Qualitative research from the At Home/Chez Soi study
Reprinted from "Supported Housing" issue of Visions Journal, 2017, 12 (3), p. 25
The national At Home/Chez Soi study showed that the Housing First program can successfully address homelessness for people with mental health and addictions problems. The study was run in five sites: Vancouver, Winnipeg, Toronto, Montreal and Moncton. Results showed that, compared to study participants in the “treatment as usual” group, Housing First participants had superior outcomes on measures of housing stability, community functioning and quality of life. In terms of cost-effectiveness, Housing First is also a better strategy to support participants who are “high users” of resources (such as emergency departments and inpatient services for addictions or mental health treatment).
Housing First provides housing based on tenant choice about housing type and neighbourhood. Housing choice is enabled through a portable housing subsidy that people can apply towards the housing of their choice. At the same time, a housing procurement team helps prospective tenants with their housing search, and with any ongoing concerns with their landlord once they are settled. Consistent with the supported housing model, the Housing First approach separates treatment from support. Tenants typically live in their own apartments, and a mobile case management team provides support related to illness management, addictions, employment and social integration.
In contrast, study participants in the comparison (treatment as usual) programs are typically offered housing in congregate settings with on-site support. Treatment as usual programs are usually based on a treatment-first approach, which requires individuals to first participate in psychiatric treatment and attain a period of sobriety as a prerequisite for housing. In a small number of cases, Housing First participants may live in congregate housing situations, but the operative difference from treatment as usual is choice: that is, in the Housing First program, people live in a congregate housing complex because they prefer a setting with built-in supports and other residents present, not because it is the only option available.
Another key difference between Housing First and treatment as usual is that Housing First participants have full tenancy rights. In the event of an extended hospitalization or incarceration, their rent continues to be paid so they can return to their home when they are ready.
The At Home/Chez Soi study was a mixed methods study. In addition to collecting quantitative data, we also collected qualitative data from research participants in both the Housing First and treatment as usual groups in order to better understand the similarities and differences between the experiences of both groups. At two points during the study— as people came into their housing, and 18 months later—we conducted in-depth interviews about their experience prior to and during the study so we could understand the transition process over time. That process could be characterized in terms of three stages: (a) from street to home; (b) from home to community; and (c) from present- to future-focused lives. In line with the quantitative findings, we also found that while the experiences of Housing First participants were similar in some respect to those of the treatment as usual group, there were also marked differences.
Transition from street to home
At baseline, all participants described their typical days prior to becoming housed as being dominated by basic living concerns and focused on immediate preoccupations such as the weather, food, their physical safety, and having to navigate an environment of social chaos. As one individual said, “I was just in survival mode.” When interviewed 18 months later, participants in both groups talked about coming out of survival mode and gaining a sense of peace and safety in their daily lives. One person described this newfound sense of freedom as the “lifting [of] a giant weight from my shoulders.” This feeling was most commonly expressed by those in the Housing First group, whose housing tended to be in neighbourhoods that they experienced as safe and secure.
Transition from home to community
Once participants had moved out of survival mode and had settled into routines, their days tended to become more focused on “being productive,” by making household repairs or engaging in creative activities like painting. These changes were mentioned by individuals from both groups, but they tended to be more predominant in the Housing First group. For example, one Toronto Housing First participant referred to this as “doing stuff that matter(s).” It also involved making plans for significant activities, such as registering for and/or attending school, finding work or more generally getting their lives back on track.
As individuals became more rooted in their homes, they started to develop a sense of belonging in the broader community. Numerous Housing First participants (and also some treatment as usual participants) spoke of activities like going for coffee with neighbours; visiting more drop-in centres, libraries and parks; and socializing more often with people in the neighbourhood. One individual from the Housing First group in Winnipeg talked about his regular routine of getting up and going for coffee at his favourite restaurant. As he elaborated, “I’m getting to be a regular there too … I’m getting back into the scheme of things here, a regular grind you know … I’m slowly going back to being a regular Joe.”
Transition from present- to future-focused lives
As people became more involved in the community, they began to move towards lives that were increasingly oriented to the future. Part of this was due to their growing confidence that they could live a meaningful life despite experiencing problems with mental health. At baseline, many participants spoke of having experienced a sense of entrapment because of their homelessness, and also because of their struggles with mental illness and addictions.
In contrast, an emerging theme during the 18-month interviews, particularly for those in the Housing First group, was a growing sense of control over their mental health. As one person explained, “[C]oming into the program is when I realized that I was living with depression and anxiety and [post-]traumatic stress syndrome.”
For background and more detail on the quantitative findings discussed in the article, see Goering, P., Veldhuizen, S., Watson, A., Adair, C., Kopp, B., Latimer, E., Nelson, G., Macnaughton, E., Streiner, D. & Aubry, T. (2014). National At Home/Chez Soi final report. Calgary, AB: Mental Health Commission of Canada. www.mentalhealthcommission.ca.
For background and more detail on the qualitative findings discussed in the article, see Macnaugton, E., Townley, G., Nelson, G., Caplan, R., MacLeod, T., Polvere, L., Isaak, C., Kirst, M., McAll, C., Nolin, D., Patterson, M., Piat, M. & Goering, P. (2016). How does Housing First catalyze recovery? Qualitative findings from a Canadian multi-site randomized controlled trial. American Journal of Psychiatric Rehabilitation, 19(2), 136-159.
Another theme related to making the transition to the future was gaining a sense of self-worth. As one Housing First participant stated, “Having a nice place to live makes people think more about themselves. It gets them started. [It gets them feeling] like they’re worth something. Maybe that’s the home they’ve always wanted and never had.”
By enabling people to gain a sense of control over their illness and a sense of self-worth, Housing First helps people feel hopeful they can reclaim lost parts of their identity. For instance, one participant stated, “I used to be an ice-maker. Maybe I could go back to doing that.” Others envisioned that their housing would enable them to reconnect with family, friends or significant others. By helping people orient to future goals, Housing First motivated them to address the issues (such as mental illness and addictions) that were standing in their way. While participants in both groups mentioned such experiences, the theme of orientation towards the future was mentioned more frequently among members of the Housing First group.
Listening to the experiences of participants helps us understand what works well and what aspects of the Housing First model could be improved. Isolation and loneliness are still a challenge for some participants, who usually live in their own apartments rather than in a congregate setting with other residents. So even though it helps people move “in” to the community, Housing First (and supported housing programs in general) needs to consider more closely how it can more actively support people to gain a sense of belonging in those communities.
Another challenge is to help people move beyond the barriers that continue to exclude them from jobs and educational opportunities. While all Housing First teams include an employment specialist, it can be difficult for them to prioritize the needs of people who are further along in their recovery, when certain tenants still require a great deal of support to maintain their stability.
Despite these challenges, in comparison with treatment as usual care, Housing First is better able to help people move through a very difficult transition: freeing themselves from being stuck in survival mode; gaining a sense of safety and security in their housing; establishing a productive and creative daily routine; and living meaningful lives in a community of their choice.
About the author
Eric was a member of the national qualitative research team of the At Home/Chez Soi study. Formerly Director of Policy & Research at CMHA BC Division and Editor-in-Chief of Visions, Eric is now a Research Associate at Wilfrid Laurier University and consults on the implementation and evaluation of community mental health programs. He lives in Vancouver