Partners in Prevention Learning SeriesPartners in Prevention Learning Series

Mental Illness, Addiction, and HomelessnessMental Illness, Addiction, and Homelessness

Cheryl Forchuk RN PhDCheryl Forchuk RN PhD

OverviewOverview

-relationship between homelessness and mental illness/addiction

-preventing homelessness after psychiatric treatment

-approaches for homeless youth with mental health and substance use problems

relationship between homelessness and

mental illness/addiction

People with mental health and addiction People with mental health and addiction challenges are consistently overrepresented challenges are consistently overrepresented

in homeless populations?in homeless populations? Why?Why? Something about mental illness per se that predisposes Something about mental illness per se that predisposes

to homelessness?to homelessness? Something about homelessness that predisposes to Something about homelessness that predisposes to

mental illness?mental illness? Something about our societal response to mental illness Something about our societal response to mental illness

and homelessness?and homelessness?

Analogy of the musical chairsAnalogy of the musical chairs

Chairs = available affordable housingChairs = available affordable housing People circling = poorPeople circling = poor Difference = homelessDifference = homeless

Housing Development Housing Development

Downloading;Downloading; From federal (pre 1990From federal (pre 1990’’s)s) To provincial (until 1995)To provincial (until 1995) To municipal (e.g. Ontario)To municipal (e.g. Ontario)

Canada is the only industrialized nation with Canada is the only industrialized nation with no national housing policyno national housing policy

Income SupportsIncome Supports

Most likelyMost likely Welfare or disabilityWelfare or disability

Less likelyLess likely WSIBWSIB CPP (Disability)CPP (Disability)

Ontario Works (OW)Ontario Works (OW)

1998 – replaced general welfare 1998 – replaced general welfare assistance programassistance program

Focus is on return to work Focus is on return to work

->temporary assistance->temporary assistance Eligibility criteria to Eligibility criteria to ‘‘encourage encourage

employmentemployment’’…only used when all other …only used when all other resources exhaustedresources exhausted

Ontario Disability Support Ontario Disability Support Program (ODSP)Program (ODSP)

Social Reform Act of 1997Social Reform Act of 1997 to provide both income and employment to provide both income and employment

supports to persons with disabilities and to supports to persons with disabilities and to their dependantstheir dependants

Strict criteria & difficult application processStrict criteria & difficult application process

Mental Health Care: Mental Health Care: Deinstitutionalization?Deinstitutionalization?

Evolving for decadesEvolving for decades Deinstitutionalization or de-hospitalization?Deinstitutionalization or de-hospitalization? In Ontario – 20 provincial planning documents in 20 In Ontario – 20 provincial planning documents in 20

years years In 1960 there were 19,501 hospitalized patients in In 1960 there were 19,501 hospitalized patients in

Ontario compared to 4,514 by 1982 (Heseltine, 1983, p. Ontario compared to 4,514 by 1982 (Heseltine, 1983, p. 19).19).

beds that will be available post -restructuring [2003] beds that will be available post -restructuring [2003] estimated at 1,767 bedsestimated at 1,767 beds

No increase to community mental health from 1993 for No increase to community mental health from 1993 for over a decade and small increases sinceover a decade and small increases since

Mirrored across the country & around the worldMirrored across the country & around the world

DeinstitutionalizationDeinstitutionalization

Or de-hospitalization?Or de-hospitalization? World wide trendWorld wide trend What else did hospitalization provide: What else did hospitalization provide:

housing, food, social supporthousing, food, social support

Implications Implications

Huge disconnect between policies with Huge disconnect between policies with psychiatric survivors caught in the gappsychiatric survivors caught in the gap

Poorly understood since it crosses sectorsPoorly understood since it crosses sectors Problem needs to be understood as Problem needs to be understood as

systematic rather than personalsystematic rather than personal

preventing homelessness after

psychiatric treatment

Critical points related to Critical points related to interventionintervention

Discharge from psychiatric ward as a Discharge from psychiatric ward as a critical period where someone is at risk for critical period where someone is at risk for homelessnesshomelessness

