Pathways to housing the homeless

In the hallway of Pathways to Housing, a loud, chaotic office in East Harlem, Hughes Smith can't stop talking about his furniture: "It's unbelievable," he says.

It's not often that someone brags about 10-year-old futons. But for Mr. Smith, shuffling down the hall wearing a tan baseball cap and yellow headphones, permanence is something to celebrate. "After being homeless so long," he explains, "you just don't believe it." His L-shaped studio, blocks from the East River and boasting three big closets, still dumbfounds him.

Since 1993 – "nine years, March 31st," he announces – Smith has been a client of Pathways to Housing, which offers apartments to mentally ill homeless New Yorkers.

Pathways doesn't require medication, abstinence from drugs or alcohol, or use of social services – a leniency that flies in the face of conventional demands that the homeless demonstrate "housing readiness" through sobriety, psychiatric visits, even cooking skills before they're provided with a place to live.

Instead, Pathways runs on a "housing first" model, with the philosophy that before someone can work toward recovery or employment, a safe, comfortable home is necessary.

Such programs as Pathways, which offer permanent housing with optional support, gained a foothold in the 1990s – bursting from almost none in the 1980s to 114,000 beds nationally in 1996.

Sam Tsemberis launched his program in 1992 with 50 apartments, a PhD in clinical community psychology, and a $500,000 grant from the New York State Office of Mental Health.

Today, the grants total $7.2 million and the program has an 85 percent success rate, he says.

Each night, about 800,000 Americans are homeless, and 31 percent of homeless adults report both mental-health and substance-abuse problems; an additional 32 percent struggle with one or the other. Those with addictions generally go through detoxification programs an average of 11 times. These are, typically, the hardest to house: Turned away by programs that demand sobriety or a clean bill of health, many people with these problems have spent years on the streets or in psychiatric hospitals.

All of Pathways clients are diagnosed as mentally ill, and 90 percent are considered addicted to either alcohol or drugs, which makes the program's success rate even more unusual.

Nationally, for every 100 individuals or families seeking affordable housing, there are only 37.84 available units. So programs that offer housing once clients are "clean" sometimes find they have no housing to give when clients are finally ready.

"There's no absolute promise that if you move through [the programs' requirements], you'll get housing," says Philip Mangano, executive director of the Interagency Homeless Council on the White House Domestic Policy Council. "You can do all the right things, make the right promises, perform well in the program. The promise of that is housing, and the difficulty is, there's a shortage."

The housing-first strategy, he continues, "puts the emphasis on the appropriate antidote to homelessness – housing. And that housing becomes the nexus point for the delivery of social services."

At Pathways, those social services include jobs at the five Pathways offices, adult education, alcohol and drug-abuse support, psychiatric and nutrition counseling, and soon, careers at a Pathways-run thrift store in Queens and a bakeshop in Harlem. Twenty percent of clients are working or in school, and 70 percent participate in some form of treatment for alcohol or drug abuse.

Those social services represent about 40 percent of the program's annual cost; apartment-rental fees soak up the rest.

Mr. Tsemberis grew up in tiny Srouka, a Greek village on the Peloponnesian peninsula where, he says, "mentally ill relatives are part of the family, live with you, have dinner with you, and are contributing to the family's well-being.

"I think that's a deeply internalized image for me," he continues, "an inclusive and helpful society where we all live, each with our own gifts to contribute to the pool."

With at least two staff visits each month – and usually more – Pathways strives for that sense of inclusion, while encouraging the autonomy of independent living. Apartments are scattered throughout Manhattan and Westchester: Congregated sites, says Tsemberis, can breed stigma and an institutional feel.

There's nothing institutional about Jane Whiley's apartment. It is full of wicker chairs and tables painted all shades of green, red, and orange, arranged with astonishing symmetry.

Family pictures, brightly colored plastic fruit, and iced-tea bottles crammed with artificial flowers crowd each surface; homemade collages line the walls. Above the kitchen sink, 18 mugs dangle from hooks on black-and-white checked wallpaper.

Homeless after losing her home of 31 years around the time she was diagnosed with schizophrenia, Ms. Whiley spent eight months in a women's shelter before hearing of Pathways at the Harlem YMCA.

She now works part time as a Pathways receptionist and part time at the Ricco/Maresca Gallery on 20th Street, which features self-taught artists, many of whom are considered to be mentally ill.

When Craig Murray introduces himself over Pepperidge Farm cookies and a beef knish, he sounds as though he's at Alcoholics Anonymous. "My name is Craig," he says earnestly, "and I'm dually diagnosed. That means I have a mental illness and a substance-abuse problem."

A heavy man with wide brown eyes, measured speech, and an easy smile, he speaks eagerly. After six years in a state hospital battling cocaine addiction, he heard of Pathways through a friend, and now lives in Washington Heights.

