Dr. Deborah Padgett – There Is a Solution to Homelessness

I'm curious. I'm curious. Welcome to Curious by Nature. I'm Jessica Johnson from NewsWise. People experiencing homelessness in the US face a wide range of challenges related to their housing situation, including mental health issues and addiction. Public debates over homelessness are often fraught with stigma, prejudice, politics, and ultimately it seems that little progress is made. When we look past our assumptions, what does the data say about how to solve the housing crisis? It's hard to measure and there are many variables at play, but one researcher at New York University is studying ways to prove the effectiveness of solutions like housing vouchers and assistance programs. Dr. Paget, welcome and thanks for joining us. Please introduce yourself. My name is Deborah Paget. I'm a professor at the Silver School Social Work at New York University. My work is at the intersection of homelessness and serious mental illness and also sadly substance use. So the focus is on the homeless population and my interest in this came from a big career turn for me. I came to New York City in the mid 80s to accept postdoc and public health. This was when homelessness was becoming a serious problem in New York. But meanwhile, a colleague of mine named Sam Semberis in 1992 founded what's called housing first. The approach which now is both our national policy and many, many countries around the world. At the time, homeless people, their only choice was to go to a shelter and gradually make themselves worthy of housing which could take months or years or never. And by worthy, I mean clean and stover, taking all their sight meds and so forth. This was a recipe really for stalling. Basically, these are people who go through the circuit. They're in jail for a while. Then they go to the hospital or the shelter. It's extremely expensive. I want to mention that doing nothing with homelessness costs a lot of money. But Sam founded Pathways to Housing. It was called and it was a real revolutionary approach. It was basically go to people who are homeless or in shelters with serious mental illness and offer them immediate access to an apartment. So I became very involved in Pathways to Housing and Housing first and kind of branched off on my own in the early 2000s because most of the research being done was what we call randomized clinical trials. You know, they take one group and randomly assign them to Housing First and the other group to care as usual. Very statistical outcomes. The early trials were showing amazing findings that up to 80% of those placed in their own apartments were still in those apartments a year later, which most of my colleagues in psychiatry, social worker, they said that's not possible. You can't put a crack using person with schizophrenia in an apartment, expect anything but a disaster. How your colleagues didn't think that drug users with also mental health problems would be maintaining and staying in their homes. Tell me more about that. Why did it actually work? It's a very good question. Even today, you have many people saying Housing First can't be real. It doesn't work. It's responsible. There have been some more conservative think tanks that have really come out, really come out. But they have no counter evidence. This is what we rely on in making sure our policies are evidence informed. And the fact that Housing First has been undergone, not only in randomized trial in New York City, but throughout the whole country of Canada. France, most of the countries of Western Europe have done assessments of Housing First, largely in quantitative, like what's their symptom levels, how much are they drinking, and sort of numerical measures. I was more interested in kind of the texture of their lives and the day-to-day ways that they recovered, but they also could have fallbacks and relapses. And I think what distinguishes the Housing First approaches, people are people. We all make mistakes. But the longer we stay with them and help them recapture their lives, the better off they are. And only, like I said, it's been almost eerie that every randomized trial, and now there are dozens of the bars I know. I haven't kept track of numbers, but every country in Europe is studying. It always puts them with an 80 to 90 percent success rate. And by that, I mean, at the end of one year, all of the people in Housing First Apartments are still housed. Whereas at the end of that year for people who are in the traditional care, which is shelters, congregate living streets, and so forth, maybe 40 percent at best would have found housing by the end of the year. You said also about how the costs of having people on the streets and through traditional means of waiting for housing to come up and being in shelters that it's expensive. So maybe people believe that the Housing First option is expensive. Is there research to show how possibly the Housing First is less expensive? Absolutely. Probably I would name first and foremost my colleague, Dennis, Dr. Dennis Collhane at the University of Pennsylvania. I was spearheaded this research, but others have as well. And they take what the costs are per capita or over time for housing first. And remember, like I said, if it's not housing first, then they're on the streets, basically. And it means they spend a lot of time in emergency rooms, jails, shelters. If you take any one of these sites, a jail or shelter, particularly in New York City, or an emergency room, you are running hundreds if not thousands of dollars, really thousands dollars a month. The average cost of a shelter bed in New York City, which is a rather narrow cot, is $3,000 a month. So I don't see how you can even make a comparison that for $3,000, how much you could do with someone rather than put them in an unsafe, unhygienic shelter. New York City has a multi-billion dollar homeless budget. And we are to be commended for having housing shelter as a right, not housing. But shelter as a right has turned into this huge, what I call it, industry. Funds of nonprofits that depend upon contracts from the city, which are both city funds, state funds, and then federal monies from HUD to keep running these congregate types of housing arrangements. If you have a serious mental illness, such as schizophrenia, bipolar disorder, you and New York's day are eligible for what they call supported housing. And that is financed heavily by the state of New York and the city of New York with federal monies as well. You had a recent publication with miracle friends and miracle money. Can you give more details about that and tell me about the conclusion about that? Well, I'm really proud to say that the principal investigator that studies a former student of mine, I feel very good about my progeny. As big as Ben Henry Wood, he's the University of Southern California, such a word. And it's UCT, unconditional cash transfer, which has been done around the world with poverty, stricken people, and in different settings. And is now being thought of as possibly a way to help people who are homeless without having to go through this whole bureaucracy, just give them cash. Right. I was going to say it earlier and I will say now for sure, there's great skepticism about this because there are books out now about how homeless people are needle users, they're irresponsible, they're unhygienic, you know, they're using drugs and alcohol to excessive degrees. So they've been kind of demonized. And so you can imagine developing a program that gets cashed to these individuals as somewhat controversial. The UCT study I'm on with Ben is a randomized trial again, but this is a spin off where I'm doing the qualitative portion of that study. So the bottom line is the treatment condition is what's called miracle money, miracle messages. This is the name of the donor and the factor. And it consists of giving a sample of individuals $750 a month for a year. And it's unconditional. Now they are asked not to spend on, you know, temptation goods as they're called, but what I wanted to do is use a wave of one and two qualitative interviews. One at the beginning of the money cash and it won at the end of the cash transfer and just talk to people about what are you doing what we're doing with the money or what is your life life. So what we found in the first wave of qualitative interviews, first of all, is they are deeply grateful for that. We all know that $750 a month is not going to pay your rent, not even close. So it's not as if you know they're being provided with housing. So we thought what would they spend the money on and what we found is is so I don't know what the word is. You can say counter intuitive but I would like to say it is almost intuitive. They're spending the money on paying off their phone bills, paying for storage where their possessions are being kept. Some of them since this is LA wanted to buy an old used car. It was very touching when they said I can buy the car. If I buy a car I can go to a job because you can't get around LA without one but also I can sleep in it. You know how many of us go around thinking of a car as a house or home. Well several of our people were sleeping at cars. So they were very honest that the money wasn't sufficient but they most of them were deeply gratified and we're beginning to look at the second wave of interviews and they're saying things like this really took a lot of stress off of me and it gave me breathing space. You know to pay off some bills, improve my credit rating because even if they were ever to get a housing voucher which you know the federal government provides, housing rental vouchers, sometimes local governments, you have to find a landlord willing to take it and if you have a bad credit rating or you know incarceration in your history no matter what rental voucher you have you're going to have trouble getting housing. So they were trying to improve their credit ratings. Several of them found part-time jobs. They were able to carry out a lot of them just bought clean and new clothes and more nutritious food because their lives on the streets are largely reliant on the cheapest of fast foods which are probably the least nutritious. There was no sign of like you know squandering it on a big night out or blowing it in Las Vegas or whatever you might think they might do they did not do. It could be argued that they're telling us what they think we want to hear but to me one of the strengths of qualitative methods is we work on trust with that person and give them the sense that we honor what they're saying and are not there to criticize or to judge and I think that goes a long way towards that person feeling like well I'm gonna you know tell them what I did with the money but we couldn't come up with many you know stories of squandering and bad judgment. Can you speak a little bit to the recent Supreme Court decision and how maybe that's affecting homeless of this now and I guess first describe what the decision was. It's called grants pass the decision for short for a small town in Oregon that basically was taking people sleeping out of doors and arresting them and there was at the time the ninth circuit which is the Western probably the United States had on the books a decision that you cannot arrest a person for sleeping you must have you must have a shelter bed or something for them but you cannot arrest them as it's not criminal sleeping public if you don't have a shelter bed or anything and the town of grants pass had nothing no shelter anything for people. So the recent the grants pass decision sadly in my opinion is the Supreme Court affirmed the right of cities to criminalize homeless people and mostly that means sleeping in public. If they are let's say sleep in the open and showing signs of mental illness the either your voices their you know their appearance is very unhygienic and so forth and there's clear evidence of that the idea is to take them to a psychiatric unit in either in a hospital or if there is a psychiatric