SSA's Emily Klein Gidwitz [the late Professor Michael Sosin] is working with Christine George, an assistant research professor at the Loyola University Chicago Center for Urban Research and Learning, and Susan Grossman, a professor at the School of Social Work of Loyola University Chicago, on a multipronged effort to measure the plan's progress, including a survey of existing shelter options, a longitudinal study of individuals in the system and a qualitative analysis of services.

For this issue's Conversation, Sosin sat down with Nancy Radner, A.M. '93, the chief executive officer of the Chicago Alliance to End Homelessness, which, in partnership with the City of Chicago, implements the Plan to End Homelessness and commissioned its evaluation. Sosin and Radner talked about different ways of understanding the causes of homelessness, the latest research and what it takes to help those who've experienced homelessness. 

Sosin: Let's start by talking about what homelessness is.

Radner: Sure. The stigma around homelessness is very extreme in our country. The feeling that it's all a matter of bad decisions and personal failings, and that these people don't want to help themselves, is very pervasive.

Sosin: There's two ways of thinking about the problem. One way is thinking about it as a circumstance, as a situation. And the second way of thinking about it is as a series of attributes in some people that make them more likely to become homeless. And I think the stress probably should be on the first rather than the second. Some attributes are important correlates of homelessness, but the relationships tend to be loose, making intervention difficult. For that reason, recent policies are placing more emphasis on reversing the situation, first, and only then dealing with personal problems and other attributes that contribute to the situation.

Our report found there were three major reasons people are homeless, although this set of reasons doesn't cover everything. We found that a little less than half [of the homeless people we surveyed] had a place to stay and lost their source of income and simply can't handle rent—the classic way you think of someone falling into homelessness.

Radner: Pure economics.

Sosin: Right. The group that's maybe even slightly larger are those who basically had others who they were depending on and no longer can. There are people who had arguments, people who live with their parents and that relationship ended, people who actually lived alone but had income sources from others that dried up.

And then the third group, which is thought about less frequently but probably is equally important, had their expenses increase.

Radner: Interesting. Yes, we as a society don't think about that as much.

Sosin: That can be a rent increase, but as important is an increase in medical expenses. And these things work together. So, for example, if you can't work and you lose your home, maybe you wouldn't be homeless if you had relatives who could take you in. So for most people, two or three of these things occur at the same time.

Radner: The truth is that most homeless people are trying the best that they can to survive. People do recover from homelessness and go on. And so the trick is to help change the circumstances. We just want to make sure that can happen. 

Sosin: What do you think of the new policy, the Housing First policy?

Radner: Housing First was a theory that started with practice in the field rather than research. We were finding that when we got someone into permanent housing as fast as possible, that we were very successful at keeping them there— their homelessness would be ended, usually for good.

The theory used to be that in order to be in housing, you had to be ready for housing, you had to have all of your problems under control. We found that, no, get someone into housing, they'll learn all those things. People who've been homeless say that when they can shut the door and have a key to the lock, there's a sense of security that is so important. It's Maslow's hierarchy of needs. Once they had the food and shelter taken care of, then they could start to think about how to get back on their feet and become independent.

Sosin: So you don't ignore services. It's an order thing, right?

Radner: Right. Chicago's Plan to End Homelessness was founded on two principles: Get someone into permanent, affordable housing and wrap services around them as much as they need them. And that's proving to have great success. And there's a third principle: homelessness prevention. Keep someone out of the homeless system altogether as much as possible, whether they are being discharged from a hospital or mental institution, or facing a short-term loss of money.

Sosin: So it would be nice if we could say that the model meant that if someone's homeless, everyone gets a house. But it's not quite that simple.

Radner: No, it's not. The resources available don't necessarily match the need, which is true with every poverty policy. So then the question becomes: How do you target resources?

Permanent supportive housing is one of our most precious resources, costing anywhere from $8,000 to $15,000 a year for an individual. Studies have found that this type of housing is actually much cheaper for society than if an individual is on the streets, where they use emergency rooms or end up in mental institutions. So there's major cost savings with permanent supportive housing. But we didn't start with the idea that we would be saving money. We started with the idea that we would be saving lives.

