Introduction
The relationship between mental health problems and homelessness and access to housing is complex. Individuals with mental health problems or mental illnesses are predisposed to experiencing housing insecurity and homelessness, and poor mental health can be caused, triggered or aggravated by homelessness or housing that does not meet a certain standard of adequacy, affordability and suitability.
In Canada, access to housing for people with mental health problems has evolved over time; from poorhouses and prisons in the 1800s, to psychiatric hospitals by the 1900s, to a process of deinstitutionalization beginning in the 1960s. Since the 1990s, those working in the Canadian mental health care system and advocates in the mental health field have displayed a greater awareness of the critical relationship between mental health and housing, in particular the role housing plays in recovery and well-being.
Housing and Homelessness as Social Determinants of Mental Health
Access to housing that meets a certain standard of adequacy, affordability and suitability (known as core housing need) is a social determinant of mental health status. High-quality housing has a positive impact on general well-being, psychological stability, independent functioning, and social connectedness.
Individuals who experience housing insecurity or are homeless are more likely than the general population in Canada to:
• have high levels of stress;
• exhibit poor coping skills, sometimes resorting to self-harm, isolation and substance abuse;
• have low self-esteem and internalized stigma and self-loathing; and
• experience feelings of loneliness, worthlessness and hopelessness.
They are also likely to have considerably lower life expectancy than the general population, partly as a result of high rates of suicide.
Homeless individuals often report severe mental illnesses, such as depression, anxiety, bipolar disorder, schizophrenia and post-traumatic stress disorder. Homelessness can be temporary, episodic or chronic, but as the period of homelessness increases, pre-existing and emergent mental health problems and concurrent disorders often worsen.
Homeless people with mental health problems are among the most underserved and marginalized in society, and they face many barriers that limit their access to mental health services. Without the stability of a permanent address and the social connectedness of a community, many homeless individuals do not have a health card, cannot make or keep appointments, do not take medication properly, and lack continuity of care which allows for proper diagnosis and treatment.
Concurrent Disorders, Including Substance Abuse
A great number of homeless people have concurrent disorders. This means that, in addition to a mental health problem, such as a diagnosed illness, an individual has a second condition, such as a substance abuse problem or mobility impairment. Studies suggest that individuals with concurrent disorders are more likely to experience chronic homelessness and face challenges in receiving suitable care.
The connection between substance abuse, housing stability and mental health is described as a complex “chicken or the egg” relationship: substance abuse can be both the cause and the result of homelessness and mental health problems.
The Housing First Approach
The Housing First approach views housing as central to recovery and as a fundamental human right that should be available to everyone, regardless of his or her mental health or substance use challenges. Through this approach, an individual is provided housing as soon as possible and offered accompanying support services to meet his or her varying needs. Harm reduction and community integration are key to the Housing First approach. The model was developed in New York City in 1992 by the “Pathways to Housing” program.
Canadian research has documented the effectiveness of the Housing First approach in improving housing retention among people who are homeless and mentally ill. The MHCC’s Mental Health Strategy for Canada supports this approach, stating that it shows promise “for improving outcomes and quality of life for homeless people living with mental health problems or illnesses, both in Canada and internationally.”
Investments in Housing First approaches have been demonstrated to reduce costs overall, as individuals with mental health or substance abuse problems in stable living conditions are less likely to make frequent, substantial and sometimes inappropriate use of health care, social services, and criminal and judicial resources. In Canada, at the provincial and municipal levels, a number of housing and homelessness strategies have used the Housing First approach.
Conclusion
While homelessness or inadequate, unaffordable and unsuitable housing often lead to mental health problems, mental health problems do not necessarily have to lead to housing vulnerability and homelessness. At issue is the availability of high-quality housing for individuals with mental health problems. The Housing First approach has demonstrated that individuals with mental health problems can remain in suitable housing if offered accompanying recovery-oriented supports.
References:
Laura Munn-Rivard, Legal and Social Affairs Division, Parliament of Canada 2014-02-14