Housing First – Mental Health

Housing First was always in a way designed with people experiencing mental health challenges in mind. This is because the model was originally focused on ending chronic homelessness, and both chronic homelessness and homelessness in general occur most often in the context of mental health challenges. Although statistics vary from study to study, on average 2/3 of people experiencing homelessness also have an active mental health challenge. This rate goes as high as 100% in studies of those considered chronically homeless. There is a bit of a chicken/egg debate to be had about mental illness causing homelessness or homelessness causing mental illness, but regardless, the two are intertwined, and it’s likely a case of both/and. As Housing First was designed by those within the sector, it is grounded in research and practice with those with mental health challenges.

So, it comes as no surprise that both historical and recent research is demonstrating that Housing First works with this sub-population. This is also the sub-population for whom we have the most established best practices to draw upon, which is why I wanted to cover it first in this series.

The At Home/Chez Soi project represents one of the largest and most comprehensive reviews of Housing First programs, and it was focused on 2000 homeless Canadians experiencing mental health challenges. Half of the participants continued to receive the usual mental health and housing services available in their community, while the other half received a variety of targeted Housing First interventions through either Assertive Community Treatment (ACT) or Intensive Case Management (ICM).

The Results

It’s hard to argue with the effectiveness of the program based on the results. “Those who received Housing First were, after two years, stably housed 80 per cent of the time, compared to 54 per cent of those who had treatment as usual.” (1)

Additionally, participants showed a rapid decline in shelter use that persisted over time. This coincided with less hospital use, drop-in centre use, and fewer arrests for drug-related offences. (2)  This equated to significant cost savings for the system as a whole, in particular for the 10% of those with highest service needs: “Over the two-year period following study entry, every $10 invested in Housing First services resulted in an average savings of $21.72.” Most importantly, from a perspective of the individual, those in the intervention experienced both better community functioning and improved quality of life, and were overwhelmingly more positive about their life course.

Best Practices for Housing First for Those with Mental Health Challenges

So here is what we can learn about Housing First for this sub-population of people experiencing homelessness:

1. Housing First is effective across various demographics such as urban/rural, various ethnocultural communities, medium or large cities, and communities with differing existing services.
2. Services are an essential component of Housing First, particularly for those experiencing a mental health challenge. These services need to be mobile, community-based, not institutional.
3. Housing provides the foundation for other changes in peoples’ lives, but we can’t be too demanding that those changes happen too quickly if our programs truly have no requirement for being ‘treatment-ready’.
4. Although there is some room to flex in terms of congregate living or live-in support is communities demand, this is highly discouraged as the best outcomes were seen with those programs that stayed truest to Housing First principles.
5. The health care system needs to be at the table, if not the lead, in providing Housing First with this population. Because the supports are essential and include either ACT or ICM, health providers are going to be involved.
6. Services are best de-linked from housing, in that they follow the individual to wherever they choose to reside, not being attached to just one apartment or building.
7. Self-determination is essential as it goes hand-in-hand with the recovery-oriented approach of mental health care.

I’ll end with a final graph, that tells strongly of the importance of reconfiguring how our system responds to those with housing needs: