences in alcohol and drug use. Treatment first participants were significantly more likely to use treatment services. These findings, in combination with previous reports of much higher rates of housing stability in the housing first group, show that “dual diagnosed” adults can remain stably housed without increasing their substance use. Thus, housing first programs favoring immediate housing and consumer choice deserve consideration as a viable alternative to standard care.

This article compares two approaches to housing chronically homeless individuals with psychiatric disabilities and often substance abuse. The experimental Housing First programme offered immediate access to independent housing without requiring psychiatric treatment or sobriety; the control Continuum of Care programmes made treatment and sobriety prerequisites for housing. A total of 225 participants were interviewed prior to random assignment and every 6-months thereafter for 2 years. Data were analysed using repeated measures analysis of variance. Participants randomly assigned to the experimental condition spent significantly less time homeless and in psychiatric hospitals, and incurred fewer costs than controls. A sub-sample recruited from psychiatric hospitals (n ¼ 68) spent less time homeless and more time hospitalized, and incurred more costs than a subsample (n ¼ 157) recruited from the streets. Recruitment source by programme interactions showed that the experimental programme had greater effects on reducing hospitalization for the hospital subsample and reducing homelessness for the street sub-sample. Three-way interactions including time indicated that in the experimental group, hospitalization and homelessness declined faster for the hospital and street sub-samples, respectively, than for comparable controls. Overall results support the Housing First approach.

This study tests components of Wong and Solomon's (2002, Mental Health Services Research, 4(2), 13-28) model of community integration, identifying both the dimensions and predictors of integration. It evaluates community integration among adults with psychiatric disabilities assigned randomly to receive either independent scatter-site apartments with the Housing First approach (experimental) or services as usual (control). Factor analysis supported a definition of community integration that includes psychological, physical, and social domains, but also suggested the existence of another factor, independence/self-actualization. Regression analysis suggested that choice and independent scatter-site housing were predictors of psychological and social integration respectively. Psychiatric hospitalization, symptomatology and participation in substance use treatment were also found to influence aspects of integration. We discuss several issues that future studies should explore including the possibility that the same factor can differentially influence discrete aspects of integration, the role of person-environment fit, integration that is not based in the neighborhood, and, finally, conceptions of community integration from the perspective of consumers themselves.

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