Research Matters Blog
Concurrent Disorders (also described as dual diagnosis orco-morbitity) describes a condition in which a person has both a mental illness and a substance use problem. This term is a general one that refers to a wide range of mental illnesses and addictions. For example, someone with schizophrenia who is addicted to crack has a concurrent disorder, as does an individual who suffers from chronic depression and who is also an alcoholic. Treatment approaches for each case could be quite different.
People diagnosed with a concurrent disorder generally have shorter life expectancies, are more likely to be homeless, have more frequent acute psychiatric admissions, and spend less time in hospital per admission than those without (e.g. either substance use or mental health problems, not co-occurring). Research also suggests that the prognosis of schizophrenia in individuals with a concurrent disorder is considerably more severe than in individuals who have schizophrenia only.
People with concurrent disorders are frequently misdiagnosed, as one disorder can mimic another. Relapse rates for substance use are higher for people with a concurrent mental disorder, as are the chances that symptoms of mental illness will return for those with a concurrent substance use problem.
Mental illnesses and substance use is more prevalent among homeless and incarcerated populations than in the general population. Those with concurrent disorders need help and services from several sectors – mental health, addiction, health care, education, and social services. Improving access to the services and supports these individuals need requires a targeted, holistic, multi-disciplinary approach of complementary mental health and addictions services designed to work specifically with concurrent disorders.
Common program elements include comprehensive assessment, intensive case management, supported housing, peer groups for support and therapy, training in independent living skills, and mental health and substance use treatment. Program philosophies typically include acceptance and tolerance of relapses, an emphasis on structured approaches, clear expectations within residential programs, and a commitment to long-term care.
When we have so many social services in a city like Hamilton, ON, how is it possible that homelessness is still so prominent?
We received this question from Kathleen M., who passed it on from a student.
Many Canadian cities have agencies and programs that try to meet the needs of people experiencing homelessness, yet homelessness continues to be a problem. The vast majority of such services fall in the emergency services category, which do little to prevent people from becoming homeless in the first place. In the words of the Homeless Hub’s State of Homelessness in Canada 2014 report: “For years we have been investing in a response to homelessness that, while meeting the immediate needs of people in crisis, has arguably had no impact in reducing the scale and scope of the problem.”
This isn’t to say we haven’t been making progress, because we certainly have. The At Home/Chez Soi project showed that with the right interventions (housing people quickly with appropriate supports), people who are chronically homeless can be and remain housed. As more municipalities adopt housing first models we will see improvements, but not complete eradication, of homelessness. The reasons why are numerous and complicated, but the two most pressing are as follows:
Lack of affordable housing
Over the past few decades, federal funding for affordable housing has slowed. In 1982 20,450 new affordable units were built; in 1995 less than 1,000; and in 2006, 4,393. The increase in 2006 was due the efforts of Jack Layton and the NDP, who secured $4.6 billion for affordable housing and mass transit. (This is considered one of Layton's biggest triumphs.)
All in all, over 100,000 units were not built due to funding cuts and cancellations.
This has left Canadians overwhelmingly dependent on skyrocketing private rental markets. According to the latest annual housing affordability survey, Vancouver, is the second most unaffordable city in the world, with Toronto, Victoria, Kelowna, and the Fraser River Valley areas also deemed unaffordable.
As a result, many cities have hundreds of thousands on waiting lists for subsidized housing. An estimated 18% of Canadians spend more than half of their income on housing, which places them at risk for homelessness.
In Canada, minimum wage has not kept up with the rate of inflation, nor have social assistance rates. This, combined with decreasing numbers of long-term, well-paying jobs with benefits, has left people less financially secure. As Vineeth wrote back in November, Canada now ranks 24th out of 35 countries when it comes to child and family poverty. And the income gap between the rich and poor is widening, with the wealthiest 10% of Canadians seeing a median net worth increase of 42% since 2005.
The real solution to homelessness
It isn’t just more shelters, beds, or emergency services—it’s a real commitment to building affordable housing as soon as we can.
To learn more about what we can do to end homelessness, read our State of Homelessness in Canada 2014 report.
This post is part of our Friday "Ask the Hub" blog series. Have a homeless-related question you want answered? E-mail us at email@example.com and we will provide a research-based answer.
Youth represent the fastest growing segment of Canada's homeless population, and a large proportion of these homeless youth are newcomers. Data from a recent survey conducted with homeless youth in Toronto shows that 22.3% of those surveyed had been born outside of Canada. The below infographic, created by the Centre for Addiction and Mental Health (CAMH) and the Children’s Aid Society of Toronto for their report on homeless newcomer youth in Toronto, looks into the experiences newcomer youth have with homelessness and provides recommendations to change the status quo. When I looked at the snapshot of survey participants, two things jumped out at me.
In the study, over one third of participants identified as LGBTTIQ. LGBTTIQ youth, because of their gender identity, are far more likely than straight youth to be the victim of further discrimination and physical violence within the shelter system. This highlights the urgent need for specialized services for LGBTTIQ youth in major urban centres like Toronto. To date, there are zero specialized initiatives directed at the needs of LGBTTIQ homeless youth in Canada.
The infographic also states over half of youth participants had a level of education of grade 12 or higher. It says youth who have credentials that do not match Canadian school systems may be told that they have to repeat high school in Canada. As well, work experience that youth may have is often discredited as being 'not up to Canadian standards.' Rather than being told that they need to start over from scratch, the presence of bridging programs and supports that would help link these youth up with other educational supports could do a great deal to help these youth.
