Joint Submission to the Ontario Ministry of Municipal Affairs and Housing Long-Term Affordable Housing Consultation Session

A submission on the provincial affordable housing strategy, jointly submitted by CMHA Ontario and five provincial organizations representing mental health and addictions consumers and service providers. (July, 2009)

For background information about the strategy and consultation, see “Ontario’s Long-Term Affordable Housing Strategy Consultation Document” at www.mah.gov.on.ca.

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Summary of Recommendations

1. Many people with mental health and/or addictions require housing that is affordable, adequate and suitable in order to maintain their recovery.
2. Ontario needs to increase the supply of supportive housing units and provide additional dollars for repair of existing supportive housing.
3. People with mental illness and/or addictions should have a choice in where they live.
4. The Ministry of Health and Long-Term Care should lead in the policy development, standards implementation, monitoring and development of housing for specialized populations.
5. Housing related strategies can contribute to the reduction of poverty among low income Ontarians and must be a key component of the provincial 10-year strategy on mental health and addictions and the Government’s poverty reduction strategy.
6. An adequately funded system of housing options that align with a harm reduction approach needs to be developed for persons with serious substance use problems.

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Provincial organizations representing mental health and addictions consumers and service providers are committed to raising the profile of mental health and addiction problems in Ontario, and strengthening the supports for the clients, families and communities affected by these problems. This submission on a provincial affordable housing strategy is submitted collaboratively by the following organizations: Addictions Ontario, the Canadian Mental Health Association Ontario, the Centre for Addiction and Mental Health, the Ontario Association of Patient Councils, the Ontario Federation of Community Mental Health and Addiction Programs, and the Ontario Peer Development Initiative.

Housing is fundamental to health. Nobody knows this more than people who have lost stable housing because of circumstances relating to a mental health or addiction problem. Nobody appreciates housing more than those who have experienced homelessness. Every day, mental health and addiction service providers witness the contribution that stable housing makes to the recovery of people with mental health and addiction problems. Unfortunately, we also witness the consequences of the failure to provide housing options for some of the province’s most persistently disadvantaged people.

Our experience with housing — coupled with empirical evidence on the importance and efficacy of housing investments — leads us to make the following assertions:

1. Many people with mental health and/or addictions live independently and require housing in their community that is affordable, adequate and suitable in order to maintain their recovery.

Affordable, adequate and suitable housing contributes to our physical and mental wellbeing. Maintaining safe and affordable housing can be difficult for people with mental illness and/or addictions. During periods of illness, individuals may be unable to work and/or experience a loss of income. Consequently, many live in substandard housing that is physically inadequate, crowded, noisy and located in undesirable neighborhoods.¹

The majority of low-income Ontarians live in some form of rental housing. Adequate dwellings are defined as those not requiring any major repairs, whereas suitable dwellings refer to those that have enough bedrooms for the size of the household. 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. Without adequate income, people may have difficulty paying rent and may become homeless.

Accommodations are considered to be affordable if they cost less than 30 percent of the total pre-tax household income.² However, many low income renters are increasingly struggling to find and maintain affordable housing.³ This, coupled with the fact that Ontario is facing an affordable housing deficit of almost 80,000 units, means that those on low and/or fixed incomes are either paying far too much of their income on housing or living in substandard conditions.⁴

2. Some people with serious mental illness and/or addictions require specialized supports within housing. Ontario needs to increase the supply of supportive housing units and provide additional dollars for repair of existing supportive housing.

Stable and supportive housing is fundamental to health, well-being and recovery for individuals with mental illness and/or addictions. It is a critical component to the success of treatment and recovery. Some have even suggested that without stable housing treatment strategies are not effective and recovery not possible.⁵

The reason for improving housing options for those with mental illness and/or addictions is clear. Stable housing improves quality of life and treatment outcomes. Research from Ontario has found that service utilization, including hospitalization rates for people in supportive housing programs, are significantly reduced. Hospitalizations were reduced from an average of 53 days per year prior to having supportive housing to only half a day after supportive housing is provided.⁶ Residential care and permanent supported housing approaches appear to yield the greatest reductions in hospitalizations.⁷ People living in housing with support have also been found to be less likely to be institutionalized in jails and prisons.⁸Those clients in supported housing also report a higher quality of life with regard to their housing, more choice and control over their housing and better quality of housing.⁹ Other research has also shown that improvements in personal coping, relationships and community involvement are greater for individuals with housing supports.¹⁰

3. Providing an adequate supply of affordable housing options enables choice. Having choice in housing has been shown to improve quality of life for people with mental health and addiction problems.

