A Workshop of the Mental Health Policy Research Group
(CMHA Ontario Division, Clarke Institute of Psychiatry, Ontario Mental Health Foundation)
Gail Donner, Moderator
Gail
Donner (unrelated to the Donner Canadian Foundation) welcomed participants to the
conference on behalf of the Mental Health Policy Research Group (the Canadian Mental
Health Association, Ontario Division, the Clarke Institute of Psychiatry and the
Ontario Mental Health Foundation), the Donner Canadian Foundation, and Metro Community
Services.
This
conference was called to give people an opportunity to hear about the Mental Illness
and Pathways into Homelessness Project and its results, and to give the project
research team a chance to receive input regarding policy implications, answer questions,
and respond to concerns. Questions were taken from the floor and in written form.
In
response to a request from the audience, $297.00 was collected from the conference
participants over lunch time as a donation for food for homeless shelters.
Both
a video and a play were shown during lunch time. The video, A Fine Line was
written and produced by clients of the Hostel Outreach Program, in Toronto, and funded
by the Atkinson Foundation. The video may be obtained through Louse Nimigon, C.R.C.T.,
(416) 482-4103. The play, Spare Change, was presented by the Cobblestone Youth
Troupe, and produced by the Mixed Company theater company. Mixed Company can be reached
at (416) 588-8580.
Dr.
Paula Goering invited conference participants to assist the Pathways project research
team in the final wording of the study findings and development of recommendations.
Dr. Goering can be reached at the Clarke Institute of Psychiatry, (416) 979-6844.
Dr.
Goering also referred people to an annotated bibliography prepared by Bruce Stewart
and David Reville of hard-to-find and/or limited circulation literature on a wide
variety of issues related to homelessness, which was created for this conference.
Both this bibliography and the literature will be available through Susan Macartney,
at the Canadian Mental Health Association, Ontario Division, (416) 977-5580, ext.
35.
All
participants of the Pathways study, including residents and staff of participating
shelters, the project advisory committee, the presenting members of the project
research team, the non-presenting members of the research team Dr. Katherine
Boydell, Carole Bentley, Nicole Tenn-Lyn, Teresa Sota-Royes and Michael Higgins,
and conference coordinator Catherine Riley, were thanked for their contributions
to the Pathways study and to the conference day.
Mayor Barbara Hall
We
know that there are more people homeless and on our streets for longer periods of
time. The suffering that they experience is monumental. It is not as if we don't
know the solutions to the problem: in my experience of working with the homeless
and housing advocates for the last 12 years, there are many examples of real success
that we have developed working together. They have brought people off the streets
and allowed them to get the kind of stability which has enabled them to become a
full part of the economy, and of the life of this community. What keeps us from providing
more of those solutions, frankly, is the lack of political will at all levels of
government.
We
have tragically, in this province at this time, a provincial minister who I think
is inappropriately called the Minister of Housing. I think he should be called the
Minister of Homelessness. We have a federal government who, for the first time since
the end of the war, has withdrawn from helping to provide solutions to housing problems
for Canadians. We have municipal governments, some of which have taken aggressive
roles, and I'm proud of the role that Toronto City Council has taken in responding
to the issue of homelessness. But we can't do it alone.
I'm proud of many of the citizens of this community, who, without knowing much about
the issue, have said through their actions that they find it unacceptable to have
people sleeping in doorways and bus shelters. They have opened their churches and
temples and come out themselves to spend the night to welcome people in. I hope that
what comes out of your work here today is a growing network of people who will pull
our federal and provincial government into working with us. We know that this is
a complex issue. We know there are solutions. We know that the solutions require
health professionals, the homeless themselves, housing advocates, the business community,
citizens, church and community leaders, and politicians at every level of government,
to come to the table to address this issue. What is happening on our streets today
is shameful. We have the capacity in this city and in this country to end this shame
and I know that you will be an important part of doing that. I look forward to being
a part with you. Thank you very much.
Dr. Don Wasylenki and Dr. George Tolomiczenko
Project
Method
Dr.
Tolomiczenko presented the study methodology.
The
Pathways Project was conducted over a period of 18 months in the City of Toronto.
The project team involved researchers from the Clarke Institute of Psychiatry, Wellesley
Hospital, and the Queen Street Mental Health Centre.
Project
objectives were: 1) to estimate the prevalence of mental illness among people who
are homeless; 2) describe pathways into homelessness; and 3) identify policy areas
for reform.
In
order to justify the study's focus on shelter and hostel users, a preliminary survey
of 561 participants of drop-in and food programs was undertaken to determine whether
these people fit the project's criteria for homelessness.
The
Pathways Project definition of homelessness is stricter than other definitions used
in the field: APeople who were without housing for 7 nights or more in the prior
month, and also had no prospect of housing in the next month. This definition
was developed through input from the Pathways Project Advisory Committee.
Approximately
half (239) of the 561 potentially homeless people in the preliminary survey met the
project's criteria for homelessness. From those 239 people, over 93 percent had used
shelters or hostels. This was a large enough majority to justify framing the project's
main sample of 300 people from single (unaccompanied) Metro Toronto shelter users
who were 18 years of age and older.
All
300 people in the study sample participated in a 2 hour interview, which gathered
socio-demographic and diagnostic data. An in depth, qualitative examination of individual
pathways into homelessness, from the perspective of the study participants, was conducted
with 29 of those 300 people. Two supplementary studies were also conducted, one examining
neuropsychological and personality factors, and the other looking at HIV prevalence
among homeless people.
The
study sample was stratified (categorized according to age, sex, and degree of shelter
use) using data from the Metro Community Services Hostel Services Division on shelter
users. This ensured that the 300 people in the sample study represented the wider
homeless population, by matching the sample's number of people in a particular category
(e.g. men, aged 18-24, who used more than one shelter in the year prior to the study)
with the corresponding percentage of similar people in the wider homeless population.
The
study did not include people who used a shelter only one or two nights over an entire
year, because it was unlikely those people would have met the higher threshold of
homelessness of the Pathways project definition.
People
were recruited from 16 different Metro Toronto shelters. More interviews were conducted
at larger shelters, as they served more people.
Prevalence FindingsDr.
Wasylenki presented the prevalence findings.
The
Pathways study reports on characteristics of the population of homeless unaccompanied
adults; the prevalence of mental illness in this population; and information gathered
from 30 people who consistently avoided shelters (and who were not part of the main
study sample). Detailed breakdowns of all findings are attached.
1. Characteristics of Homeless
Population
Marital
Status:Children:Education:Income:Encounters
with the Legal System:History
of Homelessness:Age
of First Episode of Homelessness:Time
Spent in Shelters/Hostels in Year Prior to Interview:Nights
Spent on Street in Year Prior to Interview:Out
of the Cold and Council Fire Programs:Health
Problems:Despite
the chronic and acute illnesses, 79 percent of the sample had spent no nights in
a medical facility in the year prior to becoming homeless; 11 percent had spent 1
night, and only 10 percent spent 2-7 nights.
Only 6 percent had been in a psychiatric facility in the year previous to their homelessness.
This challenges the assumption that large numbers of people in the homeless population
have been discharged from psychiatric facilities, and that Ade-institutionalization
is a major factor in the problem of homelessness in Toronto.
Nights
Spent in Police Stations or Jails in Year Prior to Interview:History
of Childhood Abuse:Childhood Sexual Abuse: Women (48.5 percent vs. 12.8 percent ); Men (16 percent
vs. 4 percent )
Physical Abuse: Women (51 percent vs. 21 percent ); Men (38 percent vs. 31.2 percent
).
When
the sample population of the Pathways study was compared to that of a Los Angeles
study on the homeless, the Toronto sample reported twice the rate of physical or
sexual abuse for women, and three times the rate of physical or sexual abuse for
men.
2. Mental Illness and Substance
Abuse in the Population:
The
study looked at the prevalence of lifetime diagnoses of mental illness in the homeless
population. Two thirds (approximately 66 percent ) of the homeless population have
a lifetime diagnosis of mental illness, which is 2-3 times the prevalence rate of
the general population. Depression is the mental illness most reported, understandable
given the extent of unfortunate circumstances in these people's lives.
A
sub-sample (29 percent ) met the criteria for anti-social personality disorder, often
in addition to an Axis I diagnosis (diagnosis of psychotic disorder, depression,
or post-traumatic stress disorder). About 25 percent of the sample had received psychiatric
outpatient services in the year leading up to the interview, and less than 20 percent
had received any kind of services for substance abuse problems.
There
are low prevalence rates for the kind of mental illness that tends to stereotype
homeless people: hearing voices, being delusional, extremely excited, or behaviourally
disinhibited. Severe mental illness (psychotic disorders, primarily schizophrenia)
had only a 5.7 percent lifetime prevalence rate. With the addition of people suffering
from Amania, a bipolar Type I disorder (5 percent ), there was a lifetime prevalence
rate of only 10.7 percent of severe mental illness in the homeless population.
