This interview was conducted by Contributor Vendor Shawn L. with assistance from Judith Tackett. It was produced with the help of The Contributor’s Vendor Leadership Team: Lisa A., Keith D., Shawn L., and Pedro L.
As part of the 2025 State of Homelessness Symposium in Nashville, globally recognized advocate for ending homelessness Dr. Sam Tsemberis, came to town to deliver a short speech as a part of the daylong event.
Ahead of his speaking engagement on June 4, Tsemberis met with Contributor vendors and staff in a hotel in Hillsboro Village to chat about his experience in homelessness advocacy and leadership. Tsemberis talked about beginning this work in the late ‘80s.
“I was living in New York City during the early years of the Reagan Administration,” he said. “When Reagan took office, just like the current regime, they were going to cut federal services, like HUD (Housing and Urban Development) and HHS (Health and Human Services). They were going to cut funding for all of these services.
“Reagan’s economic policy was called ‘supply-side economics,’ that provided cut taxes for the rich and corporations, and the wealthy would create jobs and the wealth would ‘trickle down,’ to the rest of us — ‘trickle down economics’ right?”
Tsemberis said that many economists called this approach foolish and warned that if HUD programs, especially public housing were cut, the country would soon see people lose their homes and wind up on the streets. That prediction turned out to be true.
“Before this era, the U.S. was building 350,000 units of public housing a year,” Tsemberis said. “After that, it went down to practically zero. And that’s where it’s been all of this time, through Democratic and Republican administrations. No one’s building public housing. No one’s talking about it. That was the end.”
At that time, Tsemberis was living in the East Village in New York City. He is trained as a clinical and community psychologist and was working at Bellevue Psychiatric Hospital. “I’m walking to work, and I start seeing people on the streets.”
He recalled seeing people under staircases, hiding. They were ashamed and did not want to be seen.
“Then I started seeing some of the people on the streets wearing Bellevue pajamas,” Tsemberis said. “People were just discharged from the hospital and they’re on the street. People I’d seen the week before in the hospital!”
That’s when he decided to leave his job at Bellevue Hospital and took a job as director of New York City’s Emergency Outreach Team for the Homeless at the New York City Health and Hospitals Corporation.
“Our team drove around the city in a van, going to different parts of the city where people who were homeless were staying, getting to know them, and getting to understand how they got there, and what they needed to get out of there.”
You are credited with developing the Housing First approach. How did you come up with this approach?
I’m credited with coming up with the Housing First approach, but frankly, I never called it the Housing First approach when we were doing it. The group of us that was working on the streets, were trying to help people who were on the streets get housed.
There were already some housing programs for people who were homeless and had mental health or addiction issues. But these programs required that the person on the street to be sober, to take medication in order to get the house. Then they had to follow rules, curfews, and a lot of requirements.
The people who were on the street weren’t interested in seeing a psychiatrist or going to rehab. They wanted a place to live — just a safe, decent, affordable place to live. So we were [saying], “Alright, let’s see if we can make that happen.” Because we were committed to helping them with what they wanted most, which was housing not treatment. I was a little bit out of my league there because I know about treatment. I didn’t know much about housing.
We wrote a grant. There were grants available through the New York State Office of Mental Health for a program called supported housing, which provided funding for rent and case management services. We were awarded the grant, and we started. We went back to the people on the street and said, “So, you want an apartment? Let’s go find one.”
And we just started putting people in apartments. It was very scary because we didn’t know if they would do well, or if the neighbors were going to be OK. All these other programs were not housing these people, and maybe there was a reason for that.
But there was no reason. People did extremely well in housing right from the start. They had a place that was safe and secure. The housing itself was medicine. We called it “the apartment program”. We have an outreach program, now we have an apartment program.
People from other cities started to visit this program to see what we’re talking about, “Hey, you don’t have to put people in a shelter and then a detox, and transitional housing and respite housing and emergency housing, and then provide housing maybe at the end. You can have people go right from the street into an apartment,” I said. “After they are housed, then we provide treatment. We visit with everyone in the apartments asking, ‘How are you doing?’
