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Housing makes a difference to our health. Decent, safe and affordable housing contributes to physical and mental well-being, while inadequate housing or homelessness does the opposite. Having a pre-existing mental illness or a substance use problem often restricts a person's options to access, afford and maintain the very kind of home that would help promote recovery.
Because of a lack of supported housing options once discharged from hospital or treatment centre, many people with mental disorders or addictions have only substandard boarding houses or dangerous hotels to go home to.
The Experience of People with Mental Disorders
One reason for this is the episodic nature of mental illness. People with mental health problems often lose their income during long periods of illness and repeat visits to the hospital. They may have trouble paying the rent and may eventually lose their furniture and all of their household contents, along with their address.
Some people in this situation may decide they are better off on the street, but without a fixed address, they may be cut off from a range of social services including health care. Without access to medications and support, the person's symptoms may worsen and force them back into hospital, often for a longer period than the previous visit.
A small number of people may go without treatment for the disorder until they are arrested, and depending on the circumstances, end up in BC's criminal justice system. Emergency rooms also repeatedly see and discharge frequent users, many of whom are mental health clients, with most recovery gains lost when the person is back on the street.
Known as the "revolving door syndrome," this cycle is perpetuated by the lack of affordable housing and emergency supports available for people with mental illness.
British Columbians who believe there are more people wandering the streets with mental illness today than there were ten years ago are probably right. Between a quarter and a third of people who are homeless also have a mental illness; 60 to 70% of them also have an addiction. For many, mental illness predisposed them to homelessness; for others, the hardships and conditions associated with homelessness trigger mental illness. Shelters have been trying to pick up the slack with some success: there has been an 88% increase in specialized shelter capacity for people with mental disorders in BC since 1987. Through the Premier's Task Force on Homelessness, Mental Illness and Addictions, the province has allocated money to increase emergency shelter capacity by 153 beds (to a total of 864 beds).
There are 14,000 households on the provincial waiting list for affordable housing; many of these include people with mental illnesses or addictions. The province's Mental Health Plan and a 2006 federal senate report both name housing as the single highest priority for service for people with serious mental illness.
In recent years, health care reforms have resulted in the closure of long-stay psychiatric facilities in favour of a holistic, community-based model for recovery. Although mental health advocates support the shift towards community care, they say the money saved in hospital beds has not been re-invested in appropriate housing and treatment supports which would allow people with mental illness to successfully re-enter the community.
In January 1998, the provincial health minister announced a major reform of the province's mental health care system, including a multi-year plan to replace BC's main psychiatric institution, Riverview Hospital, with 660 tertiary mental health beds and approximately 270 specialized residential mental health beds in smaller facilities throughout the province. At the end of 2005, 227 Riverview replacement beds have opened across all major health authorities.
This initiative will bring services closer to home for many people with mental illness, allowing them to benefit from the support of friends and family. Still, the plan to expand community treatment services in outlying areas will only work if it receives adequate funding, offers flexible supports and provides a range of housing options for people with different needs, mental health advocates say.
In many cases, access to housing and support services depends on participation in a structured program within a specific neighbourhood. But certain options such as segregated group settings are not always effective in helping people integrate successfully in the community. People with mental disorders most often prefer to live independently, with access to flexible supports. The housing most people would like to live in is a self-contained suite or apartment in the general community.
The success of alternative housing such as semi-independent living and supported housing programs offered throughout BC is proof that people with mental illness can live well on their own in the community. Through these kinds of options, people receive rent subsidies in addition to other services like individualized skills training. Run by various non-profit agencies in the province, the program helps people locate and secure permanent housing and provides ongoing flexible support such as access to 24-hour crisis and care services, peer support programs and assistance with household maintenance, meal planning and money management. Funded by the Ministry of Health and administered by BC Housing, the Provincial Housing Program provides rent supplements to 3100 households in BC. Accepted tenants typically pay no more than 30% of their gross monthly income.
Part of the program's mandate is to help people retain their housing during periods of illness, and avoid being bounced from one residence to another when their mental health needs change. The cyclical nature of some mental illnesses should not deprive a person of a place to call home, which is an important aspect of recovery.
The Experience of People with Substance Use Problems
Many of the issues identified above also apply to persons with addictions and concurrent mental health and substance use problems. However there are some unique factors relative to housing in the field of addictions. Often housing options like supportive recovery or even crisis shelters require abstinence in order to accept clients. This requirement does not parallel the mental health system, since supported housing does not require that clients be free of the symptoms of their mental disorder. The result is that many addicted persons fail to qualify for entry into these facilities, and remain on the streets or in environments that are not conducive to addressing their substance use problems. This situation suggests the potential viability of "wet" or "damp" housing options, that provide a safe environment for stabilization to clients who are unable to maintain abstinence.