Only
6 percent of the study sample had been in a psychiatric in-patient unit in the year
preceding the interview. The idea that large numbers of people are being discharged
from psychiatric inpatient units and comprising a significant proportion of the homeless
population in Metro Toronto is not supported by our data. About 50 percent of the
people who had been in inpatient units had found this experience to be unsatisfactory,
which brings into question the creation of more beds in psychiatric facilities as
part of the solution.
Very
few people in the sample identified mental illness as a precipitating reason for
loss of housing. Only 3 percent of those interviewed said they lost their housing
because of mental illness.
Substance
abuse (alcohol, marijuana and cocaine in particular) is a major problem in this population.
When prevalence rates of substance abuse (drug and alcohol abuse) are added to prevalence
rates of mental illness, the overall prevalence rate rises to 86 percent . Only 14
percent of the study sample had no diagnosis of either mental illness or substance
abuse. The prevalence rate of alcohol and substance abuse is almost identical to
the prevalence rate of mental illness; roughly two thirds of the entire homeless
population. This is 4-5 times the prevalence rate in the general population. Almost
everyone with a lifetime diagnosis of mental illness also had a diagnosis of substance
abuse. Three quarters of the people in every diagnostic category of mental illness
also had substance abuse disorders. In contrast to mental illness, about 20 percent
of the study sample identified substance abuse as the primary reason for loss of
housing, and it was found to be an important perpetuating factor in maintaining homelessness.
Shelter
avoiders are homeless people who avoid shelters and spend most of their time on the
streets. Shelter avoiders were not a representative sample in the Pathways study.
To find shelter avoiders, researchers went to drop-ins, shelters and food banks,
and asked people to identify others who were homeless but who avoided the shelter
system. Thirty shelter avoiders were interviewed. No difference was found in the
rates of mental illness among those 30 people, and the 300 people in the representative
sample. There were higher rates of substance abuse, more legal issues, and barring
from shelters reported by the shelter avoiders than by the representative sample.
2. You referred to homelessness as a apattern. I assume you were referring to a pattern of individual behaviour, not a pattern of behaviour of governments or societies. There has been a recent report of a 67 percent increase in the number of homeless people accessing Metro shelters. Does this suggest a 67 percent increase in mental illness in Toronto? You need to question whether psychiatric treatment can increase the supply of housing.
Thomas Wolken's article on October 29 in the Toronto Star, stated
that the Donner Canadian Foundation generally funds agencies that focus on personal
failure and individual responsibility rather than societal problems. I find it appropriate
that the Donner Foundation has funded this conference to focus on individual failure
rather than the supply of housing. Everyone has personal problems. If a person has
personal problems and loses their housing, the problem is the supply of housing,
not the personal failure. The way you deal with personal failure is to increase support
services for that individual, not throw them out on the street. This conference has
the whole thing backwards: you should be talking about the lack of housing as the
cause of homelessness.Dr.
Wasylenki: You raise a very important issue. This study was undertaken in the
context of the mental health field. If you read studies in the mental health literature
about homelessness, they tend to repeat that 30-50 percent of people who are homeless
have a mental illness, and that mental illness must be a major causative factor of
homelessness. What our findings say is that mental illness is not a major precipitating
cause of homelessness in Metro Toronto. There is a relatively small group of people
who are homeless, who need intensive mental health services (that group identified
as having serious mental illness). The issue for the mental health system is to create
ways to reach out and engage these people, who are clearly in need of support. More
fundamental issues have to do with entitlements, availability of housing, and employment
opportunities, and these are the important issues for the larger number of people
who are homeless.
Our
findings have produced information that flies in the face of a lot of the conventional
thinking in the mental health field about the causes of homelessness. Whether or
not the Donner Foundation who funded our study would be pleased with this is of no
relevance to us. There has been absolutely no interference from them in our study,
nor would we brook any interference. I want to emphasize that the findings about
mental illness in our study, if anything, tend to de-emphasize its importance as
a contributor to homelessness.
Dr.
Wasylenki: The prevalence of current mental illness in the homeless population
drops to about 50 percent , vs. 66 percent lifetime prevalence. We felt that lifetime
prevalence was more significant because we were interested in the issue of vulnerability.
We shouldn't be talking about mental illness because the pathways
to homelessness are really through lack of housing. In addition, I question whether
mental illness has been scientifically proven. The fact that psychiatrists continually
bring up the issue of mental illness is a barrier to dealing with the real social
and economic problems of our society. You have no business proposing solutions to
homelessness. Where are the homeless people that should be here? Did the conference
make an effort to reach out to people who are the real experts on homelessness, the
ones on the street who would gladly have come today? Psychiatry has nothing to offer
in the solutions to homelessness. Please justify your presence here.Dr.
Wasylenki: I hope that one of the accomplishments of our study is to shift the
focus away from this emphasis on mental illness as a cause of homelessness, and to
keep it focused on the more fundamental issues that you have described. I do believe
that mental illness exists. I don't believe that the best way to treat mental illness
is to keep people in hospitals. I think the challenge to the mental health system
is to figure out ways to help people in the community, which is where most of us
want to be. What that involves is trying to work out ways of helping people with
severe mental illnesses to find and maintain reasonable housing in the community.
We have a legitimate interest in looking at the issue from that point of view. Throughout
the course of this study we worked with a panel of homeless individuals and shelter
system workers, who represented a number of different perspectives. This was a very
useful group of people, who helped keep us on track in terms of focusing on the important
issues. They, along with other individuals who are homeless, and people from the
shelter system, were certainly invited to today's conference.
Conference Participant: I wish to respond to the audience member who questioned the scientific proof for mental illness. I have schizophrenia, and I refer you to the video screened this morning (A Fine Line), created by people who have battled mental illness, to get an idea of what people have to face. It is also worth noting that people who find themselves alone, on the street, in a new city with nowhere to go, become disoriented, and disorientation is not a part of proper mental functioning. This committee is making an effort to help other people, by doing what they are doing today, and it is inappropriate for you to put them down for that.
Dr.
Tolomiczenko: We controlled for age. Study findings suggest that few people are
old enough to be homeless from de-institutionalization. In addition, few of the younger
people in the sample would have experienced psychiatric institutionalization under
the old entrance criteria.
Dr.
Wasylenki: To me, this statistic indicates that people who are homeless and may
need assistance from the mental health system, are uncomfortable with the way that
system usually provides assistance (e.g. come to the emergency department, get admitted
to the hospital). It asks us to re-think how we support and provide assistance to
people, and highlights the models that have been shown to be useful to people --outreach
models. We don't have enough outreach based programs in Metro Toronto or Ontario,
and one thing that may come out of this conference is a recommendation that we pursue
that option for the people who are seriously mentally ill and do need intensive support.
Dr.
Wasylenki: I would prefer to see dollars for mental health services allocated
to providing intensive community support for people, because that has been shown
to be the more successful approach.
Dr.
Wasylenki: Difficult question. The 10.7 percent of the population identified
as having a severe mental illness tend to need support in addition to housing, in
order to maintain a housing situation in the community.
Dr.
Tolomiczenko: Another group that would probably need support in addition to housing
are people with chronic and/or severe levels of substance abuse.
I
believe you understand and are attempting to be sensitive to the extreme prejudices
against homeless people. But the problem here is the lack of knowledge of poverty
issues. That is our concern. For example, you are referring to substance abuse without
putting it in context. You are speaking about people who are unemployed, very poor,
and under a lot of stress. Did you conduct studies to try to understand what people's
lives are like in regard to poverty, and poor housing, prior to becoming homeless?
These are the issues that must be examined, to understand why some people might try
to self medicate, as opposed to having a psychiatrist prescribe medication. Without
reference to the stresses faced by the people we are discussing, you might understand
why some of us are asking why you are discussing substance abuse. It wasn't substance
abuse that caused people to lose their housing. These people are, in fact, poor.
There is not enough affordable housing for people who are poor.
Ms.
Donner thanked the presenters on the quantitative findings of the Pathways study,
and the conference participants. She opened the presentation and discussion of the
qualitative findings of the project, with the following quote from one of the conference
participants:
I
am a consumer survivor, I am active in the area, and furthermore I am a mental health
worker (and a good one). For me it is not important what my 'diagnosis' is but that
I do the best I can with my life. However, I have seen shelters, and if I ever got
homeless, I would suicide rather than go there.
Dr. Paula Goering and Dr. Tammy Morrell-Bellai
Dr.
Goering presented on the objectives and some of the findings of the qualitative study.
The
study combined two different ways of approaching the problem of homelessness. One
(quantitative research) used more standard research tools, such as questionnaires
and statistics. The qualitative research piece involved speaking to people in more
depth about the details in their lives. In addressing the question of pathways to
homelessness, it is important to have both kinds of information: numbers and stories.
The study was particularly interested in the predisposing and precipitating factors
related to homelessness, and in the very large group of people in the sample who
were homeless for the first time. It is very important, in terms of prevention and
solutions, that we do not look simply at those people who have been in the system
for a long time, and need help in terms of rehabilitation and recovery. We should
intervene earlier in that course, and try to prevent people from ever being on the
street. It is crucial to look at what our subjects told us regarding the reasons
why they were homeless for the first time.