[The response we got from these visits was,] “Oh, you’re doing it backwards. You’re doing the housing first, instead of the treatment first.”
So we said, “Yes! We’re doing the housing first because that’s what people want.” And that became a kind of shorthand catchy way to describe the program: Housing First — as opposed to treatment first. So, that’s how we came up with it.
It was really because we were honoring the thing that mattered most to people who were homeless: housing, first.
What city doesn’t have homelessness, meaning that they make sure everybody has housing and has a place to go to?
There’s lots of cities that don’t have homeless people. They’re usually small cities in Europe. European cities, especially in the north and west of Europe. I’m talking about the Netherlands, Belgium, Denmark, Sweden, Finland. In those cities, the smaller cities especially, there is enough housing and of course every citizen has a right to health care. Every citizen has a right to housing. Those countries still have strong public services and safety net services and sizable public or social housing programs.
We’re the only country that has stopped building public housing. We still don’t have healthcare as a right. And we certainly don’t have housing as a right. So, in countries that have robust support services, they don’t have as many people who are homeless to begin with. If anyone loses their house for whatever reason, they can help get them back into homes.
In this country, the way that for profit housing and the real estate market works, housing supply is low and demand is high so rents continue to go up and since wages are not increasing as quickly as the rents, people don’t have enough money to pay the rent. There is more homelessness in the bigger cities, especially those cities are being quickly gentrified. Nashville is rapidly being gentrified, and the risk is that homelessness will increase here. Homelessness is also related to income disparity. We have the very wealthy and people who don’t have anywhere near as much. And then there’s the people who have nothing at all on the streets.
The income disparity is much less in Europe because in most countries, the tax system is one where the more you earn the more tax you pay. Millionaires pay 80-90 percent of their profits in taxes. We used to have a similar tax system here. That was changed with supply side economics. A fair tax system makes for more equitable societies. There are funds for social services. In this country, we have a huge deficit because the wealthy and corporations do not pay a fair share. The real estate market is unregulated. So all the new housing going up around Nashville is being built for people with money.
This kind of construction, the modernization and gentrification of American cities, which is going on pretty much everywhere, creates more homelessness. Homelessness is the product of very successful cities. Most homelessness is on the coasts — from Seattle to San Diego, down through California, and on the east in New York, in Washington. Now Nashville is getting into that kind of economic boom, and you’ll see homelessness going up here because in every city where the rents start going up, so do the homeless numbers.
Many cities say they’re doing Housing First, but are they really? What is lacking?
For most places that say they’re doing Housing First, if they’re not, it’s usually because what is lacking are the support services for people. In a housing program where a case manager has 40 clients, that’s not nearly enough support. You need to have the client-caseload ratio of 1 to 10 [or] 1 to 15 because the people housed by housing first program, just coming in off the streets, they have complex needs and need a lot of visiting, a lot of support to settle in and to begin to get their lives back on track.
The whole point of the support services is to be able to check in on the person. Are they eating right? Are they keeping the place clean? If they’re using drugs, is it safe? Or what else is going on in their lives? Do they have too many guests or guests that overstayed their welcome? Is the unit being kept well and is the person safe and secure? That’s what the social services do. They keep an eye on the person and ensure they are adjusting well to being housed.
That’s what a good Housing First program does: visits frequently, cares about how the person is doing, cares about the condition of the unit. You don’t want people to get evicted because they’re hoarding or they leave their garbage in the hallway. These are the main violations [we see when] the service support is not sufficient.
But there’s also the fact that Housing First always had two rules. One is, you have to meet the terms and conditions of the standard lease. The lease for you is the same as the lease for me. We all have to do the same thing as tenants because we’re living in a building with other people as a community. We have a responsibility to that community. We’re not going to bend the rules for anybody. If it’s hard for you to manage the rules, we’re here to help you. But you have to meet the terms of the standard lease. That includes paying 30 percent of your income for the rent. Usually it’s SSI, or public assistance, and if it’s nothing, people pay nothing. But you have to pay 30 percent of your income. There’s some sense of ownership and responsibility in that.
