Research Matters Blog
In our latest website survey, Terri G. asked us the following: “Have there been studies done linking mental health to addictions to homelessness as a trifecta of consequences (concurrent, rather than singular)?”
The answer is yes, there certainly has been. Much of the literature on homelessness discusses the prevalence of what most Western researchers and healthcare practitioners call “concurrent disorders” (or dual diagnosis, or orco-morbidity), defined by Health Canada as “a combination of mental/emotional/psychiatric problems with the abuse of alcohol and/or other psychoactive drugs.” There can be multiple mental health issues and different substances involved. In the words of CAMH’s “Beyond the Label” toolkit, “…the effects of one may compound the effects of the other, thus exacerbating symptoms and making the person’s life more challenging.”
While people with mental health issues don’t always have substance use problems and vice versa, both can make someone more likely to become homeless. As covered on our mental health page, “people with poor mental health are more susceptible to the three main factors that can lead to homelessness: poverty, disaffiliation and personal vulnerability.” Similarly, rates of substance abuse are high among people experiencing homelessness. There’s no concrete set of statistics and numbers vary by location, but rates of concurrent disorders are generally considered high. For example, the Toronto Street Health Report (2006) found that 26% of people experiencing homelessness would be considered as having concurrent disorders.
Beyond an individual focus
That said, both mental health and substance use are both individual/relational factors that, on their own, don’t automatically lead to homelessness. So even though they can certainly overlap and exacerbate each other’s effects, framing homelessness, mental health issues and substance abuse as equal but interrelated “consequences” isn’t really accurate.
Causes of homelessness are difficult to determine, partially because homelessness itself has an enormous effect on people’s abilities to cope and be healthy, but also because there are simply so many other factors to consider. By focusing on things like mental/emotional health and substance use, we place a heavy emphasis on the individual/social factors and ignore the larger structural (ie. poverty and housing availability/affordability, as discussed in the State of Homelessness in Canada 2014 report) and systemic (ie. gaps in service) issues that can also result in homelessness. The BC Social Planning Committee highlighted the problematic nature of disjointed services in their 2006 report, which advocated for innovative approaches:
The literature reports that individuals with a concurrent disorder who are homeless have more issues that need to be addressed than others with a concurrent disorder who are not homeless. Once homeless, they are likely to remain homeless longer than other homeless people. Most clients are unable to navigate the separate system of mental health and substance abuse treatment. In Toronto, for example, it was found that most mental health facilities were unable or unwilling to work with people who have an addiction, while addiction treatment facilities were not equipped to deal with people with a serious mental illness (City of Toronto Mayor’s Homelessness Action Task Force 1999). Often they are excluded from services in one system because of the other disorder and are told to return when the other problem is under control (Dixon and Osher 1995; Drake et al. 2001;Drake et al. 1997; Rickards et al. 1999; Bebout et al. 1997) (p. 6)
Though also in the individual/social realm, lack of support, trauma and victimization are often prominent in the lives of people with concurrent disorders. One Toronto study of street-involved youth found that a quarter of its participants had concurrent disorders. More of those participants “had experienced physical child maltreatment, greater transience, street victimization and previous arrest compared to youth without concurrent problems.” The same study estimated that youth with “concurrent problems” were nearly four times more likely to have been victimized in the past year. As shown in the infographic to the right, having both mental health and substance use issues can limit youth's access to certain services – some housing services will not be provided unless participants are deemed 'clean.'
In a Philadelphia study of 156 people experiencing homelessness who had been ‘dually diagnosed,’ researchers found that 89.6% had experienced at least once childhood risk factor. The most common included: living with parents who abused drugs, alcohol or both; out-of- home placements; parents with diagnoses of mental illness; and sexual abuse.
People with concurrent disorders are often thought of as being particularly ‘hard to house.’ Even so, studies are increasingly showing support for the Housing First model – meaning, helping people experiencing homelessness secure housing before providing treatment or services for mental health or substance use issues.
