Why the Treatment First Approach, Beloved by Republicans, Is Dead Wrong
by Vivian McCall
For four years, 43rd Legislative District candidate Andrea Suarez has preached the gospel of her nonprofit, We Heart Seattle.
Her gospel teaches that waste management is a form of mutual aid, even when volunteers allegedly throw away someone’s belongings. It also teaches that Housing First–the primary, evidence-based approach to homelessness, which is backed by decades of research–is an ineffective and cruel machine that chews up the vulnerable people she is trying to help. In the word according to Suarez, drugs–not economic conditions–drive homelessness, and mandatory treatment is the only way forward. As she tweeted last month, “Treatment is Housing.”
This ideology drives Suarez’s campaign–it’s practically the only real plank in her platform–but she did not create it. She shares the view with We Heart Seattle board member Michael Shellenberger, a writer who has also taken firm stances against the urgency of climate change and gender-affirming medicine. The conservative Cicero Institute, and organizations like the Discovery Institute and the Texas Public Policy Foundation, which are tied to the Heritage Foundation’s Project 2025, also sing this song. They’ve all linked arms in a march to effectively deem Housing First inhumane and insensible.
Though these people, institutions, and ideas emerge from the far right side of the political spectrum, Suarez is running for office as a Democrat. But as a self-described “pragmatic” Democrat, she’s unbothered by those associations. When it comes to homelessness, as she told me in August, she trusts the reality she’s seen with her own eyes: Seattle is not in a homelessness crisis, it is in a drug epidemic crisis.
This view is an outlier in Democratic state politics. In fact, if elected, she’d have more in common with Washington GOP Chair Jim Walsh on this issue than she would with the Democratic leaders on the State House’s Housing Committee. Nevertheless, with this banner she hopes to beat progressive activist and Statewide Poverty Action Network lobbyist Shaun Scott in the race to replace House Speaker Emeritus Frank Chopp to represent an area that includes the University District, Wallingford, Capitol Hill, South Lake Union and Madison Park. If she succeeds, she could use her position to dramatically amplify this fundamentally flawed theory.
Why We Know Housing First Works
Contrary to hyperbolic assertions from some advocates, Housing First does not mean Housing Only. Under the Housing First model, a homeless person is taken off the street and placed in housing with readily available substance use disorder and mental health treatment provided by trained social workers and case workers. However, people accepted into these programs are not forced into treatment, and administrators will not immediately kick them out if they fall off the wagon. Some struggle to wrap their minds around this approach, but when done right it works better than any process we know.
Housing First emerged in the 1990s, a decade after what researchers consider the birth of modern homelessness. While there will always be some percentage of the population that ends up homeless because they struggle to conform to social norms, a recession in the 1970s, subsequent cuts to Housing and Urban Development, high unemployment, deinstitutionalization of people with mental illness, the decriminalization of public intoxication, and austere, Ronald Regan-era cuts to social programs for poor and disabled people coalesced into an economic and social bomb cyclone that swept people into the streets in record numbers.
At the time, homeless people looking for a roof over their heads had to ascend the “staircase” model of treatment. They progressed from shelters to strict transitional housing programs that mandated training and treatment until they proved they were “ready” to live independently.
New York City’s Pathways to Housing flipped this paradigm in 1992. Founded by Greek-Canadian clinical psychologist Sam Tsemberis, the program offered stable housing first—in the form of subsidized apartments scattered across low-income neighborhoods. Tsemberis and his colleagues reasoned that people could better address their traumas, mental illnesses, and physical illnesses once they found stable housing. Unlike the rigid linear model, institutions did not push people back a step for using, drinking, or losing a grip on their mental illness. An agency not founded in congregate treatment programs encouraged people to stay, arresting a cycle of chaotic, chronic homelessness. A five-year study found that 88 percent of people who entered Pathways remained housed, a far higher success rate than the 47 percent found in New York’s residential treatment system.
In the years since Pathways laid the foundation for Housing First, researchers have gathered sheaves of evidence that supports the model. Two randomized controlled trials conducted in the US have found that Housing First programs house people faster and offer greater housing stability than treatment programs. A randomized controlled trial from Canada found that Housing First participants in five cities reported a better quality of life and spent 73 percent of their time in stable housing, while those in treatment-based programs were stably housed 32 percent of the time. In 2020, systematic review of 26 studies of Housing First programs found an 88 percent decrease in homelessness and a 41 percent increase in housing stability compared with treatment programs.
