In this excerpt from the March/April edition of Mental Health Today Magazine, Gael Scott considers if the US ‘Housing First’ model could provide better outcomes than traditional models for securing stable accommodation for offenders with mental health problems? To read the article in full click here to subscribe.
Many people in contact with the criminal justice system have a range of complex and interrelated needs, including poor mental and physical health, substance misuse, homelessness, unemployment and histories of trauma. An estimated 90% of prisoners have a mental health issue, substance misuse problem or personality disorder, while 70% have two or more of these problems and one in 10 are affected by severe mental illness.
Homelessness is linked to both poor mental health and offending, with one often compounding the other. Without a safe and stable place to live, people with offending histories and mental health problems are more likely to get trapped in a cycle of crisis and crime, becoming increasingly isolated from the services that they need to rebuild their lives (Centre for Mental Health, 2011).
Although research and policy have emphasised the importance of stable accommodation for improved mental health and reduced reoffending, there remains an absence of clear pathways into stable accommodation for offenders with mental health problems. Moreover, the evidence base for housing interventions for people with complex needs, including people with mental health problems, remains limited.
But lessons could be learned from the ‘Housing First’ model in the United States – a model based on the premise that housing is a basic human right, where clients with complex needs are directly placed into independent tenancies. This stands in contrast to the traditional approach in the UK, based on a ‘treatment first’ philosophy, where people progress through different levels of transitional housing before being placed in independent housing. However, no single model is likely to be effective for all and more research is needed on what works for particular groups, including offenders with mental health problems.
Barriers to stable accommodation
Nearly one third of prisoners have no accommodation on their release (Niven & Stewart, 2005). A small-scale study by Revolving Doors Agency (2002) – a charity working to change systems and improve services for people with multiple problems, including poor mental health, who are in contact with the criminal justice system – suggested that this figure could be higher for prisoners with mental health problems, 43% of whom had no fixed address on leaving prison.
There are obvious barriers for offenders in accessing stable accommodation, particularly for those who have been in prison. For example, people can be moved to another prison or released at short notice, making it more difficult to plan housing support. Furthermore, accommodation-related advice services that are available in prison are often not able to meet the level of demand.
‘Treatment first’ or ‘housing first’? In the UK there are many different models of housing support for people who are homeless or at risk of homelessness. However, in general a ‘linear’ and ‘treatment first’ approach to housing prevails (Johnsen & Teixeira, 2010). This approach essentially involves ‘progressing’ people through different services, including temporary emergency shelters, transitional housing and supported housing, towards independent living. As people move through projects, the support they receive is reduced at each stage. Progress is conditional on a number of factors such as sustained abstinence from substance misuse and people are only placed in independent housing when they exhibit sufficient ‘housing readiness.’
The effectiveness of this approach for people with complex needs has been questioned, particularly as it does not appear to fit with the variable process of recovery from mental illness and/or substance misuse problems. Indeed, there is little evidence demonstrating the effectiveness of a treatment first approach for people with complex needs (Johnsen & Teixeira, 2010).
Existing evidence, which comes largely from the US, suggests that the Housing First approach significantly improves housing retention rates. However, the evidence is more mixed in relation to clinical outcomes. For example, Tsemberis et al (2004) reported no significant differences between Housing First clients and those receiving normal linear provision in terms of mental health symptoms, quality of life, and drug and alcohol use. Further, there is a lack of evidence regarding which subgroups are most likely to experience positive outcomes through Housing First approaches (Johnsen & Teixeira, 2010).
There is a sense in the UK that some providers have already adopted a ‘Housing First-ish’ approach. However, Johnsen and Teixeira (2010) found mixed views among stakeholders about the potential efficacy of the Housing First model in the UK. Some stakeholders were also concerned that the approach places too great an emphasis on housing need, which could sideline other needs such as relationships and social networks.
A stable home provides a sense of identity and belonging, giving people a base from which they can rebuild their lives and move out of a cycle of crisis and crime. There is a growing view that the prevailing ‘treatment first’ model in the UK does not necessarily support the recovery of people with complex needs. It is therefore promising that a number of providers are exploring alternative forms of housing support, including the Housing First model.
However, such developments need to be robustly evaluated in order to understand what works for different groups. The current constraints on public spending underline the importance of ensuring that commissioners and providers are able to design and deliver services on the basis of good quality evidence about the effectiveness and cost-effectiveness of different interventions.
It is also crucial that homelessness is no longer seen as just a problem for housing services – tackling and preventing homelessness is crucial for improving the well-being of local populations and building safer communities. Housing, health and criminal justice agencies need to develop a greater understanding of each other’s cultures and working practices and embed joint working at all levels, in order to ensure that vulnerable people receive the support that they need to get their lives back on track.
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Centre for Mental Health (2011) A Place to Live: Securing stable accommodation for offenders with mental health problems. London: Centre for Mental Health.
Homeless Link (2011) Survey of Needs and Provision (SNAP) 2011. London: Homeless Link.
Johnsen S & Teixeira L (2010) Staircases, elevators and cycles of change: ‘Housing First’ and other housing models for homeless people with complex support needs. London: Crisis.
Niven S & Stewart D (2005) Resettlement Outcomes on Release from Prison in 2003. Home Office Findings 248. London: Home Office.
Revolving Doors Agency (2002) Where Do They Go? Mental health, housing and leaving prison. London: Revolving Doors Agency.
Tsemberis S, Gulcur L & Nakae M (2004) Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health 94 (4) 651–656.