Parhar et. al’s study (2014) compiled three Housing First case studies involving people with concurrent disorders in three Canadian cities: Vancouver, Edmonton and Regina. They found that supportive congregate housing is indeed effective, and recommended community involvement and client-specific design in creating supportive housing.
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.
Photo credit: National Learning Community on Homelessness
The term “living wage” refers to wages that are high enough to maintain a normal standard of living. Minimum wages across the country, as they stand, are not living wages. There is an ongoing myth that individuals working in minimum wage jobs are teenagers and earning extra money for pocket change. The below infographic, published by the Canadian Centre for Policy Alternatives, takes a look at who really benefits from an increase to British Columbia’s minimum wage.
The reality is that the majority of minimum wage jobs are the sole source of income for many households. Over 80% of all minimum wage jobs in BC are held by individuals aged 20 or older. A significant portion of these jobs, almost 40%, are held by workers aged 35 or older. Clearly, stereotypes about the identity of minimum wage workers are not rooted in reality.
A common perception is that individuals living in poverty, including those who are homeless, find themselves in their situations because “they are lazy” or “not willing to look for a job”. However, the rising cost of housing and other basic needs, like nutritious food, has not in any way corresponded with a similar rise in incomes for both middle and lower income households. A job, on its own, no longer guarantees freedom from poverty. Poverty persists in households where individuals are employed. In 2012, at least one member of the household was employed in a staggering 44% of all poor households in Canada. The number of temporary, low-paying jobs continue to increase while protected well-paying jobs are increasingly scarce.
One argument against increasing the minimum wage is that it will lead to serious job loss. Analysis conducted by Dr. David Green, a former chair of the Vancouver school of economics in BC, suggests otherwise. Green surveyed available academic literature and found that “estimates for BC showing job loss effects of minimum wage increases apply only to teenagers”. Furthermore, estimated job loss effects for young adult and adult workers are insignificant to non-existent.
Instead, the report notes that evidence in Canada highly suggests that an increase in minimum wages leads to low turnover rates. The term turnover rate is used to refer to the percentage of employees in a workforce who leave during a certain period of time. Workers are more likely to have jobs that are both well paying and stable as minimum wages increase. This means that increasing the minimum wage to a more livable wage can actually contribute against trends of growing employment precarity.
If we want to bridge the growing economic inequality gap in Canada, we have to begin considering measures that can directly increase the incomes of households experiencing tremendous financial strain. Increasing the minimum wage is an example of such a measure.
Community-based mental health care encompasses a wide variety of programs and services designed to meet local needs. These programs are delivered primarily by community agencies and sometimes through hospitals or health clinics. The majority of programs provided by community-based agencies are designed to serve the most vulnerable and most severely mentally ill.
Often, people that receive community mental health services have a diagnosis of schizophrenia, chronic depression, bipolar disorder or borderline personality disorder. Most have been ill for a lengthy period of time. And have suffered from a series of complex life problems such as poverty, homelessness, involvement in violent relationships, a history of child abuse, incidents of victimization through sexual or physical assault in adulthood, multiple periods of institutionalization, physical illness, and, sometimes, trouble with the law.
To meet the needs of homeless people that experience mental health problems a number of community mental health services are required:
Different types of subsidized and supported housing such as group homes, shared accommodation and apartments. Housing workers visit sites regularly offering counseling and holding tenants' meetings. Some agencies work with individuals to find appropriate housing in the private sector. Some agencies provide 'safe houses,' which provide short-term accommodation for people in crisis, designed to prevent hospitalization.
Case managers work one-on-one with individuals, often several times a week, in the setting of the client's choice (apartment, coffee shop). They help people find the services they need, access medical care, acquire new skills, find jobs and make friends. Certain case managers also provide counseling or help in overcoming addictions and work to prevent hospitalization.
Psychiatric treatment for mental illness may be offered in hospitals and includes assessment, diagnosis, the prescription and monitoring of medication, electro-convulsive therapy and interpersonal or cognitive therapy (individual, group or family). In the community, multi-disciplinary teams that include psychiatrists, social workers, nurses and case managers provide treatment to clients in their homes and in their communities so that hospitalization can be prevented.
