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Housing and Mental Illness

June 2008

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Introduction

Housing is a basic human right and requirement for good health. When housing is inadequate or unavailable, individual as well as community well-being may suffer. 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.

According to the United Nations 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."¹ 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.

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. Accommodations are considered to be affordable if they cost less than 30 percent of the total pre-tax household income.

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.

Housing Stats and Facts

Social Housing

As of 2006, Ontario has
- 84,208 public housing units
- 21,200 co-operative housing units
- 88,159 non-profit housing units
- 1,981 urban native housing units
- 9,500 supportive housing units
At the beginning of 2006, there were 122,426 low-income households on active waiting lists for social housing in Ontario.
Applicants often wait several years before they are placed in housing. (Advocacy Centre for Tenants Ontario, Rental Housing in Ontario, 2006)

Supportive Housing

Ontario has 8,500 supportive housing units for people with mental illness. (Ministry of Health and Long-Term Care, personal communication, 2008)
Wait lists for supportive housing range from 1 to 6 years, depending on the region. (District of Nipissing Social Services Administration Board, Community Services Review Based on the ODSP Client Population, 2006)

Housing and Mental Illness

For people with serious mental illnesses, a safe and affordable home can be a place to live in dignity and move toward recovery. In fact, individuals with serious mental illness frequently identify income and housing as the most important factors in achieving and maintaining their health.² 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 household contents and their home. Consequently, many live in substandard housing that is physically inadequate, crowded, noisy and located in undesirable neighborhoods.³

Why Are People Homeless?

Two trends are largely responsible for the rise in homelessness over the past 15-20 years: a growing shortage of affordable rental housing and a simultaneous increase in poverty.

Homelessness and poverty are linked.⁴ 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 illness, an accident or a paycheque away from living on the streets.

What Constitutes Homelessness?

Persons who reside in places that are not intended as, or are unfit for, human habitation, including cars, abandoned buildings, bus or train stations, under bridges, in garbage or recycling dumpsters, parks, or other places lacking basic amenities.
Persons sharing housing at the whim of other persons on an interim or emergency basis.
Persons whose primary nighttime place of abode is a supervised publicly or privately operated shelter designed to provide temporary living accommodations, including shelters for victims of domestic violence, welfare hotels, congregate shelters and transitional housing.

(Casavant, L. Definition of Homelessness. Parliamentary Research Branch, Political and Social Affairs Division, January 1999.)

Homelessness Is a Frequent Experience of Persons with Mental Illness

It is difficult to state whether homelessness or mental illness occurs first. Each case must be considered individually. Research tends to support both theories. The stress of being homeless may exacerbate previous mental illness. However, the difficulties of being homeless may encourage anxiety or depressive disorders.^5,6

Poverty is common among many persons with mental illness, which increases the risk of homelessness. The challenge of providing stable housing for persons with serious mental illness is reflected in the estimated 67 percent of homeless persons with a lifetime history of mental illness in Toronto.⁷

People with serious mental illness are disproportionately affected by homelessness. The consequences of homelessness tend to be more severe when coupled with mental illness. People with mental illnesses 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.⁸

Types of Housing and Benefits

There are many housing options available to people living with serious mental illness.

Supportive housing is often communal in nature with a small number of tenants. Support services are provided on-site with 24-hour access to case management, emergency response and homemaking. Rehabilitation is the primary focus. It is frequently transitional housing, meant to prepare people for more independent living.

Supported housing involves individuals living in affordable housing of their choice that is indistinguishable from others in the neighbourhood. Supports are individualized to a person's needs and independent from the housing itself. Community integration and rehabilitation are encouraged. Supported housing is considered a best practice model and has demonstrated positive outcomes in community residency, satisfaction and quality of life.⁹

Both supportive and supported housing promote recovery and independence, keeping people healthy and out of the hospital. For example, an Ontario study measuring participants' hospital use before and after a supportive housing intervention showed that all 34 residents in the study reduced their mean hospital days from 53.4 to 0.53 after one year.¹⁰

For those with a serious mental illness who can live independently in the community, poverty is a major barrier to acquiring housing. Rent supplements or rent-geared-to-income housing are strategies that provide individuals with the financial resources they need to access desirable housing in their community. Research shows that personal choice in housing not only increases citizens' housing stability, but also helps to improve well-being and quality of life.¹¹

Housing Makes a Difference

Research indicates that a stable and supported living environment is essential to maintaining the health and well-being of people with serious mental illness 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 illness can contribute to a reduction in psychiatric symptoms¹² and therefore decrease the need for emergency and treatment services.¹³

Community mental health services can assist people to both access and maintain their housing. Some of the key supports that have been identified by people with serious mental illness include medical services available in-house or on-call (for crisis management and medication monitoring), homemaking and personal care services, vocational training, life skills training, as well as assistance with income support and housing advocacy. 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.¹⁴

Housing Alone Is Not Enough

Improvements in housing quality lead to better mental health outcomes for residents.¹⁵ Investing in housing quality often involves major refurbishing and can lead to greater satisfaction, feelings of safety and increased community involvement. Neighbourhoods can also have a significant impact on the success of housing for people with mental illness by contributing to an individual's ability to feel comfortable and integrated within the community.¹⁶

Affordable and Supportive Housing Makes Economic Sense

Affordable housing makes economic sense. Many factors contribute to a city's economic success, such as the talent of its residents, location, transportation and government investment. Affordable housing is also part of this equation enabling employees to live in a community. As TD Economics states, "…working to find solutions to the problem of affordable housing is also smart economic policy. An inadequate supply of housing can be a major impediment to business investment and growth."¹⁷

Likewise, supportive housing is economical. It costs approximately $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.¹⁸

Furthermore, persons who cannot afford to live in decent housing are more likely to experience exposure to violence, communicable diseases and increased chronic conditions.¹⁹

Challenges to Affordable Housing

The challenges of poverty, stigma and discrimination that persons with mental illness face directly impact their ability to access, find and keep housing. 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.²⁰ In Ontario, the average market rent for a one-bedroom apartment ranges from $453 to $896.²¹ However, the maximum shelter allowance for a single person receiving ODSP is $436. Thus, persons in receipt of income support face an increased risk of becoming homeless.

Due to stigma, the typical reaction encountered by someone with a mental illness is fear and rejection. Many living with a mental illness are often denied housing in the private market as a result of their psychiatric illness.

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. Since 1995, there has been a net loss of 13,000 affordable housing units in Ontario.²²

Current Activities

CMHA Ontario is active in supporting persons with mental illness to access adequate, safe and affordable housing. We do this by advocating for more affordable housing, supportive housing, community supports and rent supplements.

We are also involved in promoting mental health through highlighting public issues and recommending options to create inclusive and supportive environments.

References

United Nations, Office of the High Commissioner for Human Rights, "International Covenant on Economic, Social and Cultural Rights," 1976, www.unhchr.ch.
J. Trainor, E. Pomeroy and B. Pape, eds., Building a Framework for Support: A Community Development Approach to Mental Health Policy (Toronto: Canadian Mental Health Association, 1999).
M.J.L. Kirby and W.J. Keon, 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, 2006.
Canadian Mental Health Association, Ontario, "Backgrounder: Poverty and Mental Illness," November 2007, http://www.ontario.cmha.ca/backgrounders.
C. Walker, "Homeless People and Mental Health," American Journal of Nursing 98, no. 11 (1998): 26-32.
T. Morrell-Bellai, "Becoming and Remaining Homeless: A Qualitative Investigation," Mental Health Nursing 21, no. 6 (2000): 581-604.
P. Goering, G. Tolomiczenko, T. Sheldon, K. Boydell and D. Wasylenki, "Characteristics of Persons Who Are Homeless for the First Time," Psychiatric Services 53 (2002): 1472-74.
R. Benger and B. Cameron, "Asylum: Falling through the Cracks," Witness, Canadian Broadcasting Corporation, 2000, retrieved January 31, 2003, from http://www.tv.cbc.ca.
R.J. Calsyn, J.P. Winter and G.A. Morse, "Do Consumers Who Have Choice of Treatment Have Better Outcomes?" Community Mental Health Journal 44 (2000): 439-450.
J. McCarthy and G. Nelson, "An Evaluation of Supportive Housing for Current and Former Psychiatric Patients," Hospital & Community Psychiatry 42, no. 12 (1991): 1254-56.
Calsyn et al., "Do Consumers Who Have Choice."
T. Middelboe, "Prospective Study of Clinical and Social Outcome of Stay in Small Group Homes for People with Mental Illness," British Journal of Psychiatry 171 (1997): 251-55.
McCarthy and Nelson, "An Evaluation of Supportive Housing."
Toronto District Health Council, "Toronto Mental Health Housing Study," September 2001.
S.M. Hunt and S.P. McKenna, "The Impact of Housing Quality on Mental and Physical Health," Housing Review 41, no. 3 (1992): 47-49.
P. Yanos, S. Barrow and S. Tsemberis, "Community Integration in the Early Phase of Housing among Homeless Persons Diagnosed with Severe Mental Illness: Successes and Challenges," Community Mental Health Journal 40, no. 2 (2004): 133-150.
TD Bank Financial Group, "Affordable Housing in Canada: In Search of a New Paradigm," TD Economics Special Report, June 17, 2003, www.td.com/economics.
Ontario, Ministry of Health and Long-Term Care, "Provincial Summary - Average Costs for CMH&A Service Recipient Activity," 11 August 2006.
B. Moloughney, Housing and Population Health: The State of Current Research Knowledge (Ottawa: Canadian Institute for Health Information, June 2004).
Ontario, Ministry of Community and Social Services, special run data.
Canada Mortgage and Housing Corporation, "Rental Market Report - Ontario Highlights," Spring 2007, www.cmhc.ca.
Ontario Non-Profit Housing Corporation, "Where's Home 2006: A Picture of Housing Needs in Ontario," 2006, www.onpha.on.ca.