Lecture 22 Flashcards
What approximate percentage of people who experience homelessness experience transitional homelessness?
- 80%
What is Mean annual societal cost associated with people experiencing both homelessness and serious mental illness in Canada?
$59000
Which promises were made but not kept of housing?
◦ Funding/implementation of community-based housing and supports
◦ Patients were transferred to general hospitals, or discharged to families, some became homeless, others were eventually incarcerated and others…
Explain custodial housing
◦ Congregate housing with staff providing custodial care (subsistence & medicine)
◦ Typically for-profit
◦ Dependency maintained (no expectation of chores, responsibilities, or rehabilitation to increase independent functioning)
◦ No choice (in housing, services, nor roommates)
◦ Usually located in inner city (e.g., board and care homes, SROs)
◦ Custodial housing provided similar custodial care provided in psychiatric hospitals
What is the assumption with custodial housing?
people experiencing mental illness “required caretaking… and [were] seen as disabled object of care…”
What were the custodial housing outcomes?
- Generally poor outcomes beyond having relatively low rates of psychiatric re- hospitalization
◦ Increase mental health symptoms
◦ Low independent functioning
◦ Poorer overall health
◦ No difference in community integration
What is the consumer/survivor rights movement?
Consumer/survivor rights movement involved people experiencing mental illness directly organizing and advocating for right to self-determination, community integration and against stigma/discrimination
What was developed in the 70s and 80s and addressed some of the criticisms/limitations of custodial housing
- supportive housing
what is the conceptual framework of supportive housing
While custodial housing was based in large part on the same institutional model, supportive housing was based on the “linear residential continuum model”
◦ Also commonly called “continuum of care” or “staircase” model
What is the focus of supportive housing?
- skills building and independent functioning
What is the staircase approach?
- Clients move up the staircase as their independent functioning improves
- Restrictions/rules, treatment intensity, supervision decrease and independence increases with every step up
- Clients moved down to a previous step if independent functioning deteriorates
- Amount of time spent in each setting predetermined by the average of previous clients
What is at the bottom of the staircase?
◦ Congregate settings (e.g., halfway houses, hospital)
◦ Greatest amount of restrictions/rules
◦ (Mandated abstinence, treatment engagement, curfew)
◦ Intensive treatment (Rehabilitation)
What is at the top of the staircase?
independent apartment in the community
What is the assumption of the staircase approach?
- mastery of rules and rehabilitation is needed before independent housing/living
What are some positive outcomes associated with supportive housing relative to hospital or custodial housing settings?
◦ Reduced hospitalization rates
◦ Increased employment
◦ Improved independent functioning
◦ Increased social support
◦ Increased participation in leisure activities
What are some criticism of supportive housing
- Many people did not complete the staircase
◦ Many were asked to leave as a result of non-adherence to rules
◦ Many didn’t access program in first place because of all the restrictions - For people completing the staircase, there was often no available independent housing
- Unreasonable to expect everyone completing the staircase to not require supports during independent living
- Continuums of housing/services used were inconsistent
- Undue stress imposed by mandating multiple moves according to continuum/staircase approach
- Housing was segregated based on mental illness status
- In addition to the above criticisms of supportive housing, a number of other developments prompted a paradigm shift in housing and support, including mass homelessness, the consumer/survivor movement, new service/treatment models, and mounting evidence of recovery
What was the paradox of supportive housing?
The more independent (hence demanding) the living setting, the less intensive the services
What is social safety net?
- services from government that help guide or aid life, pension, healthcare services, etc.
After WWI, the social safety net strengthened in Canada. For example:
◦ Introduced Dominion Housing Act (1935; first housing legislation at national level)
◦ Employment insurance (1940)
After WWII, social safety net strengthened :::::
the Canadian federal government treated housing as human right without formal legislation
◦ 1945 Canada Mortgage and Housing Corporation (CMHC) created to “administer the federal role in housing as described by the National Housing Act”
◦ Tens of thousands of social housing funded annually by the government (growth especially in 60s and 70s)
◦ Rent subsidies in private market
Canada’s social safety was strengthened after WWII and especially in 1960s. LIKE:::::
◦ 1965: Canada Pension Plan
◦ 1966: Universal Health Insurance
◦ 1966: Guaranteed Income Supplement (senior citizens)
◦ 1966: Canada Assistance Plan (made welfare universal right and funded social assistance programs like income assistance, vocational services, health care costs not covered)
define stagflation
- high inflation and unemployment
What drove stagflation into the 1980s?
- global oil crisis (1973) and other influences
define neoliberalism
- “a term used to describe an ideology that promotes adherence to the free market principles of classical economics while opposing state interventionist theories”
What is stagflation and the rise of neoliberalism characterized by?
- deregulation, commodification (e.g., financialization of housing as market commodity), lower taxes, smaller government, less government social spending (privatization of social services), globalization of markets, ”trickle-down” economics
What is Canada’s neoliberal response to stagflation?