Research shows that personal choice in housing not only increases housing stability, but also improves well-being and quality of life.¹¹ Individuals with mental illness and/or addictions, however, report that they have to choose between housing that is affordable and housing that is independent, safe and includes the supports they require.¹² Ensuring choice in housing and supports should, therefore, be part of any approach to housing policy and planning.

Ensuring that persons with mental illnesses and addiction have access to a variety of affordable housing options supports recovery. It also lessens the likelihood of creating low-income ghettos.

A variety of policy options can be implemented to support individuals in securing and maintaining affordable housing of their choice. Some of these strategies include rent supplements, rent that is geared to income, and a universal housing benefit that is available to all low-income Ontarians.¹³

4. Housing is a requirement for good health and a key component of recovery. The Ministry of Health and Long-Term Care should lead in the policy development, standards implementation, monitoring and development of housing for specialized populations.

In Ontario’s existing mental health policy framework, Making It Happen, the government acknowledges the key role played by housing and the need to coordinate housing services with the supports that many people with mental health problems require to live in the community. (Making It Happen is in the process of being replaced by a new mental health and addictions strategy; a discussion paper on this subject was released at a mental health and addictions summit earlier this month.)

We agree that the coordination of housing and supports is critical. Supportive housing is fundamental to the long-term provincial objective of maximizing community-based supports and facilitating the greatest possible community integration and participation of people with mental health and addiction problems. The availability of supportive housing is a critical component of the province’s objective of reducing the number of alternative level of care patients — those patients in hospital who would be better served in community settings.

The need to coordinate accommodation with health-related supports, and the critical role supportive housing plays in achieving key health objectives, reinforces the need for the Ministry of Health and Long-Term Care to continue playing a lead role in monitoring and implementing the Government of Ontario’s supportive housing policies and programs.

5. Housing related strategies can contribute to the reduction of poverty among low-income Ontarians and is a key component of the provincial 10-year strategy on mental health and addictions and the Government’s poverty reduction strategy.

The high cost of rental accommodations and home ownership has created a critical shortage of affordable housing and is a leading contributor to poverty in Ontario. Without adequate income, housing security is jeopardized and people are at risk of homelessness.

People with low incomes are frequently unable to manage the multiple costs of housing, food, child care, health care and education. People who live with a serious mental illnesses and addictions experience higher levels of poverty on average than Ontario residents. Being poor means being an illness, an accident or a paycheque away from living on the streets.¹⁴

Low-income Ontarians who experience the worse levels of poverty are those receiving social assistance benefits. In 2006, 77,430 people with a mental illness received income support from the Ontario Disability Support Program (ODSP), comprising 35 percent of the caseload.¹⁵ Moreover, rental assistance offered through rent supplements and public housing are available to fewer than half of ODSP recipients, leaving 54% of ODSP recipients to pay full market value for their rental housing.¹⁶ In Ontario, the average market rent for a one-bedroom apartment ranges from $453 to $896. However, the maximum shelter allowance for a single person receiving ODSP is $445. Thus, persons in receipt of income support face an increased risk of becoming homeless.

The affordable housing strategy should provide an opportunity to revisit the government’s shelter allowance component of social assistance and align it with existing affordability guidelines.

6. An adequately funded system of housing options that align with a harm reduction approach needs to be developed for persons with serious substance abuse problems.