Some
Reasons for Homelessness (full findings attached)
Some
Experiences in the Year Prior to First Homeless Episode (full findings attached)
People
were asked what kind of stresses they had experienced in the year prior to their
first becoming homeless.
Approaching
the discussion of pathways to homelessness in terms of individual versus social factors
creates a false dichotomy. Both individual and social factors are behind homelessness,
and cannot be effectively examined in isolation. Social support protects us, when
we are ill or in distress, from ending up without resources or a place to stay. When
we asked people who they could rely on in their lives, a significant number (42 percent
) replied they had no one. This is unsurprising, because part of what starts the
pathway to homelessness is the loss of a loved one, or having a relationship end.
There are individual factors that make people vulnerable, and there are broader social
issues, such as the lack of basic social supports, that allow that vulnerability
to translate into ending up homeless and on the street. Another researcher, Paul
Koegel, says it this way:
We
cannot address homelessness at its source unless we recognize that it is inextricably
connected to other social ills, and the biographies of homeless people are what best
attest to that particular message.
The
Pathways study explored how social and individual factors interacted, by focusing
on first-time homeless individuals and their stories. These people explained to us
the series of events in their lives that they felt led up to the loss of their homes.
Four pathways to homelessness were identified, as well as possible strategies and
intervention targets.
There
is a relatively small group of people who are on the streets as a direct result of
having a relapse of a psychiatric illness, with the symptoms themselves playing a
major role as a precipitant. The individuals in this group do not have good social
supports, often due to their illness and how it has affected their lives. Their symptomatology
(particularly paranoia), precipitates disruptions in relationships, which then contribute
to a lack of supports, and homelessness. Unfortunately, in two of the three qualitative
interviews that fit this category, the individuals had been hospitalized and discharged
directly to a shelter, which they felt was improper at the time.
People
in this group experienced many ups and downs prior to becoming homeless, primarily
related their psychotic illness. Homelessness may result if there is a support failure
after a relapse of their illness.
JessicaJessica
is a middle aged, white woman, divorced, with no children, and with a history of
bipolar illness (manic depression). She spoke with insight about her own history.
She worked as a secretary off and on, but her work history was very interrupted due
to becoming sick and going into hospital. For 10 years, she lived happily with people
who rented her a room in their house and had become like family. This situation broke
down after she had a relapse, became depressed and suicidal, and acted on those suicidal
impulses. The people she was living with felt they couldn't take it any longer, and
asked her to leave. She also lost her job at the same time because of that relapse.
In
summarizing why she ended up on the street, she said: AI became ill. I guess I was
a burden to the people I was living with, and they just didn't want to take care
of me anymore. They got tired of taking care of me and they evicted me. I was working,
but then I got fired when I got sick. I'm only mean when I'm sick. I'm really sarcastic,
but that's a part of the illness. I suspect everybody, I don't believe that anyone
is a friend of mine, and I get suspicious, paranoid, etc.
Jessica
was treated for her illness with lithium for 6 years, which ended up damaging her
physically. It was when that she was taken off of her medication because of resulting
medical problems that she had a relapse. She tried to commit suicide, which had a
dramatic effect on her living situation. She was admitted to hospital involuntarily
after she was evicted and then discharged: AI ended in the hospital, and from the
hospital I ended up in the shelter. Now she has a significant medical problem, and
is very distrustful about the kind of help she can get from the treatment system.
Jessica's
story illustrates how her illness and the breakdown of her work and social supports,
combined with a failure of the treatment system, interacted to result in her homelessness.
This is one pathway that needs to be paid attention to, because it has direct implications
on how treatment services are provided, and the way we set up our shelter system.
There
was also a group of individuals interviewed who prior to being homeless were well,
with reasonably stable lives. Many had a strong sense of independence, self confidence
and pride, which had helped them in the past. However, this sometimes translated
into an inability to seek help when help was crucial. There was often a serious communication
problem between the individual and the welfare system, that prevented them from understanding
or receiving advice which could have kept them from being without a place to live.
The major issue discussed in the interviews was finding work, and sometimes the breakdown
of relationships.
These
people described how they felt at the point they were on the street and using the
shelter: they were overwhelmingly distressed, disorganized and confused. In that
extreme situation, the normal coping responses and common sense suddenly couldn't
be relied upon: AI had common sense and then I lost it, in that situation.
These
people spoke little about their childhood, as they didn't identify the reasons for
their homelessness as being that far in the past. They focused on the events immediately
preceding their homelessness. Things had been going smoothly, and then Athe bottom
dropped out.
Dave
is a middle aged, black man, married, with 3 young children. He was very depressed
during the interview. Unlike many people in the sample who said their depression
had preceded their becoming homeless, Dave described himself as always being in Agood
mental health. Clearly the depression was reactive to what had happened to him and
his family.
In
the early 1980s, he had owned a successful warehousing business. The business ran
into difficulties, and he mortgaged his house to try to save the business. At the
same time, he developed a kidney problem, and ended up losing the business and the
house.
He
went onto general welfare, which was helpful to him, and found a job in the construction
industry. As soon as he was hired, he told the welfare office he no longer needed
the benefits. The job lasted from June to December, and he was laid off just before
Christmas. He returned to the welfare office and asked for assistance. Welfare told
him he had to apply for unemployment insurance, as he was ineligible for welfare
because he had been working. He applied for unemployment insurance, and 8 weeks later,
discovered he was ineligible for unemployment insurance because he had not been working
enough weeks.
During
the 8 weeks he was waiting for unemployment insurance, Dave tried to provide for
his family by visiting foodbanks and looking for work. He found out about an agency
that could provide casual labour for the day, if people showed up early in the morning.
He would leave home on foot at 3 a.m., because he had no other transportation, and
arrive at the agency at 5 a.m. He did that every day for 3 weeks without finding
work. The rest of the day was spent in trying to find food. Dave was very angry about
the problems he encountered in finding benefits. He had been honest and had told
Welfare when he found work, and felt they had failed to recognize just how severe
the situation was for him and his family.
His
marriage began to deteriorate during this time. He described himself and his wife
as always quarreling: AIt seems that everything I do is no good. That made her more
frustrated, she was taking it out on me, I was angry. That was one of the reasons
I decided to leave, because I was going to explode, and somebody might get hurt.
I didn't want that. But I want to be with my children.
He
chose to leave his family, because he decided his family would be better off without
him, and have more chance of getting emergency assistance if there was just a mother
and children. He ended up in the shelter system. He became extremely depressed after
having made that choice, because of the loss of his family. He felt that nobody wanted
to help him, even though he had tried to seek assistance: AI lost every inch of pride
that I had. I need to talk to somebody, I need some help, some guidance, somewhere
along the way, so that I can get my focus and strength back.
This
was one of the few interviews where the interviewer felt worse at the end of the
interview than the beginning. Most of the time it was a positive experience for both
parties to do this kind of story telling. In this case it wasn't, because of the
despair and depression of this individual, who had tried very hard to make things
better.
Dr.
Morrell-Bellai described the two other pathways to homelessness identified from the
qualitative interviews.
These
individuals were young adults who had left their childhood home for the first time.
They described difficulties in separating from their families and becoming independent
adults, and troubled family backgrounds, including abusive situations. In leaving
home and coming to a new city, they needed to establish new relationships, housing,
and work, and there were many circumstances where that didn't work out. When faced
with becoming homeless, there was reactive depression at being unsuccessful at making
a new start.
JenniferJennifer
is a woman in her mid-twenties, who grew up in a small, Northern Ontario town. Due
to the lack of jobs where she lived, she left her family home to find work, preferably
as a musician. Her manner during the interview was friendly, open, and somewhat dramatic.
The
key predisposing factor in Jennifer's story was the crib death of her younger sister
when she herself was three years old. Her father's reaction was to withdraw emotionally
from her. From that day forward my father ignored me. Treated me like the mailman's
kid, like I didn't exist. It was just very, very hard, to try to rationalize why,
if I didn't do anything bad, why my dad didn't love me anymore. She felt somehow
responsible for her sister's death.
Jennifer
came to Toronto with another young woman, and the two moved in with a male friend,
from the same town, already living in Toronto. That situation didn't work out, and
was the main precipitant to her becoming homeless: AIf I would have listened to my
woman's intuition a little more. We moved in there, she moved right into his bedroom.
She kept always saying Awe have to find an apartment , but she was never actively
looking for a place or a job.
Inability
to maintain employment was another precipitant. She was able to find work easily,
but was unable to hold onto it once she got it. She felt that was related to the
depression or dysthymia she had experienced over much of her life, which she connected
to the problems with her relationship to her father. AI find it very hard to keep
a job. I get there for a couple of months and then I just don't want to do it anymore.
I don't want to be working in a coffee shop. I want to be making music. As soon as
there's a little bit of shit that I have to put up with, I'm out of there.
