Earlier this week I wrote a post about a mentally ill homeless woman in Westboro. Several commenters and I mulled over how she could best be helped. (Followed, sadly, by another commenter who declared the woman to be a crazy bitch who should be overpowered and locked up forever.)
Coincidentally, two days later, The Canadian Institute for Health Information (CIHI) released a new report called Mental Health and Homelessness, which is freely available online.
I think it’s a little disappointing that this report takes the approach of individualizing homelessless, and virtually ignores its structural causes, such as poverty. Nor does it get into the recent regression of housing policy in this country, such as the dismantling of our national housing strategy in 1993.
That being said, it was still an interesting read and it does provide a useful overview of the issues. If you don’t feel like reading the whole report, here are some of the main points.
Pathways to Homelessness
People who are homeless are more likely to experience mental illness. In some cases, the mental illness may have been a factor in them becoming homeless. In other cases, the homelessness may have been a factor in them experiencing mental health problems. Mental illness can become worse with continued homelessness.
People who don’t have homes are more likely to suffer a variety of physical health problems too, including respiratory infections, arthritis, infectious diseases such as tuberculosis and HIV, skin and foot problems, poor dental health, injuries and poor management of chronic conditions such as diabetes.
People who don’t have homes die younger than people who do. One study showed that half of homeless women in Toronto died before their 40th birthday.
Homeless people tend to be subjected to more stress than people who have homes, and are more likely to have low self-esteem and insufficient social supports.
Suicide attempts and suicidal thoughts are more common among homeless youth than those who have homes. (In Ottawa, 4% of non-homeless male youth and 21% of homeless male youth report at least one past suicide attempt.)
There are higher rates of schizophrenia among the homeless population than in the general population. Less than 1% of the population reports having been professionally diagnosed with schizophrenia. Equivalent data is not available for the homeless population. However, in Toronto, 6% of 300 shelter users surveyed reported a psychotic disorder, primarily schizophrenia.
In 2002, a street needs assessment project was undertaken in Ottawa, and 80 homeless people who do not use shelters were interviewed. Of these, 33% said they have mental health concerns (20% depression, 6% anxiety disorders, 4% schizophrenia and 3% personality disorders.)
Toronto’s Pathways into Homelessness Project found that 29% of shelter users met the criteria for anti-social personality disorder, often in combination with other diagnoses such as depression or post-traumatic stress disorder.
Rates of substance abuse are higher among the homeless population.
Some people have both substance abuse disorders and mental illness diagnoses (‘concurrent disorders’). Homeless people with concurrent disorders are likely to remain homeless longer than people with just one disorder.
Depression is more common among homeless people than people who have homes.
One-third of Ottawa’s adult street people report mental health problems; of these, 20% report depression.
In Kitchener-Waterloo, almost half of the street youth in a study reported a decrease in their depression since leaving home; 28% reported an increase.
Barriers to Getting Help
Some of the barriers identified by Los Angeles street youth who felt they needed help but didn’t get it:
Mental health and behavioural disorders is the most common reason for Emergency Department visits by the homeless (35%).
The #1 reason for inpatient hospitalization of the homeless is mental diseases and disorders (52%), followed by significant trauma (7%). That’s a huge gap between the most common reason and the second most common reason.
Policy and Programs
In the 1800s, the mentally ill were often warehoused in prisons or poorhouses. By the end of the century, asylums were developing.
Starting in the 1960s, psychiatric patients were being discharged into the community when there wasn’t room for them in the hospitals. This move towards deinsitutionalization was prompted by several factors: economic contraints, human rights, and pharmaceutical improvements.
Community mental health services did not increase at the same rate that patients were being released into the community.
Current and future developments
In 2006, a Senate report recommended establishing a Canadian Mental Health Commission and a national mental health strategy [and Harper announced its establishment just this Friday.] The report noted that affordable housing is a key issue. It said that the percentage of people with mental illness who need access to housing is double that of those who do not have mental illnesses.
Two housing models
Continuum of Care Models (Treatment First)
Three stages: outreach, treatment, housing. Essentially the housing is offered as a reward for the successful completion of the psychiatric or substance abuse treatment.
Housing First Models*
The homeless and mentally ill are offered housing that is not contingent on treatment or sobriety. They tend towards harm reduction approaches rather than abstinence. Other community services are offered but are not compulsory.
American research indicates that participants in the Housing First model remain housed much longer than participants in the Treatment First mode (5 years later: 88% vs 47%). Another study found that homeless participants with a major mental illness such as schizophrenia or bipolar disorder who were in the Housing First program spent more time in stable housing and less time in hospitals than their counterparts in the Treatment First programs.
Existing programs are typically only able to serve a small number of the homeless, despite large numbers of homeless people across Canada.
*My note: The Housing First Model may not be as appealing as it might first appear. It’s actually being widely promoted here in Canada by Bush’s Housing Czar, Philip Mangano. It’s deceptively simple, and it’s also just plain deceptive, as in the US it’s accompanied by deep slashes to social housing budgets, along with punitive crackdowns on the homeless, such as legislating them out of the downtown core and introducing laws against feeding them. For more information, see Cathy Crowe’s newsletter, or this Wellsley Institute backgrounder by Michael Shapcott, or this article in the Toronto Star.
However, it could be reasonably argued that this is not a failing of the model itself, but of the way it’s being implemented in the US. Maybe this model – combined with a respectful and pragmatic attitude towards people who are mentally ill and homeless – could help meet the Westboro woman’s needs.