Sosin: So about how many of those units do you have?

Radner: Chicago has 6,600 units of permanent supportive housing. Since we created the Plan to End Homelessness, we've added over 3,000 units. We have one of the largest stocks of this housing in the country.

Sosin: So if there aren't enough resources, how does the system decide who gets housing?

Radner: The housing that we build is primarily HUD-funded housing. HUD has prioritized people with disabilities, because that's the housing that existed in the least numbers.

For other folks, folks who are not disabled, we have to piece together different types of housing. So with a number of our advocacy partners we created the rental housing support program, which is a state-funded program that has funded up to 4,000 units across the state for people who are rent distressed, some of whom are homeless. Someone has to have an income to use this housing.

Then we have a third model, which is called permanent housing with short-term support, usually for families that have an employment history but need some time to get to a greater income source. We provide two years of rental support and services wrapped around them, and then they assume the lease of the place that they've been living in.

Sosin: So if I read this right, the model and the research first considered the benefits of supportive housing. Several studies conducted in New York City tested the benefits, first using statistical matching and later conducting random sample experiments. Generally, the New York experiments focused on people with serious mental health problems. Those experiments suggest that supportive housing seemed to increase stability remarkably. There are other cities running experiments where the housing stability of those placed in supportive housing is similar to that found in New York, but where the control group doesn't fare as poorly. That is, post experiment, the New York control group was as bad off as you can imagine a control group being.

Radner: It proved that you can house people who we previously thought were difficult to house.

Sosin: But there is very little research on models that don't supply supportive housing.

Radner: I think that's right. That's the state-of-the-art in homeless services, to figure out how best to target the resources.

Sosin: Then there are programs like rapid rehousing. You recruit people who are homeless out of shelters who meet the criteria, who you think, again, have or can get some income so they'll be able to sustain housing. I know there's a national federal experiment going on that's trying randomly controlled experiments: One group will get rapid rehousing and another will get a two year program that's like the type that you described. But it will be the end of this year at best before we know anything.

Radner: [Programs like rapid rehousing] get people through the crisis that you were describing initially. They were able to maintain housing before something happened to them. They don't need to be in our shelter system and they don't need long-term rental support and supportive services. The economy has really put a lot of folks into that situation that they wouldn't have been in before.

What we don't know about rapid rehousing is do people need three months of help? Do they need six months? So we've been slowly doling out the money to try and figure it out over time. Now, again, with this economic situation, it's unclear how long it will take before people get back on their feet.

Sosin: Plus, many of these are special demonstration programs. And then the question becomes, what do you do when you have these models? How do you get from these models to citywide programs?

Radner: I think in Chicago we tend to take big bites. When we said we were going to end homelessness, we didn't say we were going to end it for chronically homeless people, which some cities did, we said we were going to end it for everyone. Bringing a big initiative like this to scale is more about political will than anything else. That's where my organization comes in, to say, "We have the five or six interventions and we have the evidence to prove that those interventions work."

We have more homeless prevention money than we've had in the past. And that was because we were able to make an argument to the Obama administration that it was what we needed in this economic crisis. So part of the economic stimulus package was over a billion dollars of homeless prevention funding nationwide. We're always looking for that window of opportunity. 

The following section of the interview is a web-only exclusive. 

Sosin: The other way the people think about this, of course, is the attributes of what makes people homeless. And that's fair enough. But again, I think it's complicated, because compared to who? If you want to ask the ultimate cause of being homeless, you'd need to talk in terms of the causes of being poor. And it doesn't get you very far to talk about that.

Radner: Right. The research says there's not a lot of distinctions between the two, [people in poverty who keep housing and people in poverty who become homeless].

Sosin: Right. There are distinctions, but they're not huge.

Radner: And they're not good predictors of homelessness.