People
in this group experienced parental alcoholism or abuse in childhood. The precipitant
for this group was described by one as a Adownward spiral Ba year in which a number
of unfortunate things happened, such as the death of loved ones, ending of relationships,
job loss, and eviction. The pathway was an unstable beginning, and then a rapid accumulation
of events that overwhelmed people's ability to cope with their situation.
DannyDanny
is a young, white male, who was strikingly positive and pleasant during interview.
Both Danny's parents were alcoholic, and his father regularly beat his mother. He
described her waking up every Sunday Awith a set of shiners. His father died when
he was 7 years old of alcoholism. Danny was then required to assume a parental role,
responsible for taking care of his physically disabled brother: AI always looked
after Mom and John. Mom and John. It's always been Mom and John. I used to do the
housework, laundry, dishes, groceries, cut the lawn. I love my Mom very dearly, but
she's a drinker.
The
main precipitant for Danny was the death of his mother. He had been living with his
mother his whole life, and she constituted his support system: ARight now it's very
hard. She's gone, and there's no phoning and saying, Mom, can we have some help.
The
other precipitant was a one-time cocaine binge: he had been living with his younger
sister, who used drugs. At a party he was persuaded to try cocaine with his brother,
and ended up spending all of his money on the cocaine. He has not used it since.
He emphasized about how badly he felt about doing this, and it seemed connected to
the loss of his mother rather than a substance abuse problem. It was however, the
reason he didn't have money for housing.
His
siblings (older and younger sisters) were not sources of support. He moved to Toronto
after his mother's death, and initially lived with his younger sister. She asked
him and his disabled brother to leave, although they didn't have money to get a place,
which is how he ended up in the shelter. He was too embarrassed to admit to his older
sister that he had become homeless.
Danny
spoke a lot about the lack of available employment. He was unable to find work in
Toronto. He had worked as a prep cook up North, and had few other job skills. >
Dr.
Goering presented the conclusions of the qualitative study.
The
kind of interventions that would be of assistance to the people representing these
four pathways to homelessness must be multi-faceted, as is clear from the many and
different precipitating factors. There is no one solution or approach that can address
this problem.
Severely
Mentally Ill (Jessica):Young
Adults (Jennifer):The
Vulnerable (Danny):
Dr.
Morrell-Bellai: The rates of physical and sexual abuse reported in our study
were much higher than those in the Los Angeles study. However, the rates reported
may be somewhat under-represented because there may be people who felt uncomfortable
reporting experiences of abuse. In terms of method, we placed those questions quite
late during the interview, in the hope that by the time they were asked, there would
be some rapport between interviewer and interviewee. The questions also required
a simple yes-no answer, so it was less intimidating than a qualitative situation,
where the subject would have to go into a lot of detail.
Dr.
Morrell-Bellai: We did not have a representative sample for the qualitative study,
as this is not a part of qualitative work. The quantitative findings did show that
the rates of experience of abuse were much higher for women, which is consistent
with other research.
Dr.
Morrell-Bellai: Study results do not demonstrate how maintaining housing would
be effected by trauma resolution. However, the chronically homeless individuals in
the qualitative sample reported more experiences of abuse. As well, based on the
qualitative information, it appears that someone who suffered more serious abuse
as a child would be more likely to re-experience homelessness, or less likely to
get out of a homeless situation. Substance abuse was very much an issue for perpetuating
homelessness in the chronically homeless group. They may have been using the substance
to cope with an abusive history that had not been properly dealt with. People in
this group also noted the lack of affordable housing in neighbourhoods without an
environment of substance abuse (dealers and users). This kind of situation is an
illustration of how individual and macro factors can interact to keep a person homeless.
Notwithstanding, I have some questions about the study's findings
on mental illness. Your study indicated that 67 percent of the study sample had a
lifetime diagnosis of mental illness, with 10.7 percent being seriously mentally
ill. What is the relationship between the 3.7 percent of the sample reporting mental
illness as a precipitant to homelessness, and the 67 percent reporting a lifetime
diagnosis of mental illness? As well, what is the diagnosis of the approximately
50 percent of the sample who were neither schizophrenic nor manic depressive, and
what impact does this diagnosis have on those individuals' quality of life?Dr.
Goering: This research project had three objectives, one of which was to look
at the prevalence of mental illness in Metro Toronto's homeless population. As a
psychiatric institute, the Clarke Institute of Psychiatry is interested in mental
illness as a possible issue for homeless people. The public is also interested in
this issue, because mental illness and homelessness are commonly associated with
each other. Therefore, we believe it was a worthwhile focus, among others, for this
study. We certainly know that it is not the only important focus, but we are not
emphasizing jobs and housing solutions at this conference because that is not what
we are about. We hope that we are giving you the message that they are important,
and that mental illness and its influence as a factor in homelessness has been exaggerated.
We are trying to communicate to you that mental illness is just one part of the picture.
To
answer your second question, the bulk of the mental illness reported was major depression.
Major depression can require and be helped by treatment, but does not usually require
hospitalization. When we asked the people who had, in their lifetime, met the criteria
for a diagnosis of major depression, 87 percent of them said it had been prior to
their homelessness. The depression was not a reaction to the homelessness, but neither
was it necessarily a cause. We are not saying that the depression these people experienced
in their lives was a cause for homelessness. The childhood histories, the disadvantages
in terms of education, the difficult life events and the breakdowns in social support
create a risk for depression, and a risk for homelessness. That is why we see them
coexisting.
Dr.
Goering: We asked people whether an experience of discrimination because of race
was one of the precipitating factors of their homelessness. Very few people said
yes to that question, but it was probably not the best way to get at this issue.
The design you use in a research study is very much tied to the questions that you
are asking. The questions we were asking were about mental illness and the particular
pathways that led immediately to people becoming homeless. If you were going to design
a study that looked at racial discrimination, or income and jobs, and their effect
on homelessness, you would use a different approach. Literature available on those
issues has been noted in our annotated bibliography (distributed in the conference
booklet).
Dr. George Tolomiczenko
This
is one of two add-on studies to the Pathways study. Collection of neuropsychological
data expands on prior research conducted in Boston. The researcher was Dr. Tolomiczenko
and the research assistant was Teresa Sota-Royes. The National Alliance for Research
on Schizophrenia and Affective Disorders has funded the project. (Note: Due to time
constraints, additional material is presented here which was not presented on at
the Conference.)
In
Boston, neuropsychological testing was done with a group of previously homeless persons
with severe mental illness who were housed and followed-up for 18 months. The testing
was done to detect improvement over time. The Boston sample of 116 people demonstrated
significant deficits in cognitive functioning consistent with a chronic and severe
mental illness.
In
contrast, the Toronto sample was not nearly as impaired on tests of cognitive functioning.
105 of the 330 people interviewed for the Pathways study completed additional testing
and interviews designed to identify cognitive strengths and weaknesses.
The
tests covered different domains of functioning, including verbal, visual/spatial,
motor, attention/orientation, math, and memory. The study looked for differences
in these domains between sub-categories of homeless individuals, and whether there
was a need to account for cognitive functioning in assistance strategies.
Another
way of interpreting the scores of the homeless persons tested is to compare them
with what you'd expect to find among groups of adults in general. This comparison
shows the homeless group scoring below par but not at levels which would characterize
the group as clinically impaired.
Sub-group
comparisons were also done. Two ways of dividing the group which were associated
with differences in cognitive test scores were childhood abuse (sexual or physical)
and cocaine abuse during the year prior to interview. Lower scores were associated
with histories of childhood abuse and current cocaine abuse. These associations were
no longer significant, however, when years of formal education was included as a
covariate. How these background factors interact and account for variation among
the scores of our sample of homeless adults will be the subject of subsequent research.
In
Toronto, an additional component of testing looked at dimensions of personality (traits
or prevailing patterns of interaction with others). Based on a self-evaluation questionnaire,
various aspects of personality were assessed. Scores were converted into a format
that allowed for comparison with adults in general and between sub-groups of the
sample tested. An additional seven subjects completed the personality questionnaire
without completing the neuropsychological testing bringing the total to 112.
Overall,
the group was more aggressive, more anti-social, more fluctuating in mood and sense
of self, less open to take responsibility for change, more suicidal, more avoidant
and more irritable than adults in general. Some of these differences were amplified
when particular subgroups were compared. Those who reported having been abused as
children were not, however, significantly more aggressive than subjects with no history
of being abused. In a separate analysis cocaine abusers were more aggressive, anti-social
and irritable. Other significant between-subgroup elevated scores were observed among
those homeless at least once before, persons with an Axis I psychiatric diagnosis,
and among the supplementary group of shelter avoiders interviewed.
Personality
style, as reported in the results of these questionnaires, always reflects a combination
of trait and current behavioral state. It's not surprising that people who are homeless
are more likely to have engaged in verbal aggression, for instance. This might reflect
a natural response and necessary adaptation for coping with street life (current
state). On the other hand, there is no reason, a priori, that a person who is without
housing is more likely to describe him or herself as someone who seldom turns down
a dare (an aspect of stimulus-seeking which contributes to the anti-social dimension).
