Home/Chez soi, and beyond Laurence Roy, PhD Douglas Mental Health - PowerPoint PPT Presentation

Mental health and homelessness among Canadian adults: At Home/Chez soi, and beyond Laurence Roy, PhD Douglas Mental Health University Institute

Today ’ s presentation

The faces of homelessness in Canada: A few figures Estimated number of Canadians experiencing homelessness in 2014: 235,000 Severe mental illness among those experiencing homelessness: 20%-50% Lifetime criminal justice involvement: 60%-90% Fazel et al 2008; Fournier & Bonin 2001; Gaetz et al 2014; Goering et al 2002; Roy et al 2014

Faces of homeless women in Canada Viola, Winnipeg participant: http://athome.nfb.ca/#/athome/video/82 Theresa, Toronto participant: http://athome.nfb.ca/#/athome/video/10

Mental health and homelessness: complex trajectories Individual factors Systemic factors  Lack of affordable housing in  Co-occuring mental health Canada problem with substance misuse  Institutional silos  Severe personality disorders  Lack of community resources  Some personality traits (e.g. for those with complex needs impulsivity)  Inefficient social safety net  Victimization and child abuse  Criminal justice system involvement  Multiple stigma Caton et al 2005; Martijn & Sharpe 2006; Connolly et al 2008; Fischer et al 2008; Gaetz et al 2014

Mental health and homelessness: correlates  High rates of morbidity and mortality  High rates of substance misuse and physical health problems  Criminal justice involvement and criminal victimization  Extensive use of health, social, police and justice services Hwang 2000; McNiel & Binder 2005; Poulin et al 2010; Roy & Hurtubise 2007

What do we do?

Approaches to homelessness  Diverse service users call for diverse services Women with Women Homeless children and men youth with severe mental Couples and Adults living with illness Families addictions

Leaving homelessness: “ Treatment First ” or “ Housing First ” ? Principles Housing First Treatment First Independent housing is A prerequiste An outcome Conditions to independent Desire to obtain independent Various, often including housing housing sobriety, compliance with medical/psychiatric treatment, absence of agressive behavior Choice Necessary for both housing and Contingent on available service use services Housing context Single or scattered sites Single or scattered sites

What is Housing First? Basic principles 1. Rapid, low-barrier access to permanent housing in independent units (service users are legal tenants) ; 2. No sobriety or compliance to psychiatric treatment required; 3. Off-site clinical services offered according to needs (Intensive case management or assertive community treatment) ; 4. Housing team manages relationships with landlords, housing insurances and other housing-related issues; 5. Rapid re-housing and continuous support in case of eviction; 6. Clinical practices informed by recovery approach, motivational interviewing and harm reduction principles. 7. Case management is centered on service user empowerment, choice, hope, personalized goals, and resilience.

Previous studies on Housing First  Mostly American studies  Previous trials indicate a significant effect of Housing First vs Treatment First/usual services on residential stability;  Some studies indicate positive effect on substance misuse after 12 months in a HF project. Culhane et al. 2002, Larimer et al. 2009, Sadowsky et al. 2009

A Canadian research and demonstration project on Housing First: The At Home/Chez soi project

Overview of the project 2,255 homeless adults with mental illness randomized into Housing First or usual services

Montreal intervention Needs HF Intervention Housing Usual First (HF) services (TAU) High Housing team + 82 81 needs Assertive community treatment Moderate Housing team + 204 102 needs Intensive case management

Montreal participants  33% are women;  Mean age of 44 years old;  Many have been homeless for a long time (mean duration of homelessness of 52 months);  35% have been involvement with the justice system within six months prior to entering the project  80% have been victims of crime within six months prior to entering the project

Effect of HF on residential stability / 16

Effect of HF on nights in hospital, jails and unstable housing / 17

Overview of research results When compared with usual services,  HF significantly reduces homelessness and increases residential stability for adults with mental illness that have severe or moderate needs;  HF significantly increases the self-rated quality of life of these participants;  There are few differences between HF and usual services on psychiatric symptoms, substance misuse, justice involvement, and victimization.  Cost offset

After At Home/Chez soi: Eight challenges for the years to come

Mental Health and Homelessness: 8 challenges for the years to come 1. Community integration is the next frontier.

Mental Health and Homelessness: 8 challenges for the years to come 2. Service users have a right to be involved in the design, delivery and evaluation of interventions, programs and research.

Mental Health and Homelessness: 8 challenges for the years to come 3. We need to prevent discharge into homelessness for youth, men and women who leave institutions (hospitals, detention centers, jails).

Mental Health and Homelessness: 8 challenges for the years to come 4. Young men and women with emerging severe mental illness from all regions are at risk of homelessness.

Mental Health and Homelessness: 8 challenges for the years to come 5. We need to do more to understand and tackle the invisibility of many homeless women.

Mental Health and Homelessness: 8 challenges for the years to come 6. All services for persons (particularly women) experiencing homelessness should be trauma-informed, and should include direct interventions that address trauma.

Mental Health and Homelessness: 8 challenges for the years to come 7. All services should be equipped to address the specific needs of parents, children, and families experiencing or at risk of homelessness.

Mental Health and Homelessness: 8 challenges for the years to come 8. Silos do not work – bridges do. More intersectoral work, more knowledge exchange.

Selected references Caton, C. L. M., Dominguez, B., Schanzer, B., Hasin, D. S., Shrout, P. E., Felix, A., McQuistion, H., Opler, L. A., & Hsu, E. (2005). Risk Factors for Long-Term Homelessness: Findings From a Longitudinal Study of First-Time Homeless Single Adults. [Article]. American Journal of Public Health, 95, 1753-1759. Gaetz, S., Gulliver, T., & Richter, T. (2014). The state of homelessness in Canada: 2014 . Toronto: The Homeless Hub Press. 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. Fournier, L. & Bonin, J.-P. (2001). Enquête auprès de la clientèle des ressources pour personnes itinérantes des régions de Montréal-centre et de Québec, 1998-1999 (Vol. 1). Québec: Institut de la statistique du Québec. Roy, S., & Hurtubise, R. (2007). L'itinérance en questions . Québec: Presses de l'Université du Québec. Roy, L., Crocker, A. G., Nicholls, T. L., Latimer, E., & Reyes Ayllon, A. (2013). Criminal behavior and victimization among mentally ill homeless individuals: a systematic review. Psychiatric Services, submitted.

Thank you! For more information: laurence.roy@mcgill.ca