In 2009, the Journal of the American Medical Association published a study from Seattle’s pioneering Downtown Emergency Service Center, which housed people who struggled with alcohol at its 1811 Eastlake apartment building. Researchers found the apartments, which permitted drinking and provided on-site services, were more cost-effective than allowing people on the street to cycle through the City’s jails, hospitals, detox programs, and Medicaid-funded services. Taxpayers saved an estimated $4 million in the building’s first year of operation. A two-year study at 1811 Eastlake in 2012 found residents drank 8 percent less on their heaviest drinking days for every three months they stayed; after two years, residents cut consumption an average of 35 percent.
A later meta-analysis echoed DESC’s success, finding that Housing First programs reduced costly visits to emergency rooms and time spent in the hospital without increasing “problematic” substance use. One study in Chicago found the approach saved more than $6,000 annually per homeless adult with a chronic medical condition, and nearly $10,000 per year for chronically homeless people. Researchers estimated it could save $5.5 billion at scale.
Why People Think Housing First Doesn’t Work
In conservative media today, operatives portray Housing First as yet another example of Marxist nonsense run amok in America’s blue cities. But for about two decades, Democrats and Republicans actually saw eye to eye on the issue.
Hardly Marxist, George W. Bush’s administration established Housing First as a best practice at the federal level. The federal government doubled down under Obama. Between 2007 and 2016, the number of people experiencing chronic homelessness fell from more than 119,000 to just over 77,000.
At first, this trend continued under Donald Trump, whose Housing Secretary, Ben Carson, praised the approach. But after Trump’s Council of Economic Advisers published a report expressing skepticism of Housing First, the former President changed course. He pushed out Matthew Doherty, the Obama holdover leading the Interagency Council on Homelessness, and–to the horror of homeless advocates–appointed Robert G. Marbut, a fierce Housing First critic and current fellow at the conservative Discovery Institute in Seattle. Marbut left the agency shortly after Joe Biden took office in 2021.
Around the same time, conservatives seized on homelessness to open a new front in the culture war. As they told it, homelessness was not a broad economic consequence but rather thousands upon thousands of personal failures manifested as visible, unsheltered living, people with mental illness phasing in and out of psychosis in public and record overdose deaths.
They blamed Housing First for coddling people and wasting heaps of government money to enable drug addicts, transforming gutless, liberal, dependably Democrat-voting cities into needle-strewn, pooped-upon wastelands. Conservatives pointed to instances of failure inside low-barrier housing–dirty, trash-strewn apartments, inadequate services, violence, overdoses, and murders–to define Housing First as brainless dogma that lent vulnerable people a place to destroy themselves. From this perspective, a return to conditional housing seems inarguable, even obvious.
It’s neither, but more on that later, because this faulty argument has been incredibly persuasive, partly because it appeals to American bootstrap thinking and assumptions about why and how people become homeless, and partly because people believe what they see. And they did see homelessness rise to new heights.
Last year, HUD recorded a record-high count of 653,104 people on a single night in January 2023, a 12 percent increase over the year before. That’s likely an undercount, as point-in-time data collection represents an assemblage of limited snapshots from regional organizations all over the country. The agency’s report also found a sharp rise in people becoming homeless for the first time, and the highest-ever number of people living in temporary shelters like tents, tarps, and cars. Another HUD report found that more people were chronically homeless in 2022 than in 2007. In Washington, homelessness had increased by 11 percent.
In the face of public outcry, Democrats in liberal cities and counties have variously failed to raise enough money to build enough supportive housing and shelter for everyone who needed it, failed to overcome political opposition to siting those projects, and in the meantime turned to quick, off-the-shelf solutions, such as criminalization, sweeps, and appeals to philanthropy.
Conservatives on Seattle’s city council have praised Suarez and We Heart Seattle. In July, Council Members Tanya Woo, Bob Kettle, Sara Nelson, and Joy Hollingsworth posed with a Suarez sign outside her campaign event. None of them returned a request for comment.
What’s Eating Andrea Suarez?
Suarez says she was not politically active before her personal crusade against homelessness in 2020, which initially involved picking up trash and needles off the street. She told KTTH host Jason Rantz in 2021 that she had trusted the government to do the right thing, but she and others were “waking up,” asking where their money was going and why the problem seemed to be getting worse and worse. In an interview with The Stranger, she said her knowledge of what does and doesn’t work is based entirely on what she’s learned through We Heart Seattle. That’s not entirely true.