Increasingly it is being recognized that substance use problems are caused by a complex range of factors. It is critical that people with substance use problems receive integrated care and supports, and research has shown that treatment outcomes improve when more services are offered.¹⁷ When supplemental social services (including case management services for education, employment, housing, recreation and parenting issues) were offered to individuals in addictions treatment, there were improvements in outcomes such as number of days of any drug use (from 13 to 4); days of psychiatric problems (from 10 to 6) and days of committing a crime (from 13 to 4).¹⁸

Recently the Ministry of Health and Long-Term Care and Ontario’s Local Health Integration Networks (LHINs) announced new funding for supportive housing for people with substance use issues. The new units and accompanying services will focus on a ‘Housing First’ model and will be based on a harm reduction approach.¹⁹ Harm reduction has been defined as “any program or policy designed to reduce drug-related harm without requiring the cessation of drug use. Interventions may be targeted at the individual, the family, community or society.”²⁰ In the context of housing, this approach does not require the tenant/client to either abstain or reduce their drug use in order to be eligible for a unit. Harm reduction is also a basic tenet of the Housing First model. This model provides housing with supports without requiring clients to engage in treatment and has been successfully used with clients who have difficulty maintaining housing due to severe addictions and/or concurrent disorders.²¹ The Housing First model has been gaining acceptance among many in the mental health and addictions field.²²

Housing First models have been successfully implemented in other jurisdictions. In a study of a Housing First program in New York City, it was found that participants showed high rates of housing stability and no increases in their use of substances.²³ This study and a study in Seattle of another Housing First program also showed a reduction in alcohol use by participants when housed in Housing First.²⁴ The Seattle study also found that the length of time in a Housing First program, the greater the reductions in use of institutional and social services (e.g., jail, EMS, hospital) and related costs.²⁵ Housing First programs were in part established to provide housing to individuals who were not ready or not inclined to enter treatment, because the program does not require adherence to treatment but provides services when and if the client chooses to utilize them. In the New York Housing Study, individuals in Housing First programs reported more choice in housing, which may also be connected to the high degree of housing retention in Housing First programs.²⁶

Conclusion

Many of the most important investments the Government of Ontario makes in health are made outside the health treatment system. Affordable housing policies and programs make an enormous contribution to the health of Ontarians, particularly those who live with mental health and addiction problems. Yet Ontario’s record in housing is nothing to boast about. The Government of Ontario spends less per capita on affordable housing than any other province.²⁶

When the government invests in affordable housing it is making an enormous contribution to both community and individual health. It is also contributing to its own policy goals for the mental health system. The Government has a long-term interest in building a system of care that provides people with serious mental health problems “the ability to live in the community with the least intervention from formal services.”²⁸ This is a goal that is economically sound and offers the greatest promise of enhanced quality of life. It is a goal that cannot be achieved without investments in affordable housing.

Our six organizations would be pleased to provide the Ministry with further information about the need for enhanced housing options for persons with mental health and addiction problems, and the enormous contribution that housing investments make to both health outcomes and enhanced quality of life. Our organizations have a wide range of expertise based on personal experiences with mental health and addiction problems, the experience of providing service, and empirical analysis. Please do not hesitate to contact us for further information.

Respectfully submitted by:

Addictions Ontario – www.addictionsontario.ca
Canadian Mental Health Association, Ontario (CMHA ON) –www.ontario.cmha.ca
Centre for Addiction and Mental Health (CAMH) – www.camh.net
Ontario Federation of Community Mental Health and Addictions Programs (OFCMHAP) – www.ofcmhap.on.ca
Ontario Association of Patient Councils (OAPC) – (416) 633-9420 ext. 1-6969
Ontario Peer Development Initiative (OPDI) – www.opdi.org

For more information on this submission, please contact:

Michelle Gold, Senior Director of Policy and Programs, CMHA Ontario
Barney Savage, Director of Public Policy, CAMH
Deb Sherman, Executive Director, OPDI