"Pathways came and scooped me out of the madness," he says, "found that I was articulate, open-minded, civic-minded – a nice person, aside from what was documented in some chart I never saw."

Armando Vasquez has likewise found a haven in Pathways – though as "a street character," he insists it was easy to survive. He met a Pathways worker while visiting homeless friends at Grand Central Station and jumped at the opportunity to obtain permanent housing.

A street kid at 11, Mr. Vasquez was sniffing heroin at 12. "I was a drug addict all my life," he says over lunch. "For 30 or 40 years, all I did was get high." Now he's been clean for 14 years.

As Vasquez talks of his struggle with drugs and "weirdo problems," Tsemberis leans forward. "I don't think it would have been possible for you to deal with your clinical problems if you were homeless," he says.

"Without a doubt," agrees Vasquez. "Without a doubt."

Not everyone in the Pathways program is happy: Clients push for bigger apartments, or insist their buildings are too noisy, too dangerous, too drug-infested.

"That's always a sign of progress," says Tsemberis, "for them to know that they deserve better, that they can do better."

Darlene Lee, Pathway's East Harlem service coordinator, describes one client who was so used to street life that he'd salvage garbage for decor, cramming seven televisions into a one-bedroom apartment. Tempering that pack-rat instinct, says Ms. Lee, has been "a therapy for him." Now he has four TVs instead of seven – a measure of progress that would count for little in a traditional program, where recovery might be gauged by the number of drinks not taken.

"Especially for people who have been institutionalized," says Tsemberis, "it's a huge conceptual shift to be in a social-service system [that makes] people feel like they're in charge of their lives."

Even enlightened social workers sometimes admit to surprise as they see clients assume the privileges of routine life.

When one of Lee's clients asked for money for a manicure and pedicure, Lee agreed – with a flash of surprise. "This was a normal adult, taking care of herself," Lee says. "Working in the field, we still have these ideas – so I can imagine how people on the outside make all kinds of judgments about what [the formerly homeless] deserve."

Consistent with its focus on independence, Pathways doesn't control clients' funds, but takes a "harm reduction" approach to finance. One-third of each client's Social Security disability checks, or other income, goes to rent. For the rest, they get their money in monthly lump sums – or, if they prefer, weekly allowances, so that spending sprees don't waste everything.

Those who have drug or alcohol habits that devour cash go food shopping with Pathways workers, who make sure they buy necessities first.

Harm reduction, in this sense, is a safety net to "minimize the extent of the damage, so the person will not end up homeless again," says Tsemberis.

Though critics decry such leniency as "enabling" addiction, supporters of Pathways and similar programs say that what clients do behind closed doors is up to them: The important thing is that they have doors to close.

Critiquing programs that demand "housing readiness," Tsemberis shakes his head. "People with [mental illness and addiction who are] on the street ... see acutely the need for housing, for a place to feel safe and secure, before they're even ready to consider treatment. Recovery starts when you have something you care about, a place where you can go."

Still, most homeless advocates say that sobriety mandates have their place. Sue Watlov Phillips, president of the National Coalition for the Homeless, and executive director of Minneapolis-based Elim Transitional Housing, insists that both approaches are crucial.

Like Pathways, Elim operates on housing-first and harm-reduction models, on the philosophy that "If you can handle chemicals and handle life responsibilities, then it's not an issue for us," she says.

But for those seeking a stricter lifestyle, Elim offers two chemical-free sites. The "dry" environment, says Ms. Phillips, is crucial for those with life-threatening addictions, or those who must be sober to regain custody of children.

The Goose Hollow Family Shelter in Portland, Ore., likewise forbids substance use. But that, explains executive director Chuck Currie, is because the shelter serves families.

"I totally agree with what Pathways is doing," Mr. Currie says, lamenting the lack of similar local organizations. "Programs in Portland are pretty hard-core in saying: 'If you use alcohol or drugs, then we're not going to help you.' If you have severe mental health problems [here], you're more likely to end up living on the streets than in a shelter."

Costs for housing the homeless aren't cheap, but Dennis Culhane, professor of social welfare policy at the University of Pennsylvania, found that such programs as Pathways actually save money.

He determined that the cost to society for the average mentally ill person on the street was $40,500 per person annually in social and health services. Pathways' apartments and services, according to Tsemberis, cost only $22,000 per person each year.

But beyond the potential cost savings, the key to the success of Pathways and similar programs is that social services are offered – but not mandated.

"To attach services to housing is certainly a good idea," says Brad Paul, a housing-policy analyst at the Washington-based National Coalition for the Homeless, "but everyone should have the right to a place to live – regardless of whatever else they're dealing with."

For most Pathways clients, home is more than a right; it's a marvel.

After almost a decade, the wonder of his East Harlem studio apartment has not diminished for Hughes Smith: "It's like a dream, having your own place, being able to function like a human being," he says.