- Reduction of corporate taxes
- 1977: Established Programs Financing Act (EPFA) reduced federal spending on
post-secondary and health care (reduced percentage of cost-sharing) - Reduced federal government social spending
◦ E.g., Canada Health and Social Transfer was a block transfer resulting in cuts to social spending (social services, welfare, and health)
◦ E.g., it replaced Canada Assistance Plan (CAP) and EPFA. CAP was 50-50 cost sharing agreement and spending was decided by provinces (Madore, 2003)
Review part of canada’s neoliberal response to stagflation
- Funding for social housing reduced (in part to also stimulate home ownership)
◦ Reduction in low-interest loans provided by government for incentive to build new affordable housing units which reduced affordable housing supply and increased rent (Kalman-Lamb, 2017)
◦ Social housing cuts started in 1984 (Hulchanski et al., 2009)
◦ Federal government completely stopped funding new social housing in 1993
(Hulchanski et al., 2009)
◦ Provinces expected to fund/manage social housing in 1996 (Gaetz, 2010)
◦ People increasingly had to rely on private market for housing (Gaetz, 2010)
What was the promise to neoliberalism?
- prosperity for everyone was the intention
- trickle-down economics through the private market
What was the reality check in the world?
- Reality check: Poverty increased and homelessness became new normal
- Social assistance provided to marginalized and vulnerable populations became inadequate
- People with higher socio-economic status did benefit, including during subsequent recessions
What started in the 1980s
- mass homelessness
explain the decreased new units of social housing
◦ A peak of 30,000 new units were built in 1972 decreasing to 1,000 in 2010 (Walks et al., 2015)
◦ Home ownership and number of condos increased considerably with corresponding reduction in affordable rental units (Gaetz, 2010)
- Efforts to address homelessness were largely emergency services (e.g. homeless shelters)
*Gaetz (2016) argues that a primary focus on emergency services is not enough to address primary prevention and to end homelessness after its onset
Review Homelessness Among People Experiencing Serious Mental Illness (PESMI)
- Homelessness among PESMI became major political issue (Ridgway et al., 1990)
◦ PESMI among first to be noticed among PEH even though other populations were also experiencing homelessness at unprecedented rates (Draine et al., 2022) - Hulchanski (2009) argues that at individual-level inadequacies in 31 of these domains contribute to homelessness: Housing; income; support services
◦ Economic circumstances in 80s made it difficult to secure affordable housing, employment, living wage or income assistance, health/social supports - Neoliberal policies created perfect storm and affected all three of the domains
What are the contributors to. theincreasing number. ofPESMI becoming homeless during rise of mass homelessness (increased from 20% to 33% during 1980s)?
- reduced supply of affordable housing
- increasing poverty
- inadequate housing and support services during deinstitutionalization
- discrimination and stigma
What was the recovery movement
- Consumer/survivor movement in 1970s, 80s, and 90s strengthened in direct advocacy
- PESMI clearly articulated their need for basic human needs and community integration, including “housing, jobs, income, relationships, and a place in the community” with a special emphasis on housing
- PESMI also wanted to exercise choice and autonomy arguing that choice/self- determination in treatments/services received was a human right
- PESMI also articulated their firsthand experiences of “leading ‘meaningful and productive’ lives in their communities…often without assistance from, and in some cases despite, mental health services…”
- The concept of recovery developed from the advocacy of PESMI (Davidson, 2016) in 1980s (Deegan, 1988) and has become embedded in systems of mental health care aiming to be “recovery-oriented”
define recovery
“a process of restoring a meaningful sense of belonging to one’s community, and positive sense of identity apart from one’s condition while rebuilding a life despite or within the limitations imposed by that condition” (Davidson et al., 2007)
- Recovery is individually defined and hence looks different across individuals
- Recovery is holistic, taking into account hope, interpersonal relationships, trauma, culture,
spirituality, education, employment, housing, and clinical treatment (SAMHSA, 2012)
What is recovery
◦ Is not an outcome; it’s a process
◦ May or may not include abstinence from substance use
◦ Goes beyond a focus on just symptoms
What is used to describe the process of recovery?
recovering citizenship
What are the 5 components of the process of recovery?
CHIME!
Connectedness - sense of belonging, supportive relationships, peer support
Hope and optimism about the future - motivation to change; self-efficacy about recovery
Identity - developing positive self-identity; stigma
Meaning in life - having goals, social roles that are meaningful, spirituality, and QoL
Empowerment - feeling control over one’s life; focus on strengths, personal responsibility
What are some services and systems that aim to facilitate recovery that have the following values that are called “recovery-oriented”?
◦ Choice and self-direction
◦ Person-centred care
◦ Empowerment (facilitated by having choices over daily life activities and services)
◦ Strengths-based (as opposed to traditional medical model of focusing on symptoms and deficits)
◦ Personal responsibility
◦ Hope for the future
What is community integration?
- physical
- psychological
- social
How did mounting evidence in the 1970s support existence of recovery among PESMI?