Peer support and self-help programs:
These groups bring together people with similar circumstances or illnesses to share experiences, challenges and coping strategies. Family members also have their own support groups.
Community mental health agencies respond to people who are in a crisis situation by assessing their immediate circumstances, providing short-term counseling, getting prescriptions for medication or assisting with hospitalization if it is required.
Mobile crisis services:
These services operate 24 hours a day and provide immediate care where and when they are needed.
Court diversion programs:
People with a mental illness who have committed a minor offense need not go to jail. Instead, court diversion programs work to get them the help that they need outside of the judicial system. Court division programs reduce court costs and meet people's mental health needs in a more effective manner than the corrections system.
These programs provide a place for people to go to five days a week. Members participate in the running of the club but they also can receive training for work and support while in job placements.
Agencies partner with local businesses to find jobs for people with a mental illness. Staff may also provide skills teaching and job coaching.
Community mental health services are developed with the particular needs of the community in mind. Some agencies provide warming rooms for the homeless in the winter where people can take a shower, eat and have a good night's sleep. Other examples of programs include support groups for the newly bereaved, or people who are divorcing, clothing or food banks, and education programs on mental illness for high school students.
This question came from Matias C.L. via our latest website survey.
Queer and trans youth – who I will refer to as LGBTQ2 youth – are overrepresented among people experiencing homelessness.
Research from Ottawa, Ontario in 2000 found that anywhere between 25 and 40% of all youth experiencing homelessness identify as LGBTQ2. More recently, the 2012 Toronto Street Needs assessment asked participants staying in youth shelters about their LGBTQ2 identity for the first time and found that 1 in 5 youth experiencing homelessness identify as LGBTGQ2. Given these numbers, it’s crucial that we make shelters and transitional, supportive and affordable housing accessible for this population.
While youth in general have a variety of needs when it comes to housing, there must be extra considerations for those who identify as LGBTQ2. Many leave home due to lack of family/guardian acceptance, and find the same lack of support elsewhere. As Dr. I. Alex Ambramovich wrote in No Safe Place to Go:
“The threat of violence and harassment on the streets is exacerbated for LGBTQ youth due to frequent encounters with homophobia and transphobia. These threats make it especially hard for youth who were forced to leave home due to homophobia or transphobia because it makes coming out and trusting people more challenging. There are also countless situations where youth are victimized, ridiculed, and beaten up on the streets and in the shelter system simply for their gender and/or sexual identity. Regardless of their gender or sexual identity, homeless youth most often come from family situations of conflict, abuse, and neglect.”
While overt discrimination due to trans- and homophobia is a large issue for many LGBTS2 youth, there are also situations in which it is subtlety present or systemic, as in shelter systems. In the same report, Abramavich highlighted this as well: “Most shelters are segregated by birth sex, which increases the risk for gender discrimination and gender violence to occur within shelters. Shelter staff members tend to have minimal training around transgender-related issues, needs, and terminology.” It is estimated that 1 in 3 transgender youth, who experience more violence than any other group, are turned away from shelters based on their gender expression/identity.
Abramavich recommended that homelessness support services (such as shelters) increase training re: LGBTQ2 issues, adopt harm reduction approaches to substance use, revise complaint systems to improve shelters, implement strict anti-homophobic and anti-transphobic language policies, and openly identify as a LGBTQ2 positive space. At the government level, Abroamavich recommends developing a specific strategy to address the homelessness of this group. Indeed, the city of Toronto Street Needs Assessment came to similar conclusions – with 54 beds specifically for LGBTQ2 youth included in the city’s 2015 budget. These beds will come in the form of Sprott House, pictured right – which will be the first specifically LGBTQ2 youth housing program in Canada.
None of this, however, directly addresses how to make low-income or social housing more accessible. Unfortunately, as I wrote a few weeks ago, there has been little research on LGBTQ2 youth outside of their experiences within urban shelter systems. That said, I think many of the recommendations made by Abramavich and other researchers/advocates/community members can be applied to low income and social housing.