Despite the high proportion of homelessness youth who are also newcomers, data about the needs and experiences of these youth is hard to come by. Engaging these youth in decision-making processes about how services are structured and designed will go a long way towards creating informed changes to how we provide supports to this group. This means including youth in the design of targeted action plans, identifying which tailored supports are most needed and developing safe spaces in which these youth can voice their ideas and concerns. Advocating for, and supporting, specialized programs that demonstrate commitment to newcomer youth living in critical housing situations is one way to bridge the gaps present in their social safety net.
A few weeks ago I tweeted about three things I learned while working on the Leaving Home report on Youth Homelessness in York Region. Oxana from the Homeless Hub promptly messaged me – and planted the idea that ‘this would be a good blog post’. I have taken some time to expand on what I learned, though they aren’t to be mistaken with the ‘key findings’ of the report:
- Youth are resilient – but they need support.
This was particularly clear when you listen to the details of the stories that youth told during interviews. For example. Chris, who is 20 reported the following:
My dad had prostate cancer and my mom had diabetes so it was up to me and my sister…we had to take care of them most of the time. Then we kinda got depressed and started taking pills for that.
While this might not seem immediately connected to the concept of resiliency – it’s this kind of narrative and story that demonstrates some of the struggles that youth go through – and adapt to.
Before I started teaching my course on Homelessness, I spoke with a friend who had been street involved when he was younger. I asked him if there was anything that I should make sure to tell to my students – he said:
Humans will adapt to anything, just put someone in an environment – and they’ll do what they have to do to survive.
The question that becomes more important is – how do we get better at helping people thrive, not just survive. I feel strongly that the answer is to move towards a more coordinated system that draws, and strengthens, the resources that we already have in communities like York Region. This includes providing more funding to service agencies, as well as using schools, community centers and public libraries as partners to facilitate better access to services.
- Youth are likely to blame themselves for their experiences of homelessness- even if the situation has to do with physical or emotional abuse.
Just over 20% of youth reported leaving home because of abuse, another 70% left home because of conflict with their parents. Not all conflict is emotional abuse (I remember being a teenager, sorry mom) – but I would hazard a guess that some of that is, and may not be identified as such.
We know that victimization is much higher for youth experiencing homelessness. There is also a major need for addressing trauma for those who have experienced victimization while still at home. This applies to the youth homeless sector in general – and not just York Region. Unfortunately – the way the sector is now, there are not enough resources to address trauma related to life experiences.
- Service providers are working very hard to help youth access services - but they need more resources.
We know that integration is important. We often talk about the importance of having a system of care – or an integrated homelessness service system. I think it’s important to keep in mind that service providers are working very hard within a system that isn’t integrated – maybe even harder than they should be for their own self-care and well-being. It’s hard not to when you’re so committed to helping the youth that access services with you. This commitment showed in many different ways, but two stood out:
- There was common sentiment from the executive director level that there was very low employee turnover in their agencies. This might be suprising to some, considering the amount of emotional energy it takes to provide services.
- Workers had many examples of going out of their way to help youth access the services that they needed. One worker drove a youth to Hamilton to access a detox program that wasn’t available in York Region because the youth had come to say that they were interested in enrolling. We know with substance use, it’s terrible to turn someone away if they’re interested in working towards recovery.
Speaking with service providers, and people involved in services, throughout York Region was inspiring. There are solid groups of people that are working hard towards the goal of ending youth homelessness in York Region. The service sector in York Region has, what I find to be, an unparalleled commitment to connecting, sharing resources and focusing on solutions to common problems that has allowed them to make great strides without having access to population proportionate funding. Imagine what could be done with sufficient funding.
People with poor mental health are more susceptible to the three main factors that can lead to homelessness: poverty, disaffiliation, and personal vulnerability. Because they often lack the capacity to sustain employment, they have little income. Delusional thinking may lead them to withdraw from friends, family and other people. This loss of support leaves them fewer coping resources in times of trouble. Mental illness can also impair a person’s ability to be resilient and resourceful; it can cloud thinking and impair judgment. For all these reasons, people with mental illness are at greater risk of becoming homeless.
Homelessness, in turn, amplifies poor mental health. The stress of being homeless may exacerbate previous mental illness and encourage anxiety, fear, depression, sleeplessness and substance use. The needs of homeless people with mental illnesses are similar to those without mental illnesses: physical safety; education; transportation; affordable housing; and, affordable medical/dental treatment. When providing care to the homeless, it is essential to create a non-threatening and supportive atmosphere, address basic needs (e.g. food and shelter), and provide accessible care.
People with mental illness remain homeless for longer periods of time and have less contact with family and friends. 30-35 percent of the homeless, in general, and up to 75 percent of homeless women specifically, have a mental illness. 20-25 percent of homeless people suffer from concurrent disorders (severe mental illness and addictions). People who have a severe mental illness are over-represented in the homeless population, as they are often released from hospitals and jails without proper community supports in place.
Community-based mental health services play an important role. Homelessness could be drastically reduced if people with severe mental illness were able to access supportive housing, as well as other necessary community supports. They encounter more barriers to employment and tend to be in poorer health than other homeless people. Housing outreach services that provide a safe place to live are a vital component of stabilizing the illness and helping individuals on their journey to recovery.
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The analysis and interpretations contained in the blog posts are those of the individual contributors and do not necessarily represent the views of the Canadian Observatory on Homelessness.