Change in agency culture and service system culture when implementing housing first

Overview

This module is an overview of how agency and service system culture often needs to change when implementing Housing First. It is organized into three sections: (i) Key Messages, (ii) Key Questions and Challenges, and (iii) Appendices and Resources.  The Key Messages section gives a brief summary of how one can think about cultural changes that may be needed to effectively implement Housing First. The Key Questions section is organized into a series of general questions about common challenges that agencies and systems face related to cultural change that is needed to implement Housing First. Finally, the Appendices and Resources section contains additional information about the cultural change involved in implementing Housing First that includes external links to additional resources.

Key Messages

• Housing First represents a culture and logic to homelessness services designed to be consumer-directed, strengths-based, recovery-oriented, and focused on human rights.
• Housing First stands in contrast to a more traditional service system culture that has been described as hierarchical, directive, paternalistic and based on provider (rather than consumer) expertise in which there are organizational policies, procedures and practices that emphasize client compliance and adhering to the rules. There is often a subtle implication that those being served, in addition to their clinical and economic problems may also be lacking in character or moral worth.
  • These practices and values over many years has created social service system that require individuals to earn housing by demonstrating adherence to treatment, clinical stability, and abstinence.
• Cultural change within an agency implies that providers (both administrative and frontline staff) change or shift attitudes in the following ways:
  • From compulsory to voluntary services
  • From clinician driven to client driven
  • From compliance to activation and participation
  • From risk aversive to assuming some risk [see inset box below]
  • From sobriety and abstinence based to stages of change and harm reduction
  • From prescriptive treatment plans or simply completing treatment plans to meet compliance to helping tenants actively participate and set their own personal goals
  • From discharging clients because of rule or program violations to being committed to building and maintaining long term positive relationships with tenants
  • From defining a tenant based on a diagnosis to respecting a person’s identity and the helping to support the challenge of coping with an illness.
  • From an expectation of a maintenance or a downhill trajectory to one of recovery and hope.
• Changing organizational or system culture is difficult and takes: (1) Awareness; (2) Learning; (3) Practice; and (4) Accountability.
• To the extent that Housing First not only represents a different structure of services but also a different philosophy and culture that cannot be easily reconciled in a traditional service model, the implementation of Housing First will likely represents some degree of transformative change (i.e. changing how “business as usual” gets done).  This applies to the work of the support services team and to the agency’s organizational and practice culture.

Key Questions and Challenges

What are the challenges to fostering a housing first culture?

Challenge #1: Changing agency or service system culture to be consistent with a Housing First approach can be difficult due to:

• Moral judgments regarding the worthiness of various populations for housing can lead to a perception that the program is “enabling” client by giving active users a place of their own;
• Fears that clients will “take advantage” of staff or agency if staff or agency are too flexible and accommodating;
• Misinterpretation of some of the key principles that the Housing First model seeks to implement, e.g., client choice mean that clients are free to do what they like including refuse home visits;
• Skepticism regarding program effectiveness and difficulty in allowing clients to continue to make choices about their treatment plan after a mistake or negative outcomes. This often translates into restricting client choice after a relapse, or eviction or other negative consequences.  Agency culture must embrace, in Pat Deegan’s terms “shared responsibility” and allow for clients the “dignity of failure” so they can learn from their mistakes.

Challenge #2: Judging a book by its cover. Co-opting occurs when agencies adopt the HF label but do not significantly change existing practices, which can include continued reliance on housing readiness and prioritizing provider determinations over consumer choice – and in many cases an implicit or explicit expectation that clinical stability remains a prerequisite for independent housing.  Expanding the definition of Housing First to the point of distortion includes some of the following:  an emergency shelter program calling itself “housing first” because “the first thing we talk to clients about is housing” or a supportive housing program claiming to practice client choice, “yes, we practice clients a choice… we tell them you can go to treatment and then you will housed or you can remain homeless—your choice.”

Challenge #3: Designing services to reflect a Housing First culture. Key to the success of Housing First does not depend solely the type of supports and services are offered, but how they are offered.

• Services should be available as needed, 24/7, not only 9am-5pm during the week.
• Clients need assistance with matters that are not defined by the traditional service modalities and can include: on-call support, grocery shopping, companionship to appointments (e.g. medical, social services), plumbing/locksmith, client emergency financial funds, negotiation interactions with neighbors/landlords.
• HF requires hiring peers support staff (i.e. people with the lived experience of similar challenges faced by HF tenants such as homelessness, mental illness, discrimination). This may require making reasonable accommodations (e.g. flexible hours or work setting) for those with non-traditional work backgrounds.

Challenge #4: Disruptive or transformative change. Introducing the practice and values changes required by Housing First in one program can create a tension between other programs in the same agency. Similarly, having one agency adopt Housing First in a community can have consequences and may push for change in the practice of other related or complementary agencies (social services agencies, health services, landlords, justice system probation and parole, benefits and entitlements, etc.)

Remaining and ongoing questions include:

• How best can we maintain a Housing First philosophy and culture if the program exists within a more traditional agency?
• How can providers habituated to traditional services be reoriented to a Housing First approach?
• Will an increased emphasis on recovery in mental health diminish differing perspectives between Housing First and other providers.