Concerns from shelters about people Concerns from shelters about people coming directly from hospital coming directly from hospital

Review of the LiteratureReview of the Literature

Academic papers vs. public press, Academic papers vs. public press, shelter documents, websitesshelter documents, websites

Summary paperSummary paper

Forchuk, C., Russell, G., Kingston-Forchuk, C., Russell, G., Kingston-MacClure, S., Turner, K., Lewis, K., Dill, MacClure, S., Turner, K., Lewis, K., Dill, S. (2006) S. (2006) From Psychiatric Wards to the From Psychiatric Wards to the Streets and Shelters.Streets and Shelters. Journal of Journal of Psychiatric and Mental Psychiatric and Mental Health Nursing Health Nursing 13(3), 301-308.13(3), 301-308.

http://www3.interscience.wiley.com/journal/118598292/abstract?CRETRY=1&SRETRY=0

Findings: Findings: HospitalsHospitals

General Hosptial: 93 (53 male, 40 female) General Hosptial: 93 (53 male, 40 female) discharges No Fixed Address (including discharges No Fixed Address (including addresses for shelters).addresses for shelters).

Psychiatric Hospital: 74 (no gender Psychiatric Hospital: 74 (no gender breakdown)breakdown)

Total : 167 in one yearTotal : 167 in one year

Findings: SheltersFindings: Shelters

105 males that arrived at the two separate 105 males that arrived at the two separate male London shelters directly from a male London shelters directly from a psychiatric wardpsychiatric ward

89 females arriving at the two separate 89 females arriving at the two separate women’s London shelters. women’s London shelters.

Total: 194 in one yearTotal: 194 in one year

Why does this happen?Why does this happen?

System issues (shorter length of stay, System issues (shorter length of stay, accessing funds, affordable housing accessing funds, affordable housing shortage….) shortage….)

Individual issues (housing history, income, Individual issues (housing history, income, ability to manage home…)ability to manage home…)

Issues from hospital and shelterIssues from hospital and shelter No easy fixesNo easy fixes

Trying to make the system workTrying to make the system work

Finding housingFinding housing First & last monthFirst & last month’’s rents rent

Pilot Results:Pilot Results:

Forchuk, C.,Forchuk, C., MacClure, S. K., Van Beers, M., MacClure, S. K., Van Beers, M., Smith, C., Csiernik, R., Hoch, J., & Jensen, E. Smith, C., Csiernik, R., Hoch, J., & Jensen, E. (2008).  Developing and testing an intervention (2008).  Developing and testing an intervention to prevent homelessness among individuals to prevent homelessness among individuals discharged from psychiatric wards to shelters discharged from psychiatric wards to shelters and and ‘‘no fixed addressno fixed address’’.  .  Journal of Psychiatric Journal of Psychiatric and Mental Health Nursing, 15and Mental Health Nursing, 15, 569-575., 569-575.

http://ir.lib.uwo.ca/nursingpub/28/ 14 = 7 intervention, 7 control14 = 7 intervention, 7 control

Significance?Significance?

Looking just at shelter/homedLooking just at shelter/homed

Pearson chi2(1) = 10.5000 Pr = 0.001Pearson chi2(1) = 10.5000 Pr = 0.001

Fisher's exact = 0.005Fisher's exact = 0.005

1-sided Fisher's exact = 0.0021-sided Fisher's exact = 0.002

Changing Usual CareChanging Usual Care

Fall 2007 – LHSC (phase 2)Fall 2007 – LHSC (phase 2) Fall 2008 – RMHC (phase 3)Fall 2008 – RMHC (phase 3)

Available to all clientsAvailable to all clients

Program evaluation designProgram evaluation design

Using computer linkages to housing data base Using computer linkages to housing data base & to Ontario Works directly from hospital& to Ontario Works directly from hospital

256 accessed service -0nly 3 discharged 256 accessed service -0nly 3 discharged homelesshomeless

Shelter Data: Admissions directly Shelter Data: Admissions directly from Psychiatric Wards 2009from Psychiatric Wards 2009