There is no way of dis-entangling these components. From a practical standpoint of
service provision, however, it is clear that shelter staff need to be able to work
with some people who, generally speaking, are not easy to work with. Training and
ongoing support for shelter workers and volunteers would help to relieve stress and
to prevent burn-out.
1. Why are you pathologizing homelessness? These tests report information
from a certain perspective B they are not objective.Dr.
Tolomiczenko: We believe we have used the best available methods of testing,
and the study findings will hopefully provide valuable information from a fair perspective.
This study should also encourage follow up studies that can approach the issue from
different perspectives: it is but one piece of a much broader picture.
Dr.
Tolomiczenko: That is our hope.
Dr. Mark Halman
This
is the second of the two add on studies. It examined the prevalence of HIV and risk
factors for HIV in the representative sample of homeless adults taken from the Pathways
study. Co-investigators were the Pathways Project research team, and Carol Major,
of the Ontario Ministry of Health Central Laboratories. Field researchers were Dr.
Tammy Morrell-Bellai, Michael Higgins, Nicole Tenn-Lyn, and Carole Bentley. Laboratory
coordinators were Angela Francis and Suzanne Cohen. The study was funded by the Canadian
Foundation for AIDS Research and the AIDS Bureau of the Ontario Ministry of Health.
Study
objectives were to determine the HIV prevalence in a representative sample of homeless
adults in Toronto, and to correlate risk factors for HIV positive status, including
mental illness, sexual behaviours and drug use, with the HIV prevalence in this sample.
There
is a number of primarily U.S. based studies of HIV prevalence in homeless populations.
These studies report enormously varying rates, depending on their sampling methodology.
Most examined people seeking HIV testing or medical treatment, so there are biases
towards higher rates of HIV positive status.
Outreach samples:
Homeless people with psychiatric illnesses who used psychiatric facilities:
There were a number of lines of evidence in these studies suggesting that homeless
persons are at greater risk for HIV positive status.
All
Pathways study participants were asked to participate in the HIV prevalence study,
and 94 percent of them agreed. Those who chose not to participate did not differ
in any significant way from those who did. All 30 of the shelter avoiders also agreed
to participate in the HIV study.
The
study used an unlinked, anonymous saliva HIV testing methodology. This method has
a high sensitivity and specificity, and has been demonstrated to be very effective
in field research. Study design did not allow individual participants to learn the
results of their HIV test. People who wanted to find out their HIV status were referred
to places where they could receive confidential testing. The study did provide counseling
to all participants on minimizing HIV risk. Risk factor analysis was conducted by
giving all participants a unique, anonymous identifier for their saliva samples.
Participants were then asked certain risk factor questions. The study's dependence
on self reporting does introduce a bias, however, because these questions came at
the end of Pathways project, the rapport between participants and investigators was
judged to be quite good, and the information reliable.
All
risk factor items asked subjects whether he or she had ever, at any point during
his/her lifetime, had ever engaged in the behaviour. The questions were broad enough
to guard against inadvertent linkage between the data and the identity of an individual
person. Ethical issues were raised by the study's design: it did not inform the individual
of the result of their HIV test, but it also protected their anonymity and allowed
for enhanced participation. The study was approved by the Human Subjects Review Board
of the University of Toronto, and the Wellesley Hospital.
Of
the 300 people in the Pathways study sample, 282 participated in the HIV prevalence
study (226 men and 56 women). While none of the participants acknowledged being HIV
positive when asked directly, 5 of the 282 were HIV positive, creating a prevalence
rate of 1.8 percent . The fact that all the positive samples were from men is probably
a study design issue; since the Pathways sample was stratified to reflect the hostel
population, a lower number of women were interviewed. The HIV prevalence rate for
men, not including women, was 2.2 percent . In the non-representative, outreach sample
(the shelter avoiders), the prevalence rate was 3.3 percent , or 1 out of 30. No
risk factor analysis was completed for the women in the study sample because none
were HIV positive, but the prevalence of risk factor behaviours for HIV in women
was as follows:
Prevalence of Risk Factor Behaviours for HIV for Women in the Sample Population
Risk Factor Analysis of Men in the Sample Population: Correlation of Risk Factors with HIV Positive Status
Mental
IllnessThis was statistically insignificant (no bearing on HIV status: 2.1 percent of those with Axis I disorders were HIV positive vs. 2.9 percent of those without Axis I disorders).
Sexual
Behaviours (none of these behaviours was a statistically significant risk factor
for HIV positive status)Had ever had any form of sex with other men: 5.5 percent of the sample. None were HIV positive.
Had ever participated in sex exchange: 11.4 percent of the sample. None were HIV positive.
Had ever had sex with a partner who injected drugs: 3.17 percent of the sample who responded yes were HIV positive; 1.92 percent of the sample who responded no were HIV positive.
Drug
Use BehavioursLifetime
use of injection drugs: Of the 27.6 percent with a history of injection drug
use, 4.92 percent were HIV positive; 1.25 percent without a history of injection
drug use were HIV positive. This is a trend towards a statistically significant result,
although not statistically significant in itself
Lifetime use of crack cocaine: This is the one statistically significant result of the study: 43.9 percent of the sample had used crack cocaine. All those who were HIV positive had a lifetime history of crack use. 5.15 percent of those who had used crack were HIV positive, vs. 0 percent who had never used crack.
Lifetime
use of both crack cocaine and injection drugs: There is a marginally higher HIV
prevalence rate in men who were both crack cocaine and injection drug users.
These
studies were not conducted solely on homeless populations.
Toronto,
1988: 1 percent
Toronto, 1990: 4.3 percent
Vancouver, 1988: 1-2 percent ; 1994: 7 percent ; 1996: 23 percent
The Vancouver study re-sampled study participants. In the first survey, 257 individuals
were HIV negative. When re-tested 6 months later, 24 of the 257 (9.3 percent ) were
HIV positive. 22 of those 24 had unstable housing as a risk factor. The risk factor
analysis of the Vancouver study found low education, unstable housing, participation
in commercial sex, and cocaine use as the significant risk factors for HIV positive
status.
While HIV prevention strategies must continue to focus on safer sex and injection
behaviours, crack use must also be addressed as a significant risk factor. Care access
is an issue, as homeless people are at some increased risk for HIV positive status
and HIV infection.
Dr.
Wasylenki: I want to reiterate that this is one of the first studies which looks
at the purported relationship between mental illness and homelessness, and has concluded
that the relationship is much weaker than originally thought. This study has made
a very significant contribution: most studies attempting the same thing have come
out with results that seem much too high, and argue for a much more cause and effect
relationship.
Dr.
Main: In addition, I think it is important to heed the methodological point made
by Dr. Goering: the thrust of this study is not that homelessness is caused entirely
by individual behaviour. That would be as wrong as the argument that calls homelessness
a purely structural matter. It is a question of the interaction between the two.
When policy makers are faced with a choice of focusing purely on individual or social
factors as causes of homelessness, which is a false dichotomy, you get bad policy.
3. It is no accident that we keep calling for housing. The
Vancouver study cited earlier reported that people with the same risk factors for
HIV infection doubled their risk factors when homeless. I invite you to find out
how many people with AIDS who use a large shelter like Seaton House, die in hospital
of opportunistic diseases that accompany congregate living. When we propose only
solutions like more education for people, we fall short. Assuming that we don't know
how to house people is merely an excuse, a Abig out. We are not going to educate
people into how to get money and keep their housing. Your own statistics noted that
22 percent of your sample reported becoming homeless because of the welfare shelter
allowance being lowered. This is a key feature. Housing all the people in your case
study will not prevent the same number of people from becoming de-housed and ending
up in the hostel system. This is why we keep coming back to these big structural
problems.
Dr.
Halman: This is a very hard question to answer, because of the sampling methodology.
From the Ontario Laboratory testing data (people who have gone for an HIV test in
Metro Toronto), the rate of a positive test is .56 percent of all people going for
an HIV test. This is probably an at risk population compared to the general population.
The rate of positive samples from Red Cross blood donors is estimated at .0001 percent
in the Metro Toronto area. These are the two best figures I can give as comparison
data to our study's prevalence rate of 1.8 percent .
Dr.
Halman: No. Our study attempted to broadly identify what risk factors might be
putting homeless persons at increased risk for HIV. This was a way of starting to
identify this population as being at increased risk for HIV infection, and to try
and devise strategies to address this.
Ms. Donner thanked the Pathways Project research team for their presentations and the audience for its participation.
Margaret Gallow, Regional Director and Lead - Mental Health
Good
afternoon everybody. I am responsible to be a conduit between the field and the Minister
and Deputy Ministers of Health. My job is to ensure that policy makers have some
real understanding of what it is people say who provide or use this service. I have
been with the Ministry of Health for about 3 years, and almost 17 with the Ministry
of Community and Social Services, as their Regional Director for Central Region (including
Toronto and the Greater Toronto Area). I am not totally unfamiliar with the problems
that we face with this particular population, as we try to bring services to these
people.
