For decades, the standard response to homelessness among adults with serious mental illness was the "treatment first" or "housing readiness" model. People had to demonstrate sobriety, treatment engagement, and a degree of stability before they could move into permanent housing. The result, predictably, was that many people never got there. Housing First is the alternative: provide housing first, then offer the services. The model has now been studied for more than two decades and has reshaped homelessness policy across North America and Europe. This guide covers what Housing First is, where it came from, and what the evidence shows specifically for people with schizophrenia.
Housing First is a philosophy of homeless services that provides immediate access to permanent housing without preconditions like sobriety or treatment compliance, paired with voluntary support services — and it has strong evidence for housing stability and reduced crisis service use among adults with schizophrenia.
The origin: Pathways to Housing
Housing First in its current form was developed in New York City in the early 1990s by psychologist Sam Tsemberis through Pathways to Housing. The programme worked with chronically homeless adults with serious mental illness — many with schizophrenia and co-occurring substance-use disorders — and offered them apartments first, with consumer choice over neighbourhood and unit. Treatment and other services were available but not required as a condition of housing. The results were striking: housing retention rates that exceeded 80% even in a population that had been considered "unhousable."
The principles
Housing First is defined by a small set of principles that distinguish it from other housing programmes:
- Immediate access to housing with no preconditions
- Consumer choice — tenants choose where they live and what services they use
- Separation of housing and services — housing is not contingent on engagement in treatment
- Recovery orientation — services are flexible, individualised, and focused on the tenant's own goals
- Harm reduction — drug or alcohol use is not in itself a reason to lose housing
- Standard tenancy — a real lease, real tenant rights
These principles can be applied within different housing models — most often within Permanent Supportive Housing, but also in rapid rehousing and other arrangements.
Why it works in serious mental illness
The "treatment first" approach assumed that people with active symptoms or substance use could not succeed in independent housing. The Housing First evidence suggests the opposite: housing itself is therapeutic. Stable housing reduces the chronic stress of homelessness, makes medication adherence possible, creates physical safety for sleep, and provides the foundation for everything else — clinical care, employment, social connection. For adults with schizophrenia, who are particularly vulnerable to relapse under chronic stress, the stabilisation effect of a roof and a key can be substantial.
The evidence base
Housing First has been tested in multiple randomised trials, including some of the largest mental-health services trials ever conducted.
The Pathways New York studies
The original randomised trial of Pathways to Housing in New York compared Housing First to a treatment-first comparison group. Housing First participants achieved markedly higher housing retention. The study, led by Tsemberis and colleagues, was published in the American Journal of Public Health in 2004.
At Home / Chez Soi
The Canadian At Home / Chez Soi trial, conducted between 2009 and 2013 across five cities, randomised over 2,000 homeless adults with mental illness — many with schizophrenia — to Housing First or treatment-as-usual. Findings, published in journals including JAMA, included substantial improvements in housing stability, comparable or better mental-health outcomes, and significant offsetting reductions in emergency services use among high-need participants. The trial is the largest Housing First trial conducted to date.
The HUD Family Options Study
Although focused on families rather than single adults with serious mental illness, the HUD Family Options Study reinforced the broader finding that long-term subsidies plus light services produce better housing outcomes than treatment-first or transitional models.
Veterans
Among veterans, the HUD-VASH programme — which combines Section 8 vouchers with VA case management — has produced consistent evidence of strong housing retention and reduced homelessness, particularly when delivered with Housing First fidelity. Studies are summarised by the VA's HUD-VASH programme page and by USICH.
What the evidence does not show
Housing First produces strong housing outcomes and significant reductions in crisis service use. It does not produce uniform improvements in psychiatric symptoms or substance use beyond what would be expected with stable housing alone. Mental illness is not cured by an apartment — but treatment becomes far more possible from a stable home, and tenants increasingly engage with services voluntarily over time. The model is honest about this trade-off.
How Housing First is implemented
A typical Housing First programme for adults with schizophrenia includes:
- Rapid placement into a real apartment, usually with a Section 8 voucher
- An Assertive Community Treatment team or intensive case-management team that visits regularly
- Voluntary substance-use treatment available but not required
- Help with benefits, healthcare, employment, and social connection
- Crisis support and a clear plan for what happens during a relapse
Common misconceptions
- "Housing First means people don't need treatment." Wrong. Treatment is offered, often intensively. It is just not a precondition for housing.
- "Housing First doesn't work for people with active addiction." The evidence shows the opposite — housing retention is at least as good when sobriety is not required.
- "Housing First is expensive." Reductions in hospital, emergency, and corrections costs typically offset much or all of the housing subsidy in high-utiliser populations.
- "Housing First means giving people apartments with no rules." Tenants follow standard lease terms — pay rent, don't damage the unit, don't endanger others. Eviction is possible for lease violations.
Where Housing First fits in the broader system
Housing First does not replace every other housing option. People who need 24-hour medical or psychiatric care, those who actively prefer congregate settings, and those whose symptoms make independent living dangerous still need other options — group homes, assisted living, or higher-acuity settings. What Housing First has done is move the default. Where the system once assumed that supervised living was the appropriate destination for adults with serious mental illness, it now assumes that an apartment of one's own is the appropriate starting point — with other settings available when needed.
A common worry from families is that Housing First means leaving a loved one alone with no help. The opposite is true in well-run programmes: tenants typically receive more contact with mental-health workers in Housing First than in many supervised settings, and the support is voluntary rather than coercive.
The big picture
The Housing First evidence has been clear enough, for long enough, that the model is now the recommended approach for chronic homelessness among adults with serious mental illness across federal agencies (HUD, VA, SAMHSA), in Canada, and across much of Europe. The remaining barrier is supply. The number of people for whom Housing First would work far exceeds the number of subsidised units and trained services teams currently available. Building that supply is the work of the next decade.
For more, see Permanent Supportive Housing for schizophrenia and homelessness and schizophrenia.
This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.