The need for transitional housing has frequently been recognized within the addictions service system, and is provided through emergency shelters and supportive recovery facilities. These solutions however are short-term. This creates challenges since people coming out of treatment or supportive recovery may be left with no place to live, a situation which can put their recovery in jeopardy. Stable housing also gives people an environment in which they are better able to deal with their substance use problems. A Vancouver study found that a group of homeless or formerly homeless people were almost all involved with drugs or alcohol, and that they were more likely to address their addiction if they were housed.
When people are secure and happy in their living environment, their chances of maintaining their mental health increase dramatically.
Types of Housing for People With Mental Illness
Residential:
licenced community residences provide 24-hour supervision with professional staffing available on a daily basis; staff supervise use of medications unless a resident applies for permission to take his or her own medications
supported living homes offer support staff during daytime hours; residents take their own medications
family care homes are privately owned and provide care and supervision to one or two individuals who wish to live in a family setting
Supported Housing:
group homes provide subsidized rent; tenants share a home and the services of a community living support worker
supported apartment buildings are built especially for people with mental illness; subsidized rent and daytime support are provided
satellite apartments are leased in private market buildings; tenants have access to subsidized rent and outreach services
supportive hotels: single rooms are leased and managed by non-profit societies; on-site staff support provides services to adults with mental illness
Emergency Accommodation:
emergency facilities offer short-term accommodation for people with no other immediate housing options available to them. Length of stay is usually under 90 days
Housing Shortages for People with Mental Illness
In Vancouver:
Although the number of permanent emergency shelter beds in Vancouver has doubled from 300 beds in 1998 to 600 beds in 2003, the estimated number of homelessness people also doubled. It is estimated that 500 to 1200 people are sleeping on the street each night in Vancouver.
In 2003, one of the major emergency shelter operators, Lookout Emergency Shelter, served close to 3,800 people in Vancouver. This is almost 50% more than 1995. However, they had more than 5,000 turnaways, which is 227% more than 1995.
Over 2,000 social housing units were built in Vancouver in the last five years. However, with the change of provincial housing program and the increase in population, the supply of low income housing will not be able to keep pace with demand.
In 2003, more than 9,000 households are on BC Housing's waiting list for social housing in the Lower Mainland and over 60% of them are families. (Non-profits and co-ops have their own waiting lists.)
Source: City of Vancouver, Housing Centre
What Does Adequate Housing for People With Mental Illness Look Like?
units that are clean (e.g. no cockroaches), quiet, safe and close to amenities and support services
choice of housing arrangements according to an individual's wants and needs
access to housing located in a variety of neighbourhoods
affordable housing units and furnishings to accommodate the needs of people on fixed or low incomes
access to flexible, 24-hour supports as needed and wanted
options for maintaining the same housing arrangement regardless of changes in a person's mental health needs
Sources
Allegheny HealthChoices. (2005). Housing preferences survey report. www.ahci.org/Documents/Reports/Quality%20Focus%20Reports/
Housing%20Preferences%20Survey%20Report.pdf
BC Housing. (2005). Provincial housing program. www.bchousing.org/programs/housing
BC Housing. (2005). What is subsidized housing? www.bchousing.org/applicants/affordable
BC Housing. (2006). 2006/07- 2008/09 Service Plan. www.bchousing.org/aboutus/Reports/Service_Plan
Davidson, J. (2004). Homelessness. Policy Report: Social Development. Vancouver: City of Vancouver, Housing Centre. www.city.vancouver.bc.ca/ctyclerk/cclerk/20040224/rr1a.htm
Eberle, M., Kraus, D., Pomeroy, S. & Hulchanski, D. (2001). Homelessness: causes and effects. Victoria, BC: Ministry of Social Development and Economic Security. www.housing.gov.bc.ca/housing/homeless/homless_index.htm
Four Pillars Coalition. (2005). Four pillars, four years. Where to now? www.city.vancouver.bc.ca/fourpillars/pdf/FourPIllars_FourYears.pdf
Provincial Health Services Authority. (2006). Riverview Redevelopment Project. www.bcmhas.ca/News/RiverviewRedevelopmentProject
Social Planning and Research Council of BC. (2005). On our streets and in our shelters: Results of the 2005 Greater Vancouver Homeless Count. www.gvrd.bc.ca/homelessness/pdfs/HomelessCount2005Final.pdf
Tanzman, B. (1993). An overview of surveys of mental health consumer’s preferences for housng and support services. Hospital and Community Psychiatry, 44(5), 450-55.
Links in the Sources section are up to date as of June 2006