As
the study points out, mental illness is only one of a number of serious risk factors
for the homeless. 86 percent of those surveyed had experienced some mental disorder
or illness or problem, and/or some sort of substance abuse at some point in their
lives, compared to just 32 percent of the general population. 11 percent had serious
psychotic problems or disorders, that 11 percent using up a fair share of our resources.
38 percent had mood disorders, predominantly major depression. When I look at the
outcome of the research, it is certainly easy to see how, in this day and age, depression
could contribute to a fair amount of the reasons why people find themselves in this
situation.
The
interesting thing was the number of people surveyed who had little or no involvement
with the Provincial Psychiatric Hospital system, which is really where our money
is today, not just in Provincial Psychiatric Hospitals, but in beds. The Ministry
of Health currently spends $2.4 billion dollars, or 14 percent of our total budget,
on mental illness. But among other Ministries, $1.2 billion is spent on things like
drugs and general welfare. The questions to be asked by all of us are: 1) is it enough
money; 2) do we spend it on the right people at the right time, and in the right
way; and 3) do the current policies support the need for change.
In
1993, the Ministry of Health announced a document called Putting People First,
a reform document spanning ten years, to reform the system from an inpatient
to an outpatient system of care. At that time, 80 percent of our resources were tied
up in inpatient beds. What we said we wanted to do after listening to people who
used the service and people who provided the service, was to ensure that there were
alternatives to these beds, created for people so that they had a choice when they
needed treatment, which did not to have to be in a psychiatric hospital.
In
October 1995, the Mental Health Reform Workgroup on Homelessness, Social Isolation
and Mental Health Reform completed a document entitled Meeting the Needs.
As a result of that work, the Ministry developed a policy guideline entitled The
Provision of Community Mental Health Services to People who are Homeless or Socially
Isolated, and distributed it to District Health Councils and mental health service
providers, in November 1996. This guideline provides policy direction for planning
mental health services and supports to improve access to services and supports by
mental health consumers who are homeless.
This
policy guideline must now be reviewed in light of this recent study. Do our reform
initiatives provide outreach services that meet the needs identified in this study,
such as the need for personal support and safe and secure shelter? The mental health
system needs to implement proven intensive outreach, to help those with chronic mental
illness who are not comfortable with conventional services. Inflexibility and over-reliance
on hospital based care is viewed by many who are seriously ill as part of the problem
rather than an acceptable alternative. A bed in a psychiatric hospital must not be
the only alternative, and in many cases we should look at the use of a bed as a failure
in the system to provide.
A
number of significant systemic barriers prevent homeless or socially isolated people
from receiving the type and level of service and support they need. These barriers
include the following: a lack of access to, and availability of, appropriate supports
and services; the current structure of services and approaches to service delivery
that does not meet the needs of people who are homeless; and an absence of linkage
and coordination among service providers that prevent homeless people from receiving
the services they need. The Mental Health Reform Strategy, and the decisions of the
Hospital Restructuring Commission, indicate that there will be a reallocation of
existing mental health resources. This will translate into an overall increase for
all consumers of mental health services and the availability of services and supports
that are community focused. These services include case management (which includes
support to housing), crisis response, and consumer and family run initiatives.
With
an increase in the availability of community focused supports and services, it is
critical that access to services for people who are homeless or socially isolated
be ensured. Access to services and supports can be improved when case management,
crisis response and supportive housing programs offer assertive outreach to people
who are homeless and socially isolated. This means that such programs must have the
capacity to provide service and support to people where they are located: on the
street, in a hostel, or at a drop-in centre. Also, the reformed mental health system
will need to ensure the provision of drop-in services. Drop-ins offer a range of
service and supports to homeless and socially isolated people, such as providing
a meal, showers, a telephone, some social opportunities, self help, community development,
crisis response, and ongoing counseling. These services are offered to whomever approaches
the drop-in, are accessible, and located in areas where homeless people can be found.
Drop-in centres can be the entry point for people in terms of finding other services
and supports form the mental health and social service sectors. In fact, staff of
drop-in centres would work with staff of case management, crisis response and supportive
housing programs in an effort to better meet the needs of the homeless or socially
isolated person. In the reform of the mental health system, support services are
viewed as being offered by community based agencies, tailored to the person's needs,
and linked with the person rather than with the location. Housing support services
are included under case management programs, which can provide support to the severely
mentally ill in a wide variety of residential settings. With an increase in the availability
of community focused supports and services, it will be important that access to services
for people in need, especially those who are homeless or socially isolated, be ensured.
Such access to service supports will be improved when case management, which includes
supports to housing, crisis response program, offer more assertive outreach to people
in need. In essence, all of these efforts are designed to facilitate the means by
which such programs provide service and support to people, regardless of where they
are located.
Since
the distribution of the homelessness policy guidelines in 1996 (the ones I referred
to, that need to be reviewed), the mental health area of the Ministry has received
a number of proposals from various mental health and community agencies. While the
proposals vary in content and size, two emerging themes or areas of need are identified.
First are individual supports or case management to hostels, shelters and drop-ins,
and second, are specialized mobile clinical teams.
In
March 1997, the Municipality of Metropolitan Toronto held a forum on mental health
and homelessness. As a result of the forum and other consultations within the hostel/shelter
services field, Metro Community Services developed recommendations and forwarded
these to the Ministry. A document, Provision of Mental Health Service to Homeless
Individuals, suggests initiatives similar to those that I've been talking about,
that are part of our Mental Health Reform strategy, as well as ways to initiate discussion
between various levels of municipal and provincial governments. The Ministry has
relied heavily on the input from both Metro and its funded agencies and service providers,
to work together in the development of these partnerships, linkages, and increased
communication, and dialogue between service providers to ensure that the overall
strategy incorporates the use of existing mental health services, the development
of services which utilize best practice methodologies, as well as a systemic and
coordinated approach to the delivery of services. In an effort to respond directly
to the needs of the homeless people with a serious mental illness, Ministry staff
have recently met with key mental health service providers in Ottawa, London, Hamilton
and Metro Toronto, to develop and/or refine proposals for further development of
services to address the mental health needs of homeless persons. Strategies include
the development and/or expansion of clinical teams, and we are committed to Cabinet
to develop, between now and March 1998, 16-18 community treatment teams, increased
case management and individual supports as well as mental health services for special
populations. More specifically, the creation of specialized mobile clinical teams
will provide hostels and shelters with onsite mental health supports, including assessment,
treatment (including treatment for substance abuse), counseling, linkages to supportive
housing, and other, longer term mental health supports, as well as access to specialized
psychiatric services, and where needed, a hospital bed.
Increased
case management will ensure that long term mental health services are in place to
provide intensive supports, ensuring that individuals are linked to housing, and
provided with ongoing supports to individuals once housed, and ensuring that individuals
have access to all required health services as well as the provision of vocational
and social recreational supports. Similar services will become more accessible to
special populations such as aboriginal communities as this strategy develops. We
are confident that these initiatives can be implemented in the near future.
The
$23.5 million Community Investment Fund strategy serves to mainly enhance services
for people with serious mental illness. Of the approximate $23.5 million, approximately
$5.6 million has been dedicated to case management proposals, which include supports
to housing. The Ministry of Health and the Mental Health Unit currently fund 17 programs
at approximately $3.5 million in annualized funding, specifically for the homeless
and the hard to house population. Of these, 9 programs are located in Metro Toronto.
We are currently working with the organizations which submitted those proposals,
to look at how they can be funded, and will be talking with our Minister over the
next few weeks on these proposals, and how we get the funding to people as quickly
as possible. There is never enough money, it always scratches the surface, but that
doesn't mean we shouldn't move forward in a positive way in maximizing the use of
those resources in the most effective and efficient way possible.
It
is hard not to talk about supportive housing, when we talk about our hostel system
and our supports to the homeless population. We do fund, through mental health programs
and services, a variety of supports for housing programs for individuals with a severe
mental illness. Examples include supportive housing programs, boarding home support,
Homes for Special Care, and supports provided by staff of the Provincial Psychiatric
Hospitals. Supportive housing generally refers to housing that provides independent,
permanent living arrangements for people who need essential support services in order
to assist them to live in the community. Also included under this general category
are various transitional or short term housing alternatives for mental health consumers,
who require various levels of support.
The
Ministry of Health budget for the support services is about $18.5 million, with housing
providing almost $16 million in accommodation subsidies. As of January 1 1998, the
Ministry of Municipal Affairs and Housing will be getting out of the housing business.
The social housing portfolio being devolved is a done deal. However, the government
is committed to looking at supportive housing for those clients with special needs
somewhat separately, given the vulnerability of this client group. There is an Inter-Ministerial
of Assistant Deputy Ministers reviewing the options around this particular initiative.
Those of us in the supportive housing business must look at this change in housing
direction as an opportunity to develop more forward thinking policies and also better
ways to develop actual housing stock.
