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Thu, Jun

The Pseudoscience of Housing First

LOS ANGELES

iAUDIT - From the early 1800’s through the first decades of the 20th century, the “science” of phrenology enjoyed sporadic periods of popularity.  Phrenology measures bumps on the skull to predict mental traits, such as intelligence and criminal behavior.  Although it may seem preposterous to us in the 21st century, phrenology was widely considered serious science in its time. In the early nineteenth century, scientists began discovering specific parts of the brain controlled distinct functions, from processing visual information to emotions.  It seemed logical that the more a person displayed certain traits, the larger that part of the brain would be, and therefore the structure of the skull would reflect dominant and recessive brain development. 

Phrenology was supported by (for the time) rigorous scientific testing.  Phrenologists studied thousands of people and documented the relationship between skull bumps and traits ranging from learning ability to criminal psychopathy.  Phrenologists wrote long scientific studies that were published in legitimate medical journals.  Several phrenological societies sprang up in Europe and North America.   Elaborate charts showing spots on the skull that corresponded to psychological traits could be found in many doctor’s offices. By all appearances, phrenology was as legitimate as any other physiological science. Except it was complete hogwash.

As early as the 1840’s, serious scientists were debunking phrenology.  Experiments on lab animals showed there was no relationship between skull bumps and brain function. Phrenologists themselves rarely agreed on what locations on the skull corresponded to the areas of the brain they were supposed to match.  Although it enjoyed sporadic revivals into the early 1900’s, especially among racial theorists and supporters of eugenics, it was rejected by mainstream science well before the turn of the 20th century.

Phrenology is an example of pseudoscience supported by research bias. Pseudoscience is defined by the Oxford Dictionary as “A pretended or spurious science; a collection of related beliefs about the world mistakenly regarded as being based on scientific method or as having the status that scientific truths now have.”  The true scientific method creates a hypothesis and collects evidence to prove or disprove the hypothesis. Research bias turns the scientific method on its head, by assuming the hypothesis is correct, and then looking for supporting evidence. Supporting evidence is usually based on observations after the fact rather than testing to determine a link between cause and effect. Contradictory evidence is ignored or explained away as irrelevant.

Housing First is a newer entry into the realm of pseudoscience.  Apparently based on compelling evidence of success, it has shown very little objective proof of real accomplishment after more than 20 years of experience. Initially, Housing First showed signs of great success. A 2018 study by the National Academy of Sciences found that people accepted into No Barrier Permanent Supportive Housing (PSH) were much more likely to receive sustained supportive care than people who were given care before, or as a condition of, receiving housing. The US Interagency Commission on Homeless (USICH) said Housing First, when properly structured and used as one of various methods in a “toolbox” of interventions, is effective. The model was thought to be so successful, HUD adopted it as the federal government’s official housing policy in 2013, focusing most homelessness funding at Housing First programs.  The State of California followed suit in 2016, requiring local agencies to make Housing First the cornerstone of their intervention programs.

However, after initial signs of success, other rigorous studies began to find cracks in the Housing First model.  One, a Stanford Economic Policy Institute report from May 2022 cites other studies that state “Housing First showed no effects in reducing drug use, alcohol consumption, psychiatric symptoms, or enhancing the quality of life (Rosenheck et al. 2003; Mares, Greenberg, and Rosenheck 2007; Stergiopoulos et al. 2010).”  An August 2022 National Institute of Health study states “that there is no substantial published evidence as yet to demonstrate that PSH improves health outcomes.”  The NIH study is particularly interesting because it states there are positive health outcomes when Housing First is part of a whole-person service package that includes medical, mental health and recovery support as needed.  Consistent with Housing First’s original model, the study says people placed in permanent supportive housing and who receive appropriate support services are more likely to stay housed longer, and experience fewer health problems than those left on the street.

And therein lies the logical fallacy behind Housing First.  To be successful it must be part of a package of support services tailored to the individual.  Housing First advocates would have us believe the mere act of placing a person in a “home” makes a positive outcome more likely. In fact, proper services are the key to successful housing placement.  The consequences of failing to provide needed services can be seen writ large in the recent financial collapse of the Skid Row Housing Trust, due in large part to the cost of repairs needed after residents experienced psychotic breaks.  It can also be far more personal, as in the case of Bryan, a troubled soul whom the system failed.