Suarez says she met Michael Shellenberger online in 2021, about a year after she launched her nonprofit. She was the “girl next door” starting a movement; he was the failed gubernatorial candidate writing a book (🎶Can I make it any more obvious?🎶).
Published in 2021, San Fransicko: Why Progressives Ruin Cities, proved a revelatory read for Suarez. She says dog-eared “every single page” while thinking, “Wow, that’s exactly what I saw… That’s exactly what I heard about people who are living in crisis and in low-barrier housing.”
Shellenberger’s contrarian thesis–that mental illness, drugs, and “disaffiliation” from society were fueling out-of-control homelessness in West Coast cities–has struck journalists and policy experts like Ned Resnikoff as misleading. Resnikoff, the senior policy director of California YIMBY and former policy manager for University of California San Francisco's Benioff Homelessness and Housing Initiative, says Shellenberger is essentially a con artist, but he understands the appeal of his view to a frustrated electorate. “We do have to grapple with the fact that these interventions have not had the impact that we’ve hoped they would in California,” he says. “Now, the explanation for that is not the explanation that Shellenberger would provide.”
Suarez visited Shellenberger’s home in the fall of 2022. In his backyard, where she claims he sized her up over a bowl of grapes before handing her a $15,000 check to organize a leadership conference in Seattle to help found North America Recovers. Shellenberger did not respond to requests for comment. According to a guest list to that conference posted to Eventbrite, Suarez invited a who’s-who of predominantly conservative figures; leaders of libertarian and far-right think tanks, and boots-on-the ground iconoclasts such as herself. Suarez says she and Shellenberger wanted to invite people who were hated for their maverick positions.
Suarez’s local star has risen in four years. She’s spoken dozens of times on conservative podcasts, web shows, and radio, relentlessly promoting her organization in a brash, uncompromising style. “What I look at is, every day I go outside, I put my boots on, and I bust my ass every day,” she says. “And I’ve done it for four fucking years.”
The folk hero attitude helps sell Suarez’s schtick. We Heart Seattle’s social media feed, as well as her own personal page, is a blur of smiling volunteers summiting mountains of trash bags, as well as homeless people she’s photographed in crisis and those allegedly bound for residential drug treatment. Its website displays two running totals: pounds of trash collected (1,325,600) and number of people the organization says it’s helped off the streets (225). She claims cleanups have united people from across the political spectrum, and that her board is far from politically homogeneous. When she talks to people while doorbelling, she says people just want a nonpartisan debate.
Suarez projects indignation about anyone living their life outside. To solve that issue, she’s willing to work with anyone, no matter who they are or what they believe. She says she talks to conservative media so often because only conservative media let her sound the alarm against the status quo on the basis of subjective experience. During our interview, she claims to have no insight into the various agendas of her far-right allies–Democrat or Republican doesn’t matter if you’re saving lives, she says–without considering why agendas matter. Project 2025? Never heard of it. Suarez is focused on the world at her feet and what she can tangibly see, touch, feel, and believe. She’s “all practice, and no theory,” and “that’s refreshing.”
“When we think about what progressivism means, it means for progress, right?” she says. “And for results. There’s just a lot of frustration in our community and our constituency base saying what we have been doing is not yielding outcomes for those very-well-intended ideas.”
That said, Suarez’s public rejection of Housing First policy has made enemies with some in the homelessness services and activist communities. The activist website We Heart Seattle Exposed portrays Suarez as a harmful charlatan, accusing her and her volunteers of allegedly throwing away peoples’ belongings without asking, showing up to city-sanctioned sweeps to offer temporary housing in exchange for their outdoor gear only to withdraw that support days later. In an interview with KIRO earlier this year, Suarez dismissed those claims as schoolyard bullying. When the reporter asked if she had a license to do any of this work, Suarez turned the question around on him, asking if Jesus Christ had a license.
It’s Easy if You Believe
Everyone, Suarez included, intends well, and she intends to stop homeless people from taking drugs. As she tweeted to the King County Regional Homelessness Authority the day the Supreme Court ruled on Johnson v. Grants Pass, which allows cities to fine and jail people who sleep outside even if they have nowhere to go: “Treatment solves homelessness for people illegally camping in parks and in [sic] sidewalks. We coordinate pathways to sobriety and self sufficiency daily. It’s easy when you back out ideology.”
What she and other Treatment First advocates like her don’t explain is how abandoning a more effective approach for a less effective approach will result in a better outcome. Or how any approach designed to help people who are already homeless solves for people becoming homeless in the first place, and why drugs are the singular explanation for everything.