Sosin: The two biggest predictors of being homeless are being poor and having no one to live with. But those are not really attributes of individuals, that's their situations. You can ask what sort of attributes make those events occur more commonly; and you can come up with some, but again, they occur in different ways for different people.

For single individuals who don't have children, the other thing you can focus on, and I'm sure you probably agree, is substance abuse.

Radner: Yes. Maybe mental illness, too. That's where we also look.

Sosin: I would count that second in terms of frequency.

Radner: I think that's right.

Sosin: The most important reason [that it's secondary] is that mentally ill people, if they're mentally ill in a certain way, have more resources from the state to rely on.

Radner: They did before. But it's getting more complicated. Getting qualified for Medicaid these days is extremely difficult. And the other state funding for mental health has been decimated. But I agree with you, if you can meet all the criteria and get access to the resources, there is an income source. And having an income improves enormously your chance of becoming housed, if you can find housing you can afford.

Sosin: And then there's an attribute that even I don't think about as much as I should: chronic health problems. Close to half of the people in our sample have chronic health problems. It's really shocking, and we don't know how that plays out.

Radner: Yes, we found from the evaluation that the number of homeless people who are getting Social Security disability was tiny. You have something like 40 percent of those surveyed who had chronic health problems, yet only 3 or 4 percent were getting SSI. So we really need to get more people the benefit that they could get.

Sosin: Right. But it could work out to be like the mental health issue. It's very difficult to get the benefits. People are sick enough so that they can't work, but not sick enough so they're considered disabled.

Radner: Absolutely, which is why health care reform is a revolution for our industry, because people are no longer going to have to prove disability and jump through all these hoops in order to qualify for Medicaid. It's going to be income-based alone. That's pretty exciting for us. We're looking now at how to get the homeless system ready to enroll many of our clients into Medicaid.

Sosin: Right. Then there's the families; it looks like it's different for families. They're generally younger and become homeless faster. More issues have to do with relationships not working out, probably, than for the single individuals. But, like with mental illness and substance abuse, these characteristics might be important, but they're probably not as important [as circumstances].

Radner: We're still trying to figure out how many of those families actually have those issues. The evaluation that you're doing shows that nearly 40 percent have chronic health conditions and 20 percent of the families had psychiatric hospitalizations, which fits with our theory that it's about a third who have these disabling conditions.

Sosin: So homelessness is very rarely a problem, simply, of individual traits, because those interact with the resources that they have available. So you also have to ask whether there are social services available for them.

Radner: I always say that people who become homeless, it's usually because they've fallen through a number of other systems. For example, your study is finding that so many of the folks in the system are ex-offenders. They've been through the justice system, and that system did not allow them to get back on their feet. We've heard of people being [released from prison and] given the address of homeless shelters. How do we help those systems help their people so they don't discharge them into homelessness?

The Veterans Administration has vowed to end veterans' homelessness in five years, which is a pretty astounding and ambitious promise to make. Secretary Shinseki made that promise, and we're working with them to do that. I think homeless practitioners would say that the Veterans Administration has been very isolated from the homeless system and that there are a number of veterans in our homeless system who don't even think of themselves as veterans and are not connected to veterans' services.

Sosin: Veterans are also in a vulnerable age group. People become homeless often not as really young adults, but sometimes it is sort of middle adulthood. And veterans certainly reach that point. Sometimes veterans have personal backgrounds that would make them subject to homelessness. Being poor and not having anyone to count on is a reason for being homeless. Why do people join the military? Well, some people join the military because they have very few options. And so when they get out, they're going to be vulnerable. Then you have to separate that out from people whose homelessness is caused by either physical or mental health problems caused by the military service.

Radner: We're also now starting to see new veterans. During the Vietnam War, homelessness was something that happened a number of years after their service. With the Iraq and Afghanistan conflicts, what we're finding is that people are falling into homelessness faster. That may be due to the state of the economy. That may be due to the state of the housing market. That may be also due to the fact that the people who have been in those two conflicts saw a great deal of military action.

Sosin: It's also a different select group; right? It's now a volunteer army.

