Housing and Mental Health

Housing is a basic human right and requirement for good health. According to the United Nations’ Universal Declaration Of Human Rights the right to housing is protected under international law, and Canada has endorsed such rights guaranteeing “an adequate standard of living… including adequate food, clothing and housing.” Likewise, the Ottawa Charter for Health Promotion identifies shelter as a basic prerequisite for health.

Adequate, suitable and affordable housing contributes to our physical and mental well-being. It leads to increased personal safety and helps decrease stress, leading to improved sleep and diet. All of these factors result in better mental health outcomes. When housing is inadequate or unavailable, personal as well as community well-being can suffer.

The high cost of rental accommodations has created a critical shortage of affordable housing and is a leading contributor to poverty in Ontario. According to the Ministry of Municipal Affairs and Housing approximately 15 per cent of the province’s households are currently in dire need of affordable housing. Accommodation is considered affordable if it requires less than 30 percent of a household’s total pre-tax income.

Many individuals with mental health conditions are on social assistance and majority do not have access to affordable housing. Adequate dwellings are defined as those not requiring major repairs, whereas suitable dwellings refer to those that have enough bedrooms for the size of the household.

Affordable housing is an investment in health promotion and illness prevention. When a person has adequate housing they experience fewer health problems and are able to devote more of their income to adequately feed and clothe themselves and their family.

Why Are People Homeless?

Two trends are largely responsible for the rise in homelessness over the past 20 years: a growing shortage of affordable rental housing and a simultaneous increase in poverty. Homelessness and poverty are linked. Poor people are frequently unable to pay for housing, food, child care, health care and education. Difficult choices must be made when limited resources cover only some of these necessities. Being poor means being an accident, an illness or a paycheck away from living on the streets.

Homelessness Is a Frequent Experience of Persons with Mental Health Conditions

It is difficult to state whether homelessness or mental illnesses occur first. Each case must be considered individually. Research tends to support both theories. The stress of being homeless may exacerbate a previous mental illness. However, the difficulties of being homeless may encourage anxiety or depressive disorders.

People with lived experience of mental health and addictions conditions (PWLE) are disproportionately affected by homelessness. While many factors can lead to homelessness, mental health plays a significant role—an estimated 25 to 50 per cent of homeless people live with a mental health condition. Solving this social crisis will require new ways of helping these critically vulnerable Canadians. The consequences of homelessness tend to be more severe when coupled with a mental health condition. PWLE remain homeless for longer periods of time and have less contact with family and friends. They encounter more barriers to employment and tend to be in poorer health than other homeless people.

Housing and Mental Health Conditions

For PWLE, safe and affordable housing can provide a place to live in dignity and move towards recovery. Individuals with serious mental health and addictions conditions frequently identify income and housing as the most important factors in achieving and maintaining their health. However, for many, maintaining safe and affordable housing can be difficult.

During periods of illness, individuals may be unable to work and/or experience a loss of income.
Without adequate income, they may have difficulty paying rent and may eventually lose their home and household contents. Consequently, many live in substandard housing that is physically inadequate, crowded, noisy and located in undesirable neighborhoods. Furthermore, persons who cannot afford to live in decent housing are more likely to experience exposure to violence, communicable diseases and increased chronic conditions.

Housing Makes a Difference

Many PWLE live independently; however for those with more serious mental health conditions, there are a variety of supports available to them. Research indicates that a stable, supported living environment is essential to maintaining the health and well-being of PWLE and is integral to their recovery. Housing with support can generate positive outcomes, including enhanced life skills, improved health status, an increased sense of empowerment and involvement in the community. Research shows that maintaining and improving the housing of individuals with serious mental health conditions can contribute to a reduction in psychiatric symptoms and therefore decrease the need for emergency and treatment services.

Housing with supports gives an individual access to a range of housing options: supportive housing, supported housing, and rent supplements. Supportive housing provides assistance by staffing housing units with 24-hour supports. Other individuals may live in the larger community and have supports, such as homecare and counseling when they need it. This is referred to as supported housing.

Supports within housing include:

• Up to 24-hour support for PWLE and their significant others to ensure a stable housing environment
• Individualized assessment and planning, hands-on assistance with activities of daily living, coordination and support, crisis management, facilitating peer and group support and resident input to their housing environment
• Support services provided to individuals who are homeless, or at a risk of being homeless
• Support services such as connecting with landlords, matching people to housing, housing advocacy, and teaching life skills

Service providers have also identified the following factors which support successful housing arrangements: rent geared to income, community support services, a strong personal support network, and availability of case management.

Residential care and permanent supported housing approaches appear to yield the greatest reductions in hospitalizations. People living in housing with support have also been found to be less likely to be institutionalized in jails and prisons. Individuals in supported housing also report higher quality of life due to their housing, more choice and control over their housing and better quality of housing. Other research has shown that improvements in personal coping, relationships and community involvement are greater for individuals with housing supports.

Rent supplements or rent-geared-to-income housing are two strategies that can provide individuals with the financial resources they need to access desirable housing in their community.