- Training: Ensure that everyone involved (caseworkers, property managers, superintendents, etc.) receive explicitly anti homophobia and anti transphobia training; and learn about LGBTQ2 issues, experiences and terminology.
- Community involvement: Give LGBTQ2 youth experiencing homelessness opportunities to share what would make housing more accessible and safer for them in your specific building, complex, or community. Encouraging involvement and meaningful participation (not just tokenism) can make services more effectively inclusive.
- Reformed processes: Trans youth may have identification, documentation, and/or references that correspond with a different name, sex, and/or gender than what they currently identify as. Creating processes that are flexible and understanding of these changes is key to making any kind of housing more accessible.
- Integrated supports: Depending on age, circumstances and experience, LGBTQ2 youth will need a variety of supports (casework, financial assistance, education, life skills, counselling, family reunification, etc.) to help them secure and stay within housing. What is important here, as pointed out by Gaetz and others, is availability and choice - some LGBTQ2 youth will want completely independent living while others will want housing that is more deeply supportive.
Ultimately, as Gaetz et al. wrote in Youth Homelessness in Canada, moving to a homelessness prevention model is key to ending youth homelessness. In the meantime, however, we must make existing services more safe and accessible – especially for vulnerable groups like LGBTQ2 youth.
This post is part of our Friday "Ask the Hub" blog series. Have a homeless-related question you want answered? E-mail us at firstname.lastname@example.org and we will provide a research-based answer.
Photo credit: Erica Lenti on Torontoist
This week’s infographic is from a Mother Jones article that looked at the success that the Housing First philosophy has been having in Utah. Housing First is an example of an alternative to status quo approaches to homelessness, combining immediate access to permanent housing with wrap-around supports. The presence of built-in supports, including health care and counseling services, as well as employment and education supports, are essential for the Housing First approach. There are several causes of homelessness and in order to become solutions, it makes sense that approaches towards solving homelessness also need to be multifaceted.
Recent years have seen the increased criminalization of homelessness in the United States. The infographic states that 37 homeless people living in Osceola County, Florida, were arrested over 1,000 times over a ten year span, spending a cumulative 61,896 days in jail. It is estimated that the costs associated with arresting these individuals, charging them, and providing them with care in jail was well over six million dollars. Compared to the cost of providing support services to individuals living in homelessness, arresting and putting them into jail is prohibitively expensive.
However, we need not look all the way to the US for examples of laws that target individuals living in homelessness and waste financial resources. In 2000, the Ontario Safe Streets Act (SSA) came into effect. While the act was meant to address aggressive forms of solicitation, the way the law has been applied in real life is considerably different. A review of SSA tickets handed out by Toronto Police indicates that four out of five tickets were handed out for non-aggressive acts. This places increasing financial stress on individuals who, as it stands, have difficulty affording basic needs. Involvement with the criminal law system effectively acts as a barrier for many individuals seeking access to supports and services that can help them move out of homelessness. This includes educational supports, training opportunities for employment, housing subsidies, and food assistance. Fifteen years in, it's clear that the Act is an unproductive and discriminatory means of dealing with the province's growing homelessness problem.
The SSA provides a great example of how ineffective laws targeting homeless people are, compared to policies addressing affordable housing and other measures that actually address homelessness head-on. Criminality is not a synonym for the word homeless; we need to be doing a better job of supporting and enacting research-informed practices and policies. Strategies that look to address homelessness need to have a long-term focus and be informed by the experiences of people living in homelessness, rather than myths about homelessness. Spreading awareness has a vital role to play in informing the general public about real solutions to homelessness.
The SSA is a misinformed, inefficient, discriminatory piece of legislation that contributes to the criminalization of homelessness. It has no place in a province that possesses a social conscience and an interest in promoting the well-being of all of its citizens. I invite you to join the coalition to repeal the SSA. Criminalizing homelessness targets individuals living in homelessness, rather than homelessness itself.
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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.