Treat, house or shelter. Which comes first?
The best ways to address homelessness and drug addiction in Portland
Portland and Multnomah County are in a debate on Housing First. So are red states and blue states nationally. The current administration’s Housing and Urban Development (HUD) has weighed in on the issue using allocation of federal dollars as a lever. HUD wants to give precedent to Treatment First for those with behavioral health issues and will withhold money for housing those people with behavioral health conditions until they are treated. To top it off, the federal funds are withheld if state funds are mixed into the treatment and housing process. Very limiting for a state like Oregon. Nineteen states have sued HUD seeking to reverse this decision, claiming it is unlawful. They want Housing First as the status quo. So, who is “right”?
Turns out, it is really complicated, but Housing First is not working as planned.
Housing First has been national policy for a long time and is sacrosanct in blue states like Oregon and especially in Multnomah County. Only recently have knowledgeable groups in those states started to question the actual viability of Housing First and whether it is counterproductive in the way it has been implemented for those with behavioral health issues. Few would argue that a person suffering from drug addiction or psychosis would have a better shot at stabilization housed than on the street and that permanent housing would be better than just temporary day and night shelters. That’s common sense. But that begs the question “Is there enough money and staff to treat them while in housing and is some level of treatment needed before they are placed there?” It turns out there is not enough money, and Housing First, literally applied, results in a reduction of the availability of housing. We have skipped or scrimped upon the treatment too often, especially in Multnomah County.
Central City Concern (CCC), the Portland Metro’s largest provider of integrated behavioral health and affordable housing services, recently released a study of affordable housing units statewide and found that nearly 6,000 Metro area affordable housing units are either in foreclosure (1,785) or are operating at negative cash flow unsustainably (4,181). This number includes their own units. Recent articles have shown negative cash flows for Portland’s Housing Authority, Home Forward, for the same reasons. While the city, county and state struggle to produce new deeply affordable units, affordable units sit vacant while building permits for any housing units are falling off a cliff. Why?
According to Dr. Andy Mendenhall and his co-author, Brooke Goldberg, J.D., it is partly because the original assumption of Housing First was that those with behavioral health issues would get strong supportive treatment at the same time they are housed, presumably after going through a detox period for those with addiction. For those with psychosis, it is stabilization with medication and someone to ensure they remain on that medication. Turns out, in practice, we have been overemphasizing the housing and underestimating the treatment needs. Multnomah County has been using funds to rush people into housing but de-emphasizing the need for treatment and recovery. We have spent millions on a deflection center and harm reduction and shortchanged the actual continuum of treatment that leads people with addiction to recovery and those with psychosis to stabilization. For instance, we have recently discovered that only a handful of those who went through the deflection center engaged in any meaningful treatment and even the plans for the sobering center felll well short of what is needed to really get people on the road to recovery and ready for permanent housing.
How does skipping adequate treatment shrink the affordable housing supply? By focusing on getting the most vulnerable on our streets, arguably those with behavioral health illnesses, into housing before they are ready for it and without the supportive services to support them when in housing, they are at once damaging the housing they are in, leading to costly repairs to units followed by units out of use. Untreated tenants are getting evicted in large numbers and their untreated illness deprives those in serious recovery needing sober housing from it. And discouraging those without behavioral health issues from accessing affordable housing they need, by creating an unhealthy environment to live in. But most of all, it increases costs or affordable housing providers, deprives them of revenue and subjects them to loan defaults. It deprives the state and Metro of the very commodity it is desperately trying to create, deeply affordable housing. Finally, it provides additional risk for developers contemplating new affordable housing. The perfect doom loop.
We should be asking ourselves another question. Why did it take a not-for-profit provider, CCC, to do this research and connect the dots? The governor has declared a housing emergency and convened experts to advise her. We have acknowledged a behavioral health emergency in the metro area and in Portland, as well as a housing emergency. We know we have a homelessness, public safety and livability crisis in Portland. Yet, neither Metro, Multnomah County nor the state have bothered to publicly connect the dots? I have an opinion, which I can hopefully provide later, about our crisis of public service and government competence, both of which I believe we badly need.