rehab residential center well most of those a lot of those places at least in New York City gave their beds over to COVID so they don't even have psychiatric beds or the staff psychiatrist and so forth. If they do have an empty bed generally the local laws are usually you can only keep these people against their will for a period of time. Now if they're showing a you know a great deal of violence and not stabilizing with medication they might stay longer but no it's not not in jail per se they must take them to a to so you know being and being virtually incarcerated for mental illness is itself problematic but there are some conservative think tanks in the country that feels that people with mental illness would do better in a sort of a locked ward type environment. I live in Charlottesville, Virginia and it seems like there's right now a lot of tension within the community about homelessness. Yeah. What would you recommend for a community like Charlottesville? I mean I assume that small cities like Charlottesville and what's happening here is probably common around the country but what would you recommend to communities like Charlottesville and how to handle the local issue of homelessness? Well I'm well aware of the difficulties the nimbi the not in my backyard the tremendous fear of having a men's shelter or a women's shelter or a kind of red housing and California is really confronting this too by the way but amid mid-sized community like Charlottesville there are places as a matter of fact Charlottesville, North Carolina that have used housing first to significantly reduce the homeless population and then there are two cities Milwaukee and Houston who that have really put all the resources into helping people in a number of ways but mainly through housing that have reduced the street population dramatically and it is housing first. So I guess I would say that a city like Charlottesville can still benefit from housing first but you do have to work closely with the real estate boards and the city and county commission even the police department and all these places and get by and so to speak. Like I said I think this is possible with the institutional side with the courts Milwaukee did that by combining the parks department the courts the district attorney we're all going to focus on helping these people and not criminalizing them more. I think in smaller places there's a little bit more power of interest groups that have that are against housing first and I can only say that I can give examples outside of United States but Milwaukee and Houston are examples of places that really rallied and through not in my backyard is to me very interesting because in New York it's a little harder to do that especially the pathways to housing because they were scattered throughout the Bronx and Brooklyn and you know they were neighbors your neighbors. What people don't like are these concrete you know whole building given over to people. I heard you say that housing is necessary for health and also therefore for mental health and so in addition maybe to cost or not in my backyard are there other reasons why societies or communities aren't interested in going with housing first. To me the objections tend to be almost like value-based judgmentalness that these are weak people or these are people that don't know how to make they make bad decisions that's what we're all the time they've made bad decisions don't blame society for you know for all of that they're just weaker people and they're just given to these you know forms of diversion which are very damaging. Sometimes it's faith-based organizations that have difficulty with harm reduction is sometimes those are the organizations that give the most health. I guess one example I would use of housing first being a true success because it was full on committed is in the Veterans Administration because it was embarrassing that we had I forget how many it's close to 100,000 I think veterans homeless I mean these are men and women who serve their country now sleeping under a tree or in a car. So HUD and the VA formed HUD housing and urban development and the VA paired together to form what was called the HUD VASH program and they aggressively outreach to homeless veterans and they provided rental vouchers to every one of them. Housing first is a program to help people but it doesn't always have money for housing as as much as we'd like but the HUD VASH program was it reduced somelessness by over half in a period four or five years. It really. gave the, you know, proof that can be done if you put enough support into it, including a rental voucher. That's a true success story, but sometimes people are traffic more in fear and others and don't necessarily believe randomized trials or I mean, you know, this is our scientific evidence side. And that often impresses policymakers, but they also hear anecdotes. I'm really happy to hear about cases where it has worked and where there are cities that they're finding solutions. I didn't know that and from the news and media and, you know, the information that I've seen it, it seems like what can possibly be a solution. I hope that more local governments and state governments can help can listen to the research that you and your colleagues are doing and see how it can even make financial sense. Even that if it's not about humanity, right? Yeah, it's we've got we've got a ways to go in the funding end, but even the funds that are out there in the billions could be better spent. And I think that's the tough decision is to convince to have the political will, if you're on the city commission, county commission, state commission, legislative, political will to divert those funds as hard once them to at least for now away from building more shelters and just pushing the problem for other further down the road. Thank you so much. Curious by nature is a production of news wise more than 7,000 journalists get the news wise wires. Visit newswise.com and find out how to spread your news today.