As
Ontario continues the process of reforming mental health services, it is critical
that the needs of those who are homeless or socially isolated, and dealing with a
severe mental illness or mental health problem, be considered and included in both
planning activities and service delivery. The province's Mental Health Reform Strategy
must address the needs of these individuals and ameliorate, not exacerbate the problem
of homelessness. Simply focusing on one aspect such as the mental health system alone,
will not be sufficient. Preventing homelessness among adults begins in early childhood
with improved early identification, treatment, and follow up to childhood abuse.
Equally important are income supports, employment, and retraining opportunities,
and first and foremost, affordable housing. It will take careful collaboration between
Ministries, and partnerships with the federal and municipal governments, service
providers and consumers, if the answers to the problem we are dealing with today
are to be found.
This
study indeed points to the fact that mental illness is a contributing factor to this
problem, but that it is actually fundamental deficiencies in our social fabric that
form the basis for homelessness. Change is needed. The question is, what can you
and I do to influence that change? How do we work together in a creative way, to
meet the needs of this population within the framework of government policy? I am
confident that we are all up to the challenge, and I wish you well in your afternoon
activities. Thank you.
Ms. Donner thanked Ms. Gallow for her presentation. Ms. Gallow did not stay for the
Questions and Comments Period.
Dr. Thomas Main
Dr.
Main compared patterns in municipal policy making on homelessness in Toronto and
New York City.
Last
summer, Dr. Main had an opportunity to ask Mayor Barbara Hall about Toronto's policy
on homelessness during a call-in talk show. Her reply: AThere are no cookie cutter
solutions. We need to understand that cookie cutter solutions are not good. It often
takes time to build up the trust that is needed. So there is no one homeless policy
in Toronto. But everything we do is predicated on the belief that safe, affordable
housing is a right, and we should work to make it real. This was a strikingly frank
statement that Aone homeless policy in Toronto neither existed, nor was it desirable.
Change,
in municipal homelessness policy in Toronto, tends to be incremental B one piece
at a time. In any given year, the policy base from the last year is pretty much unchanged,
except for modest additions (a new program, more beds, a small increase in funding).
The budget for Metro Toronto services to the homeless in 1992 was approximately $38
million dollars. By 1997, it had risen in a series of discrete steps to about $56
million dollars. The number of homeless people in Toronto (judged from the number
passing through the hostel system in the course of a year) fluctuates at around 28,000
people.
However,
homelessness is also an urgent issue in public consciousness in Toronto. It is something
that the Mayor recognizes as a problem, and something on which she has something
to say, as evidenced by the fact she was at this conference.
The
policy of New York City, in contrast, is characterized by sudden shifts in direction,
funding, and philosophy. There is one homelessness policy, and the system is run
a certain way, at a particular point in time. People can be reasonably confident
that a current policy, if disliked, will be replaced by a different one.
In
the late 1970s, New York City had a very meager shelter system. When shelter capacity
was reached, subsequent applicants for shelter were turned back to the street. Modern,
contemporary New York City policy on homelessness began in 1981, when the Supreme
Court of the State of New York ordered the enforcement of a consent decree. New York
City and New York State had been sued in the case of Callaghan (a 54 year old homeless
man) vs. Carey (the then Governor of New York). The Legal Aid Society of New York
City sued New York City, saying that under the State Constitution, the city had an
obligation to provide shelter to every homeless person who requested it. This decree
also had quality standards attached to it that the city had to meet in providing
shelter (e.g. there had to be one toilet per 6 residents, one tub or shower for 10
residents),
This
document wrought dramatic changes. In 1978, New York City had a budget for services
to the homeless of $6.8 million. By 1983, the budget was around $38 million (a 500
percent increase), and the men's system contained 4,000 clients. In 1993, the budget
was around $500 million, where it remains to this day. New York City's shelter system
went from being a relatively small, inexpensive, static system, to a large, costly,
growing, entitlement-based system. Almost immediately after developing this entitlement-based
shelter system, New York City became discontented. Then Mayor David Dinkins felt
obliged to strike a committee headed by Andrew Cuomo, now Head of the Federal Department
of Housing and Urban Development. The Cuomo Commission was asked to review New York
City's policy on the homeless and recommend changes.
The
Cuomo Commission stated that: ADespite unprecedented levels of resources and energy
devoted to addressing the problems of homelessness, not a single member of this commission,
nor any New Yorker with whom we have spoken, can claim a job well done. The time
has come for a major overhaul in the way the government addresses the problem of
homelessness. The Cuomo Commission proposed that the system should be based on mutual
responsibility rather than a right to shelter. Men would be given shelter for participating
in rehabilitative programs. It also proposed that the city Anot-for-profitize or
Aprivatize its shelter system: that it stop running shelters itself and start contracting
out with non profit organizations. The Cuomo Commission also recommended that homeless
policy be taken away from the huge New York City Human Resources Administration,
and given to a new administrative entity. In 1993, a smaller department of homeless
services was created.
In
1992, 70 percent of the beds in the men's shelter system were run by the city. By
1996, less than half were city-run. Most private non-profits which contracted to
provide shelters for homeless men were program shelters: each had a program aimed
at a specific clientele (e.g. substance abuse, veterans, mental health). The policy
direction was to move people out of city-run general shelters into privately run,
program shelters. This happened very rapidly.
In
one Toronto you see incremental change, in New York, non-incremental change. Is one
necessarily better than another? No. I will address two questions: 1) why the difference;
and 2) given the way Toronto works, what can be done within the Toronto system to
bring about the most effective sort of change.
Why
the Difference
It
is not possible to explain the different patterns of change by looking at differences
in the homelessness problem between the two cities. That would imply that the homelessness
problem changes incrementally in Toronto and radically in New York City, and there
is little evidence for that. In general, empirical data on the homeless is rare,
and it is even more difficult to get empirical data on an entire homeless population
in an entire city. This makes it impossible to explain the different patterns of
change by saying the reality is different, nor is it likely that that would be the
case.
The
difference in patterns of change is surprising because they contradict the literature
on public administration in a number of ways. In North America, New York City is
repeatedly used as the example of a highly fragmented governance system. It has many
different centres of power: many different governments, branches of governments and
authorities, each of which has some responsibility for dealing with some piece of
any particular problem. Typical literature on urban public administration argues
that the net result of this fragmentation is the emergence of a patchwork and complex
structure of political organization that evolves in an incremental fashion. With
the most fragmented governance structure, New York should have the slowest changing,
incrementally evolving system in North America. In 1961, the widely accepted 1400
Governments by Robert Wood, (title referred to the number of governments in the
New York City metropolitan area) concluded that New York City is a multi- centered
system, with a tendency towards stasis. The system is inherently conservative: more
favorable to defenders of the status quo than to innovators. However, this is precisely
the opposite of the pattern in New York City homelessness policy over last 15 years.
Toronto
reality also contradicts the literature on urban public administration. Toronto is
the continent's poster boy for effective, centralized, and defragmented public administration
(38 governments as opposed to 1400 in New York City). The latest issue of American
Prospect uses Toronto as the example for other North American cities to follow.
The argument is that a defragmented, metropolitan government is much more able to
respond to problems and adapt to changes in its social environment. However, Toronto's
pattern of homelessness policy development is precisely the opposite of what the
literature would predict.
Why
is the literature so dramatically wrong? One reason may be that the more fragmented
the political environment, the more opportunity there is for political entrepreneurship.
Political entrepreneurship happens when someone (often an Aoutsider ) takes initiative
to organize a formerly unorganized or unrecognized interest, and successfully represents
the cause of that interest in public policy making. This is aided in fragmented political
environment. An outsider would find it much more difficult to direct policy in a
relatively centralized political environment, such as that of Toronto.
An
environment conducive to political entrepreneurship was key in the Callaghan vs.
Carey decision. Courts in United States can review administrative decisions by the
city, making it is possible for an individual to sue the city. As a result, Callaghan
(and the homeless advocates representing him) could influence city policy through
the power of the courts over the bureaucracy. This is possible because power over
New York City bureaucracy is fragmented: courts have some say about what bureaucracy
does; the mayor has some say, the bureaucracy itself has some say. There are many
different avenues to power over the policy making process. Callaghan vs. Carey was
a classic piece of political entrepreneurship: individuals claiming to represent
the interests of a previously unheard or disorganized group translated political
demands into a concrete, easy to grasp, policy idea. This idea only had to be successfully
sold to one piece of the polity (the courts) sufficient to make a big policy change.
The
second major change in recent New York City homelessness policy, the idea of mutual
responsibility, was also the result of political entrepreneurship. After Callaghan
vs. Carey, the homeless were perceived as having got much of what they wanted. The
Dinkins administration went beyond Aright to shelter and implemented a policy of
moving homeless families out of the shelter system (Awelfare hotels ) as quickly
as possible and into permanent housing. While the number of families in welfare hotels
did drop dramatically, the number of homeless families coming into the shelter system
increased, although not dramatically (by approximately 120 families per month). However,
because the city was operating on a right to shelter basis, providing immediate,
up to standard shelter for these new homeless people placed a serious administrative
burden on the city. The Cuomo Commission was struck by Mayor Dinkins in the summer
of 1990, in part, as a response to opposition to the right to shelter.
