First Things First: The Housing First Model and Maslow
Almost every day Partners In Housing, or some other agency that follows the “Housing First” model to end homelessness, provides a permanent place to live for someone who, the day before, might have been living on the streets. More than likely, that person has been abusing one or more substances for a number of years, and there is a fair chance that a mental illness has also gone untreated. This approach of moving homeless people directly into permanent housing is known as the Housing First model. In the past, a typical approach was to begin with shelter and progress through some stage of temporary housing, all the while requiring the individual to participate in treatment to deal with addictions and mental illness. When that person is stable enough, he or she can move on to permanent housing. The Housing First model turns that approach on its head by promoting permanent housing as the the first action and not the ultimate reward. The two beliefs that underpin the Housing First model are, first, that having stable permanent housing is a necessary first step before someone can deal with other issues; and, second, that having choices about treatment is important for success. Why do we think this will work and will provide motivation for a chronically homeless person improve his or her life? There is some evidence that it does work, but there was someone who,, over 70 years ago, thought a lot about what motivates someone to improve.
Anyone with even a passing interest in psychology is somewhat familiar with Abraham Maslow’s “Theory of Human Motivation,” or, as more commonly referred to, Maslow’s “Hierarchy of Needs.” Maslow’s original presentation of this theory was published in Psychological Review in 1943 where he describes five levels of needs from the most basic needs for survival up to our need to fulfill our life’s destiny. He further postulates that these five needs are in a hierarchy, and we can only be motivated to meet higher levels of need when lower levels have been met. To put it differently (and over-simply), how can I discover my inner fulfilling self if I’m more concerned about avoiding starvation? The five levels of needs, in order starting with the lowest and most basic, are: ‘physiological needs’ (the need for food, water, and the basic nutrients for life); ‘safety needs’ (avoidance of danger and generally a need for a secure environment); ‘love needs’ (love, affection, and belongingness); ‘esteem needs’ (self respect and self esteem as well as esteem from others); and ‘self-actualization needs’ (self-fulfillment and becoming all you can be).
With this in mind, the first basic principle of the Housing First model sounds very much like Maslow. That is, people need the basic necessities of life such as food and a safe and secure place to live before they can really address other concerns like dealing with an addiction or finding a job and achieving a more financially stable life style. The second principle of the Housing First model is that people must have the choice to pursue treatment, and, if so, what type of treatment to engage in. In a way, this second principle is an extension of the first, resting on the hope that, after achieving some stability in housing, treatment will be sought to address any issues like addictions or mental illnesses. A good support staff in and Housing First program can facilitate this, but the choice still belongs to the individual. Since Housing First seems to rely on motivation and also appears to have bought into Maslow’s Hierarchy theory, let’s see what researchers say about both the Hierarchy of Needs and the Housing First model.
Was Maslow right that satisfying some basic needs is required before we can seek higher goals? The answer is, well… maybe not exactly in the precise way he envisioned it. But, then that raises the question of why so many people still refer to it and believe in it. Although the research testing the theory does not seem to support the hierarchy in its most rigid form, the answer is not as simple as that. To be fair to Maslow, even in his 1943 paper, he made it clear that some people weighted the different levels in his five-level scheme more heavily than others, and some people might even put them in a different order. For example, we are all aware of the common image of the starving artist who gives up seemingly all creature comforts (physiological, safety, love, and esteem) for her art (self actualization). Oppositely, Maslow himself spent a good part of his later years trying to figure out why many people whose lower level needs were well met did not pursue the higher goals of self actualization. While some critics of Maslow’s theory of motivation have pronounced it wrong, the more thoughtful researchers have merely concluded that the Hierarchy probably doesn’t play out precisely as presented by Maslow, and, in any event, it’s very difficult to actually test its assumptions. They stop short of saying it’s wrong. So, this leaves room to believe in its validity. After all, it does make some intuitive sense, and a general belief in its validity appears to be at the foundation of the Housing First model.
If we are a little unsure of Maslow, does it make sense to believe in the principles of the Housing First model? Does it really work? The Housing First model only emerged in the early 2000s, and it has only been at the forefront of efforts to fight homelessness for a few years. Nonetheless, it’s success has been evaluated by a fair number of studies. If your litmus test for success is that homeless people are placed in housing and that they stay in that housing, then the Housing First model is a definite success. This is not a small achievement. A cynical mind might wonder why someone would not want to remain housed if provided with housing, but, in fact, the dual pathologies of addiction and mental illness that usually accompany homelessness can create behaviors that are major barriers to staying housed. It is a tribute to organizations like Partners In Housing and others that subscribe to this model that they are successful in keeping people housed. Put simply, it’s done by a combination of compassion, tolerance, and support.
If we want more for homeless persons than just housing, and would like for them (after being housed) to be motivated to move up the ladder on the Maslow Hierarchy toward a better future, the research results about the success of Housing First are murkier. Studies have examined such questions as whether homeless persons in Housing First models fare better at reducing substance dependency or managing mental illness than those who are other programs, or if physical health is improved relative to other homeless. To quickly summarize, substance dependency is reduced and mental health improves for Housing First participants but not significantly more so or at a quicker pace than with other types of programs. There is, however, evidence that Housing First is better at improving physical health, at least as measured by the cost of health services and the use of hospital emergency services. Additionally, some societal costs such as criminal justice expenses have also been shown to be reduced because homeless persons are permanently housed. These cost reductions are significant enough that some local governments and hospitals are experimenting with investments in housing for the homeless as a method to reduce cost burdens.
So, where does this leave us on the question of human motivation, Maslow’s Hierarchy, and the success of Housing First? My opinion is that the Housing First model is working based simply on the fact that it is successful in permanently housing homeless people. Further, it is as effective as other models in addressing problems of addictions and mental illness, it appears to have some cost reduction benefits, and it is more humane than the instability of shelters and temporary housing. I also believe that, as we gain more experience with it, we will see more and more evidence that providing housing as the first step in combating homelessness is the better option. So, I guess I am saying that I believe in Maslow’s Hierarchy and his views about motivation. As I said, nothing in the critiques of his theory proved it is wrong, only that human motivation is messier than his neat hierarchy (which should not be a surprise). If we are looking for real inspiration for this belief, it is in having known Partners In Housing residents who have overcome barriers created by addiction and mental illness because life had become more stable (meeting physiological and safety needs). Many then reunited with family and made new friends (meeting love and belongingness needs), and gained a new respect for themselves (esteem). Still others have become employed, left the program, and moved on to an independent and unsubsidized life. All this seems like Maslow’s Hierarchy in action.
(photo credit: By J. Finkelstein (I created this work using Inkscape.) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)], via Wikimedia Commons)