In the meantime, I do not dispute the lawsuit against HUD. We need more flexibility to address housing those with behavioral health, and we need to use any source of funding available to accomplish that. But rather than waiting years to address it while the lawsuit is pending, let’s develop a plan to use the resources we do have to address those living on our streets. There is clear evidence the feds are correct about Housing First as Multnomah County has implemented it. Treatment is needed and if not voluntarily accepted, we need to ensure it is done through civil commitment, jail or diversion as a condition to receive permanent housing placements, or we will be wasting housing resources.
Portland’s mayor is already doing what he can with the power to create shelters. These are interim steps in emergency, not a permanent solution. The county has control of the homeless and behavioral health funds and the policies to deploy them. We do NOT need their status quo. Metro is the major collector and distributer Supportive Housing Tax funds. There is work to be done there as well to ensure that funds are distributed according to demonstrated need, which flows into it from the rest of the metro. We need to talk about that later, too. But first, let’s stop the bleeding.
Readers already have my opinion on what we should do to get those with drug addiction on a path to recovery using a pilot program with a 30-day civil commitment, peer support and the unused dorm beds at the Inverness Jail. We need to start the pilot now and elect the right leaders at the county and on the City Council District 4 in the November 2026 election.
Dick Perkins confounds many who would put him on the spectrum of local attitudes on social issues. A former heroin addict and homeless person who later had a successful career in banking, he balances the needs of people suffering on the street with the interests of the wider community. He advises the Behavioral Health Resource Center and public officials on related issues. Read his recent opinion piece in the NW Examiner, Free will, ‘housing first’ strategies not working.
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Very thoughtful article. It's kind of shocking to see how slowly our local government is, in responding to the facts on the ground. Alan Evans of Bybee Lakes has been saying for years, "If you put a sick person in a house, you get a sick house." Also, everyone who works with the acutely ill people on the streets knows that most are not able to advocate for themselves; they are doing well to survive, much less make the right decisions about their health and security. Outreach professionals tell me that of every 100 people they connect with and offer services to, 95 decline because they prefer to continue their current life on the street. If we leave it in their hands, we will never be able to restore livability for the public at large.
Your article reminds me of the fatality a few months back of a man who was extremely psychotic, hanging knives out his windows, and when the police arrived ended up dead before he could be transported to a hospital. Housing first was always a way of warehousing the severely mentally ill. The culture in our city seems to minimize the severity of those suffering with severe mental disorders and underestimates the necessity of a good civil commitment capability. We have a systemic problem with the unavailability of hospital beds for those who are severely mentally ill, going back 20 years when emergency rooms started having to keep patients for days at a time, because of a lack of beds. The medical community has largely avoided this population because the laws governing hospitalization are impractical, lead to wasted efforts, and unreasonably focused on the right to refuse treatment in the face of obvious need for it. The recently passed HB2005 is an improvement from years of an overreliance on the "imminent dangerousness" standard. But it is administratively burdensome and takes too long to institute. It also defers the immediate decision of civil commitment for weeks, disregarding the liberty interests of those with severe mental disorders in the meantime.
A stronger criminal justice system and a stronger mental health system are necessary to improve neighborhoods and help the severely mentally ill homeless. Jail, followed by treatment under a civil commitment statute, for those who break public laws, rather than treatment in place of jail is a better balance. When is the city going to stop bending over backwards to accommodate those whose illnesses and choices defy ordinary and reasonable social conformity? It is going to take a politically savvy person to build up community support for effective and relatively short-term hospital care. A good place to start is to get judges deciding commitment in hospitals instead of in their usual chambers. A public emergency demands some creativity and innovation. Psychiatrists will jump to work in a system that can provide reasonable patient outcomes but will say no to a system that releases people back on the street after 3 days who will just go back to their old ways. Also, the police will be much more likely to go to the trouble of taking people to hospitals if they know there is a reasonable chance of not being such a bother to communities and or so obvious destructive to their personhood.