Radner: It's a volunteer army, right. We are finding many more women than we used to who have PTSD. While they weren't in combat, per se, they saw a lot of trauma and explosions and are suffering from that. And we're finding that there are not a lot of resources for the woman vets and their kids. And so one of the things that we're doing now is working with the Veterans Administration to see if we can increase the resources for these women.

There's another way that in the field we look at homelessness, which is less about attributes and circumstances and more about the time homeless. A study that has been very influential talks about people who are homeless falling into three categories. I'm sure you're familiar with this.

Sosin: Sure.

Radner: Episodically homeless, transitionally homeless and chronically homeless. Episodic are people who become homeless for a while and then get housed and then become homeless again, like, perhaps, some of the Streetwise vendors. They are people who are able to put some income together for a while but not long enough to sustain housing permanently.

The transitionally homeless are people who have one crisis in their life, they become homeless for three months or so, and then it's over for them, and they don't become homeless again. We tend to think of this group mostly as families. I'm interested to see if our evaluation can tease that out at all. I think we know the least about families in terms of their patterns of homelessness.

And then chronically homeless are the ones that are homeless for an extended period of time or several periods of time over a year or two. And what studies are showing us is that they were the most expensive in our system. They used the most resources, but we were having the least success with them, until we instituted our Housing First policy, which is having great success. Over a four-year period, we were able to bring street homelessness down by more than 47 percent.

Sosin: So exactly how does your organization relate to the city and how does it fit into the system?

Radner: The Chicago Alliance to End Homelessness is an organization that works through four different strategies. One is implementing Chicago's Plan to End Homelessness, which we actually helped create a number of years ago. A coalition of about 300 individuals, government partners, philanthropists, consumers and service providers all got together and drafted this plan. Chicago is unusual in that way. We have a very strong public/private partnership in all the work around homelessness.

This plan was finished in December of 2001, and we spent the next year convincing Mayor Daley that this was something he should be involved in. In January 2003, he held a press conference announcing that he was signing onto it.

So, since then, the Chicago Alliance has had a strong partnership with the city to implement the Plan to End Homelessness.

Another thing that we do is to deliver the HUD money which pays for those 6,600 units of permanent supportive housing, among other things.

Sosin: Your agency helps decide who receives the money?

Radner: It's is a community-based process. We do it through a planning body called the Chicago Planning Council on Homelessness. We help staff that process and make sure it gets done, and then we file the 3,000-page application with HUD every year. It brings, this year, about $49 million in annual funds.

We also bring a lot of best practices into the system. There are a number of interventions that are proven around the country to work, and Chicago is the lead in utilizing many of these. A good example is something we call "harm reduction housing," which is special housing that is proven to work very well for people who have mental illness and substance-abuse problems.

We also do a lot of advocacy at the federal level particularly, but also the state and local level, to create resources and opportunities around homelessness. We work a lot with Senator Durbin's office and with the Chicago Congressional Delegation, which has been, for the most part, very responsive.

Sosin: How do you manage to keep the relationship with the city working? That must be central to your job.

Radner: I think it helps that there's a division of control. The city controls city resources; the Chicago Alliance helps manage federal resources. I think that was HUD's intention, basically, to use a community-based process so that the community would have control over some of the major significant resources.

The rest is sort of how do you manage any relationship? Through as much goodwill as possible. I'm always moved by people in this field because there's no glamour in it, there's very little financial reward in it. People are here because they have a vision of helping, and it is the ultimate expression of social work in my mind, because you take some of our most ignored people in society. And you tell the world how valuable and important they are and you help to give them a second chance or a third chance, whatever they need.

What is amazing about this work is to watch people take those chances and to see them come out of a significant trauma or a difficult financial situation and regain their footing, and then they're back in society. So the people that are attracted to this kind of work are people who put heart and soul first. I've found it's very easy to find common ground because of that. 

The text above appeared in the printed version of the spring 2011 issue of SSA Magazine. To read the rest of the conversation, which appears only on the web, click here.