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

IN REPLY: Brown and Watson have described the literature review as a challenge to funding for permanent supportive housing—and in particular, the Housing First model. This conclusion must be considered in the broader context of the review, which analyzes the best available research on the subject to determine the extent to which the research can answer questions of effectiveness. Pitfalls, such as attrition and imprecise descriptions of how housing and supports were implemented, create uncertainty about the role of services for disabled populations. There is an undisputed moral argument for housing homeless individuals with mental illness and co-occurring substance use disorders. The question of how best to do this is poorly addressed in the research. Brown and Watson conclude with the need for “broad guiding principles” by which to design housing programs given the likelihood of a substantial challenge identifying “housing models that meet the needs of the heterogeneous population of individuals who have experienced homelessness.” The authors have appropriately framed the research issue as a political problem rather than an empirical one.

The enduring question of what causes homelessness among those with co-occurring mental illness and substance use disorders is secondary to the pressing needs of this population. Professionals are well aware of how inadequate funding creates a brutal game of musical chairs that in turn drives incentives to ignore more disabled individuals. Implementing supportive services—a key “active ingredient” that is not well explored in the housing research—is expensive. Providing long-term services to a population in need of extensive social as well as physical and mental supports is even more expensive. The failure of the research to answer key questions about effectiveness may well reflect the lack of political will to fund long-term supports to replace the custodial care once provided by community institutions. If it is to be interpreted politically, my analysis calls for greater funding, not the opposite.