Balancing Empirical Evidence and Ethical Considerations in the Implementation of Permanent Supportive Housing

TO THE EDITOR: The literature review by Benston (1) in the August issue provides a timely critical review of research on permanent supportive housing interventions for individuals with mental illness who are experiencing homelessness. Although we agree with the author’s call for further systematic, controlled research on housing interventions, we disagree with the contention that the current body of literature is insufficient to drive policy decisions. As Benston notes, there is wide variability in both research on and implementation of permanent supportive housing programs. However, through triangulation of the results of the research reviewed, it is evident that permanent, low-barrier housing with some form of support services is generally superior to a range of alternative interventions in terms of improving housing tenure, the fundamental goal of such programs.

The empirical argument being made in Bentson’s literature review should be considered in tandem with a philosophical shift regarding the treatment of vulnerable individuals; this shift provides an ethical rationale for policies favoring low-demand housing interventions. The Housing First model was predicated on the philosophy that providing people with housing regardless of their treatment and other personal choices is simply the right thing to do (2), a moral fact underscored by the Universal Declaration of Human Rights (3). It is also problematic that Benston does not present an alternative to permanent supportive housing. Thus one might assume that the alternative is to resume funding status quo “treatment first” housing interventions—an approach that also lacks uniformity and empirical evidence—until a thoroughly researched gold-standard approach is defined. Given the current focus on recovery-oriented and person-centered services in the field (4), it seems sufficient to conclude that a variety of housing and service options (ranging from treatment first to Housing First) should be available to individuals living with mental illness and substance use disorders. Therefore, we consider the present funding policies to be appropriate for reducing barriers to housing for individuals who are in different stages of recovery, despite noted limitations in the research methodologies used in existing studies.

Benston states that the extent to which housing agencies provide autonomy to tenants is unclear—an issue we agree is of high importance. Yet the solution to the issue is not to challenge the availability of funding for permanent supportive housing but to enhance the federal government’s oversight of these programs, perhaps through external evaluations that use theoretically based fidelity tools (5).

Finally, we resoundingly concur with Benston’s assertion that rigorous research is necessary to understand the active ingredients of permanent supportive housing models. We emphasize the need for research on enhanced posthousing interventions to support individuals’ goals by training direct service providers in more specialized clinical skills grounded in a recovery orientation. Identifying one or more housing models that meet the needs of the heterogeneous population of individuals who have experienced homelessness is a substantial challenge. Therein lies the merit of broad guiding principles that can be applied to everyone. Such an approach will have to suffice until studies yield more definitive evidence.