Federal homelessness policy shifts to a Treatment First model

The Substance Abuse and Mental Health Services Administration (SAMHSA), under the Trump Administration, continues to walk back decades of progress in the treatment of mental illnesses and substance use disorders in the United States. The first two decisions by the administration to undermine the progress that has been made were Executive Orders entitled Ending Crime & Disorder on America’s Streets and Addressing Addiction Through the Great American Recovery Initiative.

These two Orders worked to restore and increase involuntary civil commitments and undermine the success of harm reduction. While these two Orders have already been covered in detail, the administration has released its next step in the undermining of progress and treatment.

Housing First vs. Treatment First

In August 2026, Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr, Housing and Urban Development (HUD) Secretary Scott Turner, and White House Office of National Drug Control Policy (ONDCP) Director Sara Carter announced the release of the Best Practices Toolkit: Addressing Homelessness and Addiction through “Treatment First.”

The toolkit’s main thesis is that Housing First models are “Housing Only” models and have failed to: prevent overdoses, increase access to addiction treatment, or help individuals establish and sustain self-sufficiency and that the correct methodology to implement to achieve desirable outcomes is a Treatment First Model.

What is Housing First?

Housing First is a homeless assistance approach that prioritizes housing before anything else. It recognizes that people need their basic needs met—such as food and shelter— before engaging in other activities, such as receiving substance use disorder treatment, treating mental illnesses, or getting a job.

This approach recognizes that by providing individuals with choices in selecting wraparound services and housing, individuals are more likely to remain committed to remaining housed and improving their life. Simply put, the main goal of Housing First models is to move individuals experiencing homelessness into permanent, stable housing without making them jump through hoops or meet preconditions first.

Once in housing, supportive services to address individuals’ other needs are provided.

Permanent supportive housing, a common program model within the Housing First approach, is targeted to individuals with chronic illnesses, such as mental health issues or substance use disorders, who have experienced repeated or long-term homelessness. It provides long-term rental assistance and supportive services, which allows individuals to have their basic needs met before attempting to work on their mental health issues or substance use disorders.

What is Treatment First?

Treatment First is a homeless assistance approach that requires individuals experiencing homelessness, addiction, or mental illness to engage in counseling, treatment, or sobriety programs as a primary condition before receiving long-term housing.

Individuals must earn the right to housing by complying with program conditions.

The toolkit specifically defines Treatment First as a model that prioritizes coordinated and accountability-driven engagement in evidence-based treatment and recovery support services to ensure people experiencing homelessness have access to the care needed to achieve recovery and self-sufficiency. This definition is a disingenuous way to define Treatment First and specifically goes out of its way to not use the phrase “involuntary treatment,” which is a core tenet of Treatment First models.

While the toolkit might try to distance itself from the phrase involuntary treatment, it is plain that this is a decision in alignment with the Trump Administration’s approach. This is clear through the toolkit’s citation of the Executive Order Ending Crime and Disorder on America’s Streets, which highlights and advocates for homeless individuals experiencing mental illnesses and substance abuse issues to access long-term institutional settings through civil commitment, which is involuntarily treatment received through a court order. The toolkit makes clear that the administration is building a system where individuals must earn housing through treatment compliance.

Myths and misnomers in Housing First and Treatment First models

Through the release of the toolkit, the government is not attempting to argue that the debate is still open on Housing First vs Treatment First but is actually arguing that Treatment First models are the more successful, evidence-based models. This runs counter to the data and research when examining substance use outcomes and housing outcomes.

Twenty-years of research shows that Housing First policies produce significantly better housing outcomes than Treatment First models.

This holds for individuals with chronic health conditions, people with cognitive and intellectual disabilities, people who use drugs, and psychiatric disabilities. When looking at mental health and substance use outcomes, the research is less conclusive. It appears that substance use and mental health outcomes are about the same regardless of the model that is used.

What is clear is that Treatment First models produces better treatment attendance numbers ("involuntary treatment"?), which the toolkit reports as success as it illustrates compliance, but does not actually represent any improvement in outcomes.

Conclusion

The federal government’s shift towards “Treatment First” will not improve outcomes for anyone. It will not help individuals get off the streets, nor will it help individuals treat their substance use disorders or mental health issues.

We know that Housing First policies create better outcomes, as history and research has shown us.

We know that civil commitment, and the criminalization of those with serious mental illnesses, does not guarantee better mental health outcomes. We learned this in the first half of the 20^th century, leading to the deinstitutionalization movement of the 1960s.

The conscience decision to ignore evidence-based practices and lessons learned from our past signals the growing importance of advocates to ensure that these messages are highlighted and drivers for policy decisions.