Affordable Housing and Housing with Supports Makes Economic Sense

Homelessness is a significant health care issue and continues to produce enormous costs to our economy. According to the Mental Health Commission of Canada, an estimated 150,000 to 300,000 people across Canada are homeless, which results in $1.4 billion each year in costs to the health care, justice and social services systems.

Housing designed for people with mental health conditions can contribute to significant cost savings for the health system. It costs $486 a day ($177,390 per year) to keep a person in a psychiatric hospital, compared to $72 per day ($26,280 per year) to house a person in the community with supports.

Challenges to Affordable Housing

As of July 2012, 41 percent of people receiving ODSP have a primary diagnosis of mental health/psychiatric disorders, according to a recent IPSOS survey. The maximum income for a single person receiving ODSP is $1075. However, in Ontario, the average market rent for a one-bedroom apartment is $866. For most people it is not feasible to allocate on average 80% of one’s social assistance to housing; and this situation is putting people on ODSP at risk of losing their home.

The challenges of poverty, stigma and discrimination that PWLE face directly impact their ability to access and to find and keep housing. Due to stigma, the typical reaction encountered by someone with a mental health condition is fear and rejection. Many PWLE are often denied housing in the private market as a result of their mental health and addictions conditions.

Furthermore, many supportive housing projects also encounter a “not-in-my-backyard” response (NIMBYism) from neighbours, businesses, councillors, etc. This type of behaviour may include discriminating and slandering comments in person, by e-mail, or through flyers and posters which protest a new supportive housing development.

Despite improvements in Ontario’s economy and a modest level of rental development in a number of markets, there continues to be a serious housing affordability issue in Ontario. There are fewer affordable housing units available now than a decade ago. Between 1996 and 2006, after adjusting for inflation, more than 78,000 units were lost in the moderately affordable rent ranges ($400 to $800) in Ontario. According to the Ministry of Municipal Affairs and Housing :

• Between 2004 and 2012, the number of households on waiting lists for rent-geared-to-income social housing units has increased by 32,000, to nearly 158,500.
• Between 1991 and 2006, the number of Ontario households in need of affordable housing increased by over 200,000.
• 627,535 (15 per cent of the province’s households) are currently in urgent need of affordable housing.

Recent policy reports addressing housing have included Ontario’s affordable housing strategy launched in 2010, Building Foundations: Building Futures, and the Social Assistance Review‘s Brighter Prospects: Transforming Social Assistance in Ontario. Both reports speak to making the current housing system less complicated by revising rent geared to income calculations, and introducing standard rates as well as housing benefits. However, housing affordability, and supports for PWLE are not addressed in any significant way.

Current Activities at CMHA Ontario

CMHA Ontario is active in monitoring and addressing housing concerns experienced by PWLE. We do this in partnership with other housing providers and community advocates. We are also involved in promoting mental health through highlighting public issues and recommending options to create inclusive and supportive environments.
In our efforts to keep the government’s focus on the need for more affordable housing and income security for PWLE, on January 24, 2014 CMHA Ontario made a submission to Ontario’s Minister of Finance as part of the 2014 pre-budget consultations. The pre-budget submission recognized the government’s 2011 Comprehensive Mental Health and Addictions Strategy that committed to investing $257 million over three years for child and youth mental health services. However, in looking forward towards years four to ten of the Strategy, CMHA Ontario recommended that the government take concrete steps to:

• Develop a Housing First model across Ontario to support marginalized populations, where housing is provided as the first step, in combination with supportive services, to people who are homeless and living with mental health and addictions issues; ,
• Ensure that any current and new investments in housing provide access to a range of housing options, including supportive housing, supported housing, and rent supplements for vulnerable populations, including those with mental health and addictions needs;
• Incrementally increase the minimum wage of $10.25 over 5 years to reach a wage of 10% above the poverty line by 2018.

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References

¹United Nations’ Universal Declaration of Human Rights, Article 25 (1948).
http://www.un.org/en/documents/udhr/index.shtml#ap

²United Nations, Office of the High Commissioner for Human Rights, “International Covenant on Economic, Social and Cultural Rights,” (1976), http://www.unhchr.ch/html/menu3/b/a_cescr.htm

³World Health Organization: Ottawa Charter for Health Promotion. (1986).
http://www.who.int/healthpromotion/conferences/previous/ottawa/en/

⁴Ministry of Municipal Affairs and Housing. (2014) Retrieved from http://www.mah.gov.on.ca/Page10444.aspx

⁵Canada Mortgage and Housing Corporation. (2006 Census Year). Core Housing Need Status Definitions
http://cmhc.beyond2020.com/HiCODefinitions_EN.html#_Core_Housing_Need_Status

⁶Mental Health Commission of Canada: Housing and Homelessness Issue Paper
Retrieved March 31, 2014 from http://www.mentalhealthcommission.ca/English/issues/housing?terminitial=23

⁷Canada Mortgage and Housing Corporations. (2006 Census Year). Core Housing Need Status Definitions
http://cmhc.beyond2020.com/HiCODefinitions_EN.html#_Core_Housing_Need_Status