The other thing – and this one often gets lost or is misunderstood because in this program you don’t have to be in treatment, and you don’t have to be sober. But still, you have to agree to a home visit. Treatment is an option. Treatment is not required. But the home visit is not an option. It has to happen.
Staff has to figure out a way to visit the person, make sure they’re doing OK. That’s not punitive. That’s not like, “Let me see your place or else.” You’ve got to make yourself useful and be someone that the tenant sees as a helpful person, so they’ll open the door for you. You have to finesse your way to the visit. You can’t coerce your way to the visit. So you have to do it with kindness, you have to do it with compassion and respect. Not with authority or a threat. But the visit is a requirement. The staff has to be trained well enough to figure out how to make the visit happen.
And if you have just given someone an apartment from the street, and they don’t want to see you, there is something wrong in that relationship; and I’m going to look at the staff member who’s getting paid to do his job [and ask], “What went wrong here?” Because most people are like, “You just gave me an apartment, of course I want to see you. Thank you!” You’ve got a big running start there. Mostly the visits go well but there are always situations that are challenging.
So, most programs that say they’re doing Housing First, and they’re not doing it, they usually do not provide enough social services, caseloads are too high, and they misunderstand the concept of choice.
In Nashville, we have a lot of handoffs between organizations on the path to supportive housing. How do you retain and maintain that relationship from street into supportive housing?
The best way, and the most effective way is when you can have the same person who’s doing outreach hand you the keys to your apartment and also be the person that’s knocking on your door to visit. That’s optimal. But because we live in bureaucracies, money is for outreach and money is for this, or money is for that. You have people handed off from outreach to the coordinated entry system, and from the coordinated entry system to the provider and then the case manager, who’s not part of the housing provider but a different organization – it’s like we’re treating people as if they’re packages. This isn’t FedEx. These are people, and the relationship matters.
For every handoff, you risk losing the person’s trust, you lose immediately all the goodwill you’ve built up on the way there, and you lose the opportunity for the continuity of knowing the person that you’ve housed and knowing something about them [that could] give you a running start. It’s a terrible system.
It really requires a lot of effort on each of the players’ parts to try and create this through-line. I introduce the person to you, and a couple of times we see them together, and we do it gently, and we do it thoughtfully so that we can assure the person that we’re all on the same team. We’re all going to treat them the same way.
I mean one of the problems is you have outreach workers who are kind and engaging and friendly, and then you hand them over to [other transitional supports] and [there are a lot of different rules to follow]. It’s different philosophies, different approaches. It would be good if we were all on the same page because the system we’ve set up is riddled with gaps where people can fall through those holes.
What is one thing that cities like Nashville could improve to make a difference?
Same thing that any city could do. If we can create more housing opportunities for people by having more housing choice vouchers that are paying the rent. Where you can actually find rent and rent the affordable units, the few that are still remaining. There are a lot of organizations doing good work, but the provision of affordable housing it’s nowhere near the scale that is needed.
We’re doing a lot of work getting people who are already homeless into housing. And yet, there are many more people who are homeless than are being housed. The other piece of it, that we never talk about, is that every day, the construction we see, all this [booming industry], is creating more and more housing that is unaffordable for people on benefits or working for minimum wage and there are more and more people falling into homelessness. Even if we got everybody housed today, six months from now, we would have a whole bunch of new people who are homeless because we need the prevention piece.
So I would say, the one thing that cities like Nashville could improve on to make a difference, is to figure out a way to bring more resources to the problem so that the resources are sufficient to address the magnitude of the problem and use the right approach to do it.
Programs give up on people. They don’t stay long enough with people. That’s what we see.
What are your recommendations, and do you have specific recommendations for Nashville?
I have specific recommendations, and they’re for everyone, Nashville included.
And I am sorry I didn’t say this at the start because I was talking about the apartments in terms of Housing First. But the thing about Housing First is that it’s actually not about the housing.
Housing First is all about the relationship with the person. Housing First commits to this person to help them in whatever way they need.