Phrenology depended on anecdotal evidence to prove its theories.  Phrenologists would “prove” its legitimacy by studying a criminal’s skull and then claiming the bumps on his head matched the brain areas that predisposed someone to criminal behavior.  Likewise, Housing First advocates often cite anecdotal stories as proof of overall success. Many news stories about Housing First include a tale of one or more individuals who are benefiting from a place of their own after months or years on the street. Reporters rarely return months later to see if the individuals are still housed.  

When subjected to more rigorous review, Housing First isn’t the success it claims to be.  An April 2021 research paper from the journal Medical Care, published by the American Public Health Association, followed 73 chronically homeless people (the population Housing First targets), over a period of several years, and “found that housing retention was 82 percent after one year, but fell dramatically to 36 percent after five years, and to just 12 percent after 10 years. Long-term outcomes for this permanent supportive housing program for chronically unsheltered individuals showed low housing retention and poor survival.” Shockingly, the journal stated, “Nearly half of the cohort (45%) died while housed [my italics]. The co-occurrence of medical, psychiatric, and substance use disorder, or “tri-morbidity,” was common”.  A 2021 report from the Independent Institute, which included the findings from Medical Care, cited other objective studies documenting Housing First’s failure to achieve the long-term outcomes it promises.

Depending on the survey source, anywhere between one-third to three-quarters of LA’s unhoused have underlying mental or substance abuse issues. Because Los Angeles operates under the Harm Reduction/No Barrier Housing First model, people with serious behavioral and drug issues have no obligation to accept support services before being housed, and therefore are the ones who often end up back on the streets—or dead.  Service providers refer to this group as “service resistant”, people who cannot make decisions in their own best interest or prefer life on the streets for other reasons. When they are placed in housing, their erratic behavior quickly requires their expulsion. Occupants without behavioral issues, especially those with children, are forced out by their neighbors’ behavior.  A study by the National Institutes of Health followed 242 people through New York’s Housing First program, and found 88 percent remained housed after five years, as opposed to 47 percent who did not receive services.  However, the study points out those 242 people were part of a program that required commitment to treatment while housed. In Los Angeles, support services are not only voluntary, they are rarely provided at the levels needed to keep someone housed and stable.

The true scientific method looks at evidence over time.  It also looks for repeatability.  If a theory is correct, applying the same methods to the same set of circumstances will always produce the same results, and the result will not change until a new set of circumstances is applied. Water always boils at 212o F, and it will continue boiling until the heat is reduced or the water is cooled by outside factors. Applying those criteria to Housing First, we can see what an appalling failure it is.  Since Housing First became HUD’s official policy in 2013, homelessness has steadily increased. Specifically in Los Angeles, both the City’s and County’s budgets have skyrocketed as homelessness exploded.

The more resources are dedicated to Housing First, the more people become homeless. This is due to a number of factors, but as a 2022 report from the City Controller mentioned, new construction is consuming so much of the homeless intervention budget, little is left for other services like transitional shelters.  This is indicative of a national trend; in October 2020, the US Interagency Council on Homelessness noted that the number of shelter beds declined precipitously after Housing First became official federal policy as funding shifted to construction. Using the boiling water analogy, it’s as if someone uses a flame too low to reach 212 degrees.  Rather than increasing the flame, they pour more water in the pot and can’t understand why it never boils.

When Housing First is used to justify new construction, it increases program costs, delays housing, and leaves people on the streets.  The cult-like belief in Housing First can be summed up in the oft-heard mantra that “only housing solves homelessness”, which carries the same intellectual weight as saying only water puts out a fire. Housing may be the only way to cure homelessness, but building new housing isn’t the only way to get someone into a home.  It could be as simple as writing a check so someone can stay in the apartment they’re in danger of losing. It could be providing transitional housing until someone gets a job and stabilizes their financial situation. Going back to my analogy, using only Housing First is the equivalent of boiling a pan of water with a flamethrower.

In the 19th and early 20th century, the pseudoscience of phrenology was used to justify eugenics and racial policies with devastating human results.  The pseudoscience of Housing First is responsible for leaving people to languish in camps and derelict RV’s, and to die at the rate of six per night. Unless we subject Housing First to the same rigor we apply to any scientific theory, things will only get worse.   

(Tim Campbell is a resident of Westchester who spent a career in the public service and managed a municipal performance audit program.  He focuses on outcomes instead of process.)

 

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