⁸Canada Mortgage and Housing Corporation-Homeless Hub. (2007) Canadian Definition of Homelessness.
http://www.cmhc-schl.gc.ca/en/corp/li/rere/rere_008.cfm

⁹C. Walker. (1998). Homeless People and Mental Health. American Journal of Nursing 98, no. 11: 26-32

¹⁰T. Morrell-Bellai.(2000). Becoming and Remaining Homeless: A Qualitative Investigation,” Mental Health Nursing 21, no. 6 581-604

¹¹Mental Health Commission of Canada. Retrieved (March, 2014) http://www.mentalhealthcommission.ca/English/issues/housing?routetoken=90a4ae271b2c565880fe670200571cbf&terminitial=23

¹²R. Benger and B. Cameron.( 2000). Asylum: Falling through the Cracks. Witness, Canadian Broadcasting Corporation
Retrieved January 31, 2003, from http://www.tv.cbc.ca

¹³J. Trainor, E. Pomeroy and B. Pape, eds. (1999). Building a Framework for Support: A Community Development Approach to Mental Health Policy Canadian Mental Health Association, Toronto.

¹⁴M.J.L. Kirby and W.J. Keon. (2006).Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addiction Services in Canada, Chapter One: Voices of People Living with Mental Illness, Final Report of the Standing Senate Committee on Social Affairs, Science and Technology.

¹⁵B. Moloughney.(June, 2004). Housing and Population Health: The State of Current Research Knowledge. Canadian Institute for Health Information. Ottawa.

¹⁶T. Middelboe (1997) Prospective Study of Clinical and Social Outcome of Stay in Small Group Homes for People with Mental Illness. British Journal of Psychiatry 171 :251-55.

¹⁷Connex Ontario. (2014). Retrieved from http://www.mentalhealthhelpline.ca/Search/ServiceTypes

¹⁸Toronto District Health Council. (September, 2001). Toronto Mental Health Housing Study.

¹⁹Leff, H.S., Chow, C.M., Pepin, R., Conley, J., Allen, I.E., & Seaman, C.A. (2009) Does one size fit all? What we can and can’t learn from a meta-analysis of housing models for persons with mental illness. Psychiatric Services, Vol. 60, No. 4, 473-482.

²⁰Nelson, G., Aubrey, T. & Lafrance, A. A. (2007) Review of the literature on the effectiveness of housing and support, Assertive Community Treatment, and Intensive Case Management interventions for persons with mental illness who have been homeless. American Journal of Orthopsychiatry, Vol. 77, No. 3, 350-361.

²¹Ibid.

²²Nelson, G., Hall, G.B. & Walsh-Bowers, R. (1995). An evaluation of supportive apartments for psychiatric
consumer/survivors. Canada’s Mental Health, Vol. 43, No. 2, 9-16.

²³Mental Health Commission of Canada. Housing and Homelessness. (2013).
http://www.mentalhealthcommission.ca/English/issues/housing?routetoken=bfb3d5f7c38a731af637531e4c6c18ca&terminitial=23

²⁴Ontario, Ministry of Health and Long-Term Care. (2006). Provincial Summary – Average Costs for CMH&A Service Recipient Activity.

²⁵Cathexis (2012). Evaluation of the Ontario Disability Support Program (ODSP) Employment Supports Program. Final Report. http://cathexisconsulting.ca/our-work/

²⁶Income Security Advocacy Centre Social Assistance Rates Update. (November/December 2012).

²⁷Canada Mortgage and Housing Corporation. (Fall 2011) Rental Market Report – Ontario Highlights.
http://www.cmhc-schl.gc.ca/odpub/esub/64507/64507_2011_B02.pdf

²⁸Ontario Non-Profit Housing Association (2011) Where’s Home? http://www.onpha.on.ca/Content/ONPHA/About/ResearchReports/WheresHome/WheresHome_2011.pdf

²⁹Pomeroy, S. (August, 2009). Understanding the Affordable Housing Issue: Background Diagnostic in Support of
ONPHA Response to the Long Term Affordable Housing Strategy. Toronto, ON: The Ontario Non-Profit Housing
Association, p. 8.; After adjusting for inflation, 37,941 units were lost in the $400 to $599 range and 40,754 units were lost in the $600 to $799 range for a total of 78, 695 units.

³⁰Ministry of Municipal Affairs and Housing. (2014). http://www.mah.gov.on.ca/Page10444.aspx

³¹Ministry of Municipal Affairs and Housing. (2010). Building Foundations: Building Futures: Ontario’s Long-Term Affordable Housing Strategy.

³²Commission for the Review of Social Assistance in Ontario. (2012). Brighter Prospects: Transforming Social Assistance in Ontario. http://www.socialassistancereview.ca/final-report

³³Mental Health Commission of Canada. (2013). At Home/Chez Soi
http://www.mentalhealthcommission.ca/English/initiatives-and-projects/home?terminitial=38&routetoken=e97edbb456da307448350e136e4c05ad

³⁴Employment & Social Development Canada. (January, 2014) http://www.esdc.gc.ca/eng/communities/homelessness/housing_first/approach/index.shtml