Laurence Roy, PhD Douglas Mental Health University Institute

Transcription

1 Mental health and homelessness among Canadian adults: At H ome/chez soi, and beyond Laurence Roy, PhD Douglas Mental Health University Institute

2 Today s presentation

3 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

4 Faces of homeless women in Canada Viola, Winnipeg participant: Theresa, Toronto participant:

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

6 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

7 What do we do?

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

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

10 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.

11 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

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

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

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

15 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

16 / 16 Effect of HF on residential stability

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

18 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

19 After At Home/Chez soi: Eight challenges f or the years to come

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

21 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.

22 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).

23 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.

24 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.

25 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.

26 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.

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

28 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, Gaetz, S., Gulliver, T., & Richter, T. (2014). The state of homelessness in Canada: 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, (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.

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