“This idea of defunding Housing First, it’s extreme,” said Rep. Emily Alvarado, vice chair of the State House Housing Committee. “It's out of step with data and experts, and it will mean–make no mistake–it will mean more homeless people and more encampments on our streets.”
It’s true that substance use disorder can lead people into homelessness. It is also true that sober housing and transitional programs can be effective.
As noted Department of Veterans Affairs homelessness researcher Jack Tsai wrote in an editorial published in the American Journal of Public Health, some research has found limited success on clinical and social outcomes, as services can vary from program to program, all with differing levels of fidelity. Tsai concluded that more research is needed to determine who benefits most from Housing First, and what housing models may serve as “effective alternatives … when appropriate and necessary.”
But drugs and homelessness have a bidirectional relationship: Sometimes drugs cause homelessness; sometimes homelessness causes drug use.
Like housed people, some homeless people take drugs to cope with depression, anxiety, and trauma; being homeless is incredibly depressing, anxiety-inducing, and traumatic.
Drugs do not push the majority of homeless people onto the streets. A recent California study of 3,200 homeless people–the largest and most representative sample in decades–found that 50 percent had not used drugs in the last six months. Of the half who had used drugs, 40 percent began doing so more than three times a week after they became homeless. Of that subgroup, 31 percent used methamphetamines. The researchers also interviewed more than 300 homeless people and found those who frequently used meth did so to stay awake to protect themselves and their property.
A growing body of research suggests systemic forces of housing prices may better explain variations in mass homelessness far better than the latest superdrug allegedly supercharging America’s homelessness crisis, or any assortment of subjective human behaviors that we can see, smell, react to, be scared of, judge, or place blame upon.
In the 2022 book Homelessness Is a Housing Problem, University of Washington real estate professor Gregg Colburn and data scientist Clayton Page Aldern analyzed city-level data and found no evidence that drug use, mental illness, and fine weather explained why some cities had more homelessness than other cities. Vulnerable people lived everywhere, but homelessness was highest in the cities with the highest housing costs. The more expensive housing becomes, the greater the chance that the poorest people will not be able to afford housing and end up homeless.
A 2018 study from Zillow found that homelessness grew fastest in areas where average rents exceeded one-third of income. If drugs caused homelessness, end of story, then the state that leads the country in drug overdose deaths should also have high homelessness. But West Virginia, which is flush with cheap housing, boasts less homelessness per capita than almost every other state.
A working system can only serve as many as it is designed to serve. If people are becoming homeless at higher rates and officials fail to expand the Housing First approach to meet increased demand, then the approach can stem the flow of homelessness, but it cannot keep pace with it and never put an end to it. Such deficits do not reveal problems with the baseline policy but rather problems of scale, proportion, and function under the right market conditions.
Housing First works better in Houston, Texas than it does in Seattle or San Francisco because housing is relatively cheap and abundant, meaning that people are not becoming homeless as fast and providers can more easily find and cheaply buy buildings for Housing First programs.
Suarez is rightly indignant about thousands of people living outside in a fabulously wealthy city, and that Housing First can fall short of its ideals and fail people, but from a zealous point of view, each instance of failure provides proof that she is right and the system is irrevocably, tragically wrong.
This black-and-white vision of Seattle leads to false conclusions. People live outside because of the circumstances that push them into homelessness, not because of institutions designed to pull them out. Sober housing programs can work for the right person and can supplement Housing First without replacing it. People overdose in low-barrier housing not because they’ve been enabled to die but because a fundamentally good system is being pushed beyond its limits, its staffing levels, and its allocated funding.
“People are flowing into homelessness because of the broken housing system, but that's the failure of our elected officials to address the root cause of homelessness, rather than the failure of the homelessness system to get people out of it,” says Eric Tars, senior policy director of the National Homelessness Law Center.
The irony is that all the energy and time spent attacking the premise of Housing First kills the opportunity for a nuanced conversation about how to make it better. And while we quibble over all this from the safety of our homes, nothing will improve for the people without them.
In five weeks, voters will have the option to cast their vote for Suarez. She says that people often ask her what she thinks about transit, education, gender-affirming care, property taxes, and “all the policy positions that overnight I needed to be up to speed on,” and that’s not why anyone should vote for her. They should vote for her because of how she thinks and how she solves problems. In other words, she’s asking voters to go on faith.
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