Let’s say the person says I want a place to live. OK, that’s perfect. You’re in the right program. We’re going to go and get you a place to live. [Now] they’re in the apartment and then things don’t go well. Their friends are calling them, saying can I come over and get a shower? Well, you can’t say no. The friend comes over, then asks, “Can I sleep on the couch?” Another friend and yet another friend come over and say, “You’ve got the house, let’s have a beer, let’s celebrate, man!” They have a party, and then no one wants to leave. And the landlord is pushing, and the person is evicted. That happens a lot — like 20 to 30 percent of the time.
Now, what does the program do? “Oh, we tried to tell them if the party doesn’t stop, you’re going to lose the place.” But I couldn’t tell my friends no. I should have been more careful in the beginning.
It’s a huge, expensive, terrible lesson. But the program is not about that apartment. The apartment is just the vehicle for helping the person get their life back together. So, if the person loses that apartment, that’s OK. We’re not going to lose that person.
You stay with the person, and you say, “What do you want to do now? Do you want to go to detox? Or you want another apartment? What’s our next step here, because we’re on this journey with you and we’re going on this journey with you.”
The apartments are things along the way of a much bigger journey. So the commitment is to the person.
How can people with experience of homelessness be heard and truly integrated into the decision-making process?
The Housing First program is a really good program, not from a personal perspective, but from having seen it work so well in so many different places around the world. I think the ingenuity of the design of the program was only made possible because we included people who were homeless in the conversations about how to operate this program. They were there at the table from the very beginning.
[We asked] what should we do? — “I need a place to live.”
But you have a mental health diagnosis. — “I’ve been diagnosed with mental illness since I was 18. I know what I need. I need a place to live.”
What about the drinking? — “I’ve been drinking since high school, man. I need a place to live.”
OK! We’re going to get a place to live.
“How are we going to pay the rent?” Well, you’ve got to pay 30 percent of your income.
It was all co-designed. And the people would say, “OK, can you give me this apartment? I don’t want charity. I want my apartment, and I don’t want to put my beer under the couch when you come. Is that alright?” Right, you want a house with dignity, that’s your place, like everybody else [who has a place].
All those conversations were part of weaving the program design: harm reduction, Housing First, trauma-informed [care] – all that stuff came about because we included people that knew what they were talking about from the very foundation.
And we still hire people with lived experience. Part of the support staff is people with lived experience. And not only the support team but also case managers, supervisors, people on the board of directors, you want the voice of the people you’re serving through every level of the organization.
We find that having to pay one third of an income that is very low already is often a burden. Do you hear that from other people? What do you think is the solution, so that people are able to stay in housing, pay bills and pay for their living expenses? What do you think we could do to advocate for that?
Frankly, I’m not a big fan of paying one third of your income towards the rent, but that is the condition of the housing contracts that we get from the government. That’s a requirement.
We’ve talked about homelessness a lot, and the word “homeless” is not a good word for what we’re really talking about, which is poverty. The extreme of poverty is homelessness.
The idea that we’re going to hold people, who are struggling to make a few bucks a day, to pay 30 percent, to me, you have to do it because it’s part of the contract, but it’s not the right thing to do. Some apartments have utilities that are separate, and now people have to pay for utilities, which cost a fortune, they’re just going up all the time.
The question is, how are you really addressing the poverty, if you don’t have some way to be able to actually support people fully in their housing? Even though I think the Section 8 model is a great model. I mean, it’s the best thing we have. But it’s not housing as a human right where people have a right to housing because the society we live in believes that people should have housing. You don’t make it a hardship for people by including all of these other bills.
I would do whatever I could to try and wrap the utility costs into the rent, so that the person pays a third of their income, but then that third includes the utilities and the landlord covers that piece. I think that every program should do as much as they possibly can to address the poverty of the person who is struggling. I mean, we talk about mental illness or addiction as a disability. Poverty is a disability.
Poverty sets the ceiling so low of what you can do. Programs that are working with people who are that poor need to address that just like they address addiction or mental health or everything else. You’ve got to be doing something about it. It’s hard.That’s what I would advocate for. I would advocate for housing as a basic human right. And let’s get rid of these money conversations. We’re talking about chump change from a government perspective anyway.