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Notes

1. Standing Senate Committee on Social Affairs, Science and Technology. (2006). Out of the Shadows at Last: Transforming mental health, mental illness and addictions services in Canada.
2. Canada Mortgage and Housing Corporation (2007) Rental Market Report: Ontario Highlights Spring 2007.
3. Ontario Non-Profit Housing Association and the Cooperative Housing Federation of Canada, Ontario Region (2009) Where’s Home 2008. Retrieved from www.onpha.on.ca.
4. Ontario Non-Profit Housing Corporation and the Cooperative Housing Federation of Canada, Ontario Region (2006) Where’s Home? 2006: A Picture of Housing Needs in Ontario 2006; Advocacy Centre for Tenants Ontario. Rental Housing in Ontario. Retrieved from www.acto.ca.
5. Sylvestre, J., George, L., Aubry, T., Durbin, J., Nelson, G., & Trainor, J. (2007) Strengthening Ontario’s system of housing for people with serious mental illness. Canadian Journal of Community Mental Health. Vol. 26, No. 1, 79-95. Patterson, M., Somers, J.M., McIntosh, K., Shiell A., & Frankish, C.J. (2008)Housing and support for adults with severe addictions and/or mental illness in British Columbia. Vancouver: Centre for Applied Research in Mental Health and Addiction.
6. McCarthy, J. & Nelson, G. (1991) An evaluation of supportive housing for current and former psychiatric patients. Hospital and Community Psychiatry. Vol. 42, No. 12, 1254-1256.
7. Leff, 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.
8. Nelson, G., Aubrey, T. & Lafrance, A. (2007) A 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.
9. Ibid.
10. Nelson, 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.
11. CMHA, Ontario. Strategies for Reducing Poverty in Ontario. Retrieved fromwww.ontario.cmha.ca. Centre for Addiction and Mental Health. (2002) Housing Discussion Paper. Retrieved from www.camh.net.
12. Forchuk, C., Nelson, G. & Hall, B. (2006) “It’s important to be proud of the place you live in”: Housing problems and preferences of psychiatric survivors.Perspectives in Psychiatric Care, Vol. 42, No. 1, 49-59.
13. Housing Network of Ontario. (2009) Needed: A Housing Benefit for Ontario Fact Sheet. Retrieved from www.stableandaffordable.com.
14. Canadian Mental Health Association, Ontario. (2007) Backgrounder: Poverty and Mental Illness. Retrieved from www.ontario.cmha.ca/backgrounders.
15. CMHA, Ontario. (2008) Backgrounder: Housing and Mental Illness. Retrieved from www.ontario.cmha.ca/backgrounders.
16. Ontario Non-Profit Housing Corporation and the Cooperative Housing Federation of Canada, Ontario Region. (2006) Where’s Home? 2006: A Picture of Housing Needs in Ontario 2006. Retrieved from www.tdrc.net.
17. National Treatment Strategy Working Group. (2008) A systems approach to substance use in Canada: Recommendations for a National Treatment Strategy. Ottawa: National Framework for Action to Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada.
18. McLellan, A.T., Hagan, T.A., Levine, M., Gould, F., Meyers, K., Bencivengo, M. & Durell, J. (1998) Supplemental social services improve outcomes in public addiction treatment. Addiction, Vol. 93, No., 10, 1489-1499.
19. Toronto Central LHIN. (July 13, 2009) Backgrounder: Supportive housing for people with substance use issues. Retrieved fromwww.torontocentrallhin.on.ca. See also Johnson, V. (2009) Supportive housing for addictions position paper. Toronto: Addictions Ontario, Ontario Federation of Community Mental Health and Addiction Programs, Centre for Addiction and Mental Health.
20. Centre for Addiction and Mental Health. (2002) Harm reduction: Its meaning and applications for substance use issues position statement. Retrieved fromwww.camh.net.
21. Patterson, M., Somers, J.M., McIntosh, K., Shiell A., & Frankish, C.J. (2008) Housing and support for adults with severe addictions and/or mental illness in British Columbia. Vancouver: Centre for Applied Research in Mental Health and Addiction.
22. Ibid.
23. Padgett, D.K., Gulcur, L. & Tsemberis, S. (2006) Housing First services for people who are homeless with cooccurring serious mental illness and substance abuse. Research on Social Work Practice. Vol. 16, No. 1, 74-83.
24. Ibid. Larimer, M.E. et al. (2009) Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA, Vol. 301, No. 13, 1349-1357.
25. Ibid.
26. Tsemberis, S., Gulcur, L. & Nakae, M. (2004) Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, Vol. 94, No. 4, 651-656.
27. Michael Shapcott email communication, July 21, 2009.
28. Ontario Ministry of Health and Long-Term Care. Making it happen: Operational framework for the delivery of mental health services and supports. Toronto: Government of Ontario, page 4.