◦ E.g., studies demonstrated up to 67% of people diagnosed with schizophrenia improve considerably (many no longer meeting criteria for the diagnosis)
◦ This went against common belief then and now
◦ Others may improve in specific domains (e.g., employment but not symptoms)
*Research up to that point had begun to find positive outcomes associated with the demands of the consumer survivor movement (Trainor et al.,1993):
◦ “The provision of non institutional services within the home and surrounding community such as training in daily living skills, vocational skills, leisure time skills, and social/interpersonal skills has been found to improve resident integration…and reduce the length of time spent in hospital”
July 21, 2023 HSCI 214
The importance of having “choice” in where one lives
- later research in the 2000’s and 2010’s further confirmed choice to be associated with what?
- motivation for change
- increased perceived control over one’s life and self-efficacy
- psychological integration
- life satisfaction and long-term happiness
- reduced mental health symptoms
What are 2 community- based support models that were developed in 1970s and 1980s?
- Assertive Community Treatment (ACT_
- Intensive Case Management (ICM)
explain ACT
- Stein & Test (1980)
◦ Evidence-based and developed to facilitate community integration and as alternative to psychiatric hospitalization during deinstitutionalization
◦ Made up of multi-disciplinary team of health and social service practitioners addressing recovery needs of PESMI (e.g., psychiatrist, vocational specialist, nurse, social worker, substance use counsellor)
◦ Assertive means to “go to”
◦ Available 24 hours a day and services provided (in vivo)
explain ICM
◦ Evidence-based model of community-based support
◦ Individual case manager coordinates needed services and may provide some rehabilitation services (e.g., life skills, counseling)
What paved the way for a “paradigm shift” and new model of housing and support for PESMI? and what is the new model of housing?
- Consumer/survivor/recovery movement + criticisms of supportive housing + number PESMI among PEH + development of ACT and ICM
- supported housing
What is supported housing
- housing first - most well-defined type of supported housing
Who was housing first founded by in NYC in 1992?
- Dr. Sam Tsemberis
What was housing first initially created for?
- for people experiencing homelessness and serious mental illness
(including people with concurrent substance use disorders)
*clients identified via outreach or referral
What is housing first
- Immediate access to permanent housing (private market or social housing) + community-based health/social supports (ICM or ACT)
Tsemb
What is housing in housing first
- Rent subsidized (tenant pays no more than 30% of their income)
- Apartments in dispersed locations (studio to 2-bedroom)
- Makes sure no more than 20% of tenants in any one building are the program’s clients
- Apartment lease held by client (sublease in some cases)
- Program’s money management service can become client’s representative payee to ensure rent paid on time
- Program finds alternative unit in case of eviction, other crisis, or desire to move
What is the support in housing first?
- 24 hours: ACT or ICM (lower level of need for support)
◦ Rehabilitation provided in variety of life domains:
◦ (e.g., independent living, employment, education, family reunification, income assistance application, interpersonal skills, self-care, engagement in leisure activities, etc.) - Requirement for clients to meet with ACT at least once weekly and with case manager at least twice monthly
- ACT/ICM services provided in location of client’s preference
- Person-centred
◦ Treatment and service planning directed by client
What are the housing first values?
- Citizenship and rehabilitation
- Recovery orientation
- Community integration
- Consumer self-determination
- Collaboration with professionals and among consumers
- Housing as a citizenship right
- Attention to other resources (e.g., employment, education, meaningful activity)
What are the key prinicples of housing first?
- Housing as a basic human right
- Respect, warmth, and compassion for all clients
- A commitment to clients
- Scattered-site housing
- Separation of housing and services
- Consumer choice and self-determination
- A recovery orientation
- Harm reduction
What are examples of recovery-oriented services in housing first?
◦ Supported employment
◦ Supported education
◦ Social Skills training
◦ Psychoeducation
◦ Integrated treatment for co-occurring disorders
◦ Assertive community treatment
◦ Family reunification
What is housing first consistently associated with?
◦ Increased housing stability
◦ Decreased time spent homeless
◦ Vancouver At Home Study (2-year follow-up): Participants with high level of need for support in Housing First spent on average 74% of time in stable housing vs. 26% for TAU
What are some positive recovery trajectories
- Many trajectories marked by more meaning and purpose after receipt of Housing First
- New interpersonal relationships, life goals, and employment
- Greater sense of belonging to community
- “Normally, when I walk down the street, everyone is staring at me because I’m a junkie. But, a lot of the time lately…I’m feeling good and there’s a lot of smiles” (Patterson et al., 2015)
- “Life’s gone from chaotic to meaningful. I don’t know. I really want to be present…” (Patterson et al., 2013)
What is Congregate Housing First?
- Adaptation of Housing First where all tenants of a building share the experience of having been homelessness and living with a serious mental illness
◦ May have independent room (studio suite) but shares other spaces (e.g., kitchen, dining area) - Health and social services provided on-site
- Only providing congregate Housing First in given area limits client choice * 84% of PEHMSI prefer independent housing
What are the problems with current “housing first” programs
- most HF programs do not adhere to original model
- requires funding, multidisciplinary health and support teams (ACT, ICM), and time-unlimited
- 84% of people experiencing homelessness and mental disorder prefer independent housing over congregate
- BC’s modular housing initiative
Which housing and support model is underpinned by the staircase approach?
supportive housing