Referrals to London Shelter from Acute Referrals to London Shelter from Acute care London Hospital (12 months) =11care London Hospital (12 months) =11

Referrals to London Shelter from Tertiary Referrals to London Shelter from Tertiary care hospital = 4care hospital = 4

Referrals to London Shelter from Referrals to London Shelter from psychiatric wards outside of London = 4psychiatric wards outside of London = 4

Compared to 194 London total in 2002Compared to 194 London total in 2002

Hospital DataHospital Data

Still 123 to NFA from acute careStill 123 to NFA from acute care 9 to NFA from tertiary care9 to NFA from tertiary care

Costs?Costs?

the amount to maintain the program was the amount to maintain the program was approximately $3, 917 per month, which is approximately $3, 917 per month, which is less than the monthly cost of one family of less than the monthly cost of one family of four that becomes homeless ($5, 040). four that becomes homeless ($5, 040).

Other issuesOther issues

• Still had some discharges to Still had some discharges to homelessness from those not homelessness from those not accessing the serviceaccessing the service

• Difficulty in ongoing fundingDifficulty in ongoing funding

ImplicationsImplications

System issues contribute the problem of System issues contribute the problem of discharge to NFAdischarge to NFA

With multiple system changes, we can With multiple system changes, we can make things bettermake things better

approaches for homeless youth with mental health and

substance use problems

Youth matters in LondonYouth matters in London

Following 187 homeless youthFollowing 187 homeless youth Choice re service approach (housing first, Choice re service approach (housing first,

treatment first, both approaches, other)treatment first, both approaches, other) Variety of responses – none a majority Variety of responses – none a majority

choice – but one goal preferredchoice – but one goal preferred Goals shift quickly as progressed madeGoals shift quickly as progressed made

 Number children

Frequency Percent

0 131 70.11 39 20.92 10 5.33 3 1.64 2 1.1Declined to reply

2 1.1

Parenting issues: Number of children

  Frequency Percent

No 83 44.4

Yes 103 55.1

Don't know 1 .5

Head Injury“Have you ever had an injury to the head which knocked you out or left you dazed, confused or disoriented?”

The average number of head injuries sustained over a lifetime was 13.2 (SD=47.8),

Homeless Youth Homeless Youth

• Peer support can be developed as Peer support can be developed as supportsupport

• Lower level of income a challenge Lower level of income a challenge (rent gifts?)(rent gifts?)

• Avoidance of many mainstream Avoidance of many mainstream homeless resourceshomeless resources

Youth issues in service: Youth issues in service: quick tipsquick tips

Understand why homeless – why this is considered Understand why homeless – why this is considered the best alternative (personal story, personal goals)the best alternative (personal story, personal goals)

Developmental stageDevelopmental stage Homelessness means living in the momentHomelessness means living in the moment Peer relationshipsPeer relationships Family relationshipsFamily relationships Food and growthFood and growth SexualitySexuality Communicable illnesses & infestationsCommunicable illnesses & infestations incomeincome

ConclusionConclusion

Research related to homelessness is Research related to homelessness is difficult and fraught with challengesdifficult and fraught with challenges

However we can make a real difference However we can make a real difference through researchthrough research

ConclusionConclusion

Importance of acknowledging the Importance of acknowledging the disconnectdisconnect

Importance of advocacyImportance of advocacy

Web-pageWeb-page

http://publish.uwo.ca/~cforchuk/cura/http://publish.uwo.ca/~cforchuk/cura/index.htmindex.htm

ContactContact

Cheryl Forchuk, RN, PhDCheryl Forchuk, RN, PhD

University of Western OntarioUniversity of Western Ontario Lawson Health Research Institute - LHSCLawson Health Research Institute - LHSC 375 South Street – NR201375 South Street – NR201 London, ONLondon, ON N6A 4G6N6A 4G6 Phone: (519) 685-8500, ext. 77034Phone: (519) 685-8500, ext. 77034 Fax: (519) 432-7367Fax: (519) 432-7367