The
right to shelter policy idea was perceived as having unintended consequences. This
perception opened up the way for other voices and policy ideas, namely mutual responsibility,
which was developed by Andrew Cuomo. At that time, New York City's present Mayor,
Mayor Guiliani, had lost a mayoralty race with David Dinkins, and was looking for
material for the upcoming race. He picked up and ran with this idea of mutual responsibility,
arguing that Dinkins had lost control of shelter system. In 1993, the only one-to-one
debate that took place in the New York City mayoralty election was convened by a
citizens' housing and planning council. Guiliani attacked Dinkins very vigorously
on the shelter issue, particularly on the fact that Dinkins had appointed another
committee to look at implementing the recommendations in the Cuomo Commission report.
Guiliani narrowly won the election, and proceeded to implement the new direction
in shelter policy.
Mayor
Guiliani is a good example of a political entrepreneur (although political entrepreneurs
are not necessarily politicians). He found an idea that reduced a complex problem
into a Ashort form that was easily understood, and sold it to his electorate. He
was able to implement his policy because New York City has a Astrong mayor form of
governance. The Toronto system does not have a strong mayor. In Toronto, the mayor
is but one member of a council, and casts one vote. She or he is primarily a leader
and persuader. In New York because the position of mayor represents an island of
power in a fragmented system: once it is captured by a political entrepreneur, a
change throughout the system can be effected.
The
difference in the patterns of homelessness policy development between Toronto and
New York City resides primarily in how conducive the governance structures of both
cities are to political entrepreneurealism. Contrary to most literature on public
administration, policy entrepreneurs have a better chance of getting their ideas
adopted in fragmented governance structures than in centralized ones. What are the
implications for Toronto?
Implications
for TorontoA
striking change in homelessness policy for Toronto will not happen on the local,
municipal level. The new Megacity will, if anything, decrease the possibility of
effecting a dramatic policy change, because Mega Toronto has an increased centralization
of power, therefore decreased possibilities for political entrepreneurship. Homelessness
policy is likely to continue to evolve incrementally at the Metro level. For non-incremental
policy change, you must go to the provincial or federal level: to effect change in
a centralized system, you must grab the centre of power. The centre of power in Canada
is not at local level, but at the provincial and federal levels. If the current policies
of provincial or federal governments become discredited, a window of opportunity
(such as an election) will open up to effect non-incremental change. Only a change
at the provincial or federal level will allow for that kind of policy shift.
If
provincial or national policy is not discredited and windows of opportunity are not
created with a new government, change in local policy will continue to be incremental.
Local policy makers must continue to do what they already do well: determine how
to rationally expand the current system. The Pathways study clearly demonstrates
that homelessness is a combination of problems rather than one single problem. The
Toronto policy of dealing with the bevy of problems piecemeal should continue, and
should focus on strengthening the programming within the shelters. The Pathways study
provides the city some sense of the direction in which that programming needs to
move.
1. I regret that you waited until the end of your presentation to talk about the critical role federal and provincial government plays in terms of housing and homelessness policy. In the Canadian context, if we do not understand the role and the changing role of our federal and provincial governments, we will be condemned to follow the New York model, which is Aa right to shelter, as opposed to our model of a right to safe, affordable housing, and appropriate services.
Throughout the day, people have spoken about the need for housing.
In Canada, starting in 1973 at the federal level and 1985 at the provincial level,
the government funded hundreds of thousands of units of cooperative and non-profit
housing. Under the umbrella of these programs, there was a rainbow of really interesting
and innovative initiatives created to house homeless people here in Toronto and across
the country. The two problems with these programs at the federal and provincial level
were: 1) there was never enough money when the programs were in existence; and 2)
the new AReaganism at the federal and provincial government levels resulted in massive
cutbacks to these programs. We lost the federal program, and now Margaret Gallow
says that Ontario is getting out of the housing business, and it's a Adone deal.
In fact, it's not a done deal, because every major municipal politician in Ontario
is opposed to it, as well as key housing organizations such as the Cooperative Housing
Federation of Canada, the Ontario Non-Profit Housing Association, and every elected
federal politician in Ontario. Our Federal Housing Minster has stated that he will
not have any formal negotiations with the provincial government until they change
their position.
Dr.
Main: I don't know of any city that has eradicated homelessness. I'm not entirely
sure what would be involved in eradicating homelessness, and could see some rather
grim options if the problem were framed in those terms, that I would rather not see
get on the agenda at all.
Dr.
Main: New York City, has done itself some good by developing programmatic shelters
and by Anot-for-profitizing its shelter system. Toronto has a general reasonableness
in its approach and a willingness to seriously consider empirical information, unlike
New York City, where policy typically follows the loudest voice or catchiest phrase.
Dr.
Main: To reconstruct urban housing markets, you need power beyond a local level
Dr.
Main: In Canada, policy debate takes the form of empirical studies. In New York,
policy making is much more rowdy. In Toronto, power is more centralized. If you want
to have a big impact on policy, you must capture power at a provincial or federal
level, and persuade the Cabinet and Prime Minister to move on an idea. That requires
speaking the language of expertise. In New York City, to bring about change, you
can come up with a nifty idea that you can sell to the media, a judge, or an aspiring
politician. That is why, in Canada, you see policy making on this issue being more
expert centered and more incremental, than in the U.S.
Dr.
Main: I don't speak as an expert on Toronto, and I may well have made mistakes
or over-generalized in my remarks on Toronto. I certainly do not say that Canadians
don't know how to strategize on housing policy. However, my sense is that if you
really want a policy that increases the supply of affordable housing, this is not
a policy that can be achieved at the local level. It might conceivably be achieved
at the local level if you had a judiciary that was capable of intervening and ordering
the City of Toronto to supply housing, or if you had a strong mayor style of municipal
government. You do not. Whoever you elect will be one voice out of more than 50 on
the council. If you disagree with policy at the national or provincial level, you
will be left with thinking about incremental steps at the local level.
Dr.
Main: Protests are not what got a right to shelter enacted in New York City,
and protests are not going to work here in Toronto. You need some sort of institution
of formal authority.
8. I disagree. We have proven that protesting in Toronto
can be very effective. If we relied simply on professionals, voting and the court
system, we would not get anything. You are speaking about mechanics when we have
to talk about housing issues. This conference can make a decision to send notice
to the federal and provincial governments: it is our power to do that, as a democracy.
We can talk publicly about the issues, on the streets, in a lot of detail. We have
to discuss the fact that we have homeless people out in the streets. Homeless policy
does not just happen because someone from a university makes a good speech. We must
all band together and make a big call for housing, and that will have to keep coming
from our lips as it has in the past. We cannot be convinced otherwise, in this conference
or any other.
Ms. Donner thanked Dr. Main for his presentation and the audience for its participation.
Sheryl Lindsay, Dianne Patychuk, Bruce Stewart (Absent) and Jim Ward (Absent)
Sheryl
Lindsay - Social Worker, Women's Hostel Outreach Program
Those
of us working on the front-line with homeless people, regardless of the capacity
or focus of that work, have identified and been attempting to address the fact that
we are in a crisis situation and have been for quite some time. As the cold weather
comes, and we see increasing numbers of people on the streets, in shelters and drop-ins,
we recognize that each person we meet has a unique story to tell us, and we hope
to listen and learn from that personal account. Whether working with families, youth
or adults, our work focuses primarily on basic survival needs, and always, in the
back of our minds, we wonder whose death we will here of in the weeks and months
to follow, and what, if anything, we can to do prevent such further tragedies.
Many
of us working in this area believe we need first to view the issue of homelessness
within an anti-poverty framework. We must fully acknowledge the issues of social
injustice related to race, class, gender, stigma related to mental illness, and the
impact these have on the lives of the people we work with. Before we can begin to
address the many and varied individual issues that were raised by the findings today,
we need to keep this broader context in mind. It is important to recognize that the
lack of affordable housing cuts across all the groups we have heard about today.
We do indeed know how to create decent, affordable housing in Metro Toronto and Canada.
But in the last two years, in Metro Toronto in particular, we have seen the cancellation
of 80 percent of Metro's social housing development. This, combined with severe cuts
to social assistance, increases in eviction rates, release from jails and discharges
from hospitals to the streets and hostels, and the continued under-funding of services
such as drop-ins, have created an overwhelming situation in our city. We need to
continue to pressure for a coherent housing policy, which includes a range of support
options, and includes all levels of government, whether or not they are telling us
they have Aopted out.
It
is crucial to get beyond labels. It is important to acknowledge that, as individuals,
we all have different needs and require access to a variety of relevant and flexible
services. Today's research findings, and my own work experience with women on the
streets, show that many homeless individuals have experienced issues of child sexual
abuse, and desperately need access to alternative counseling services. This group's
needs may differ from people who need access to substance abuse services, detoxification,
crisis services, and other support services. On the other hand, people who do individual
outreach realize that their work is only a piece of an answer. Our work cannot exist
in a vacuum. I've worked with a woman on the streets who is barred from most of the
downtown shelters. I have a relationship with her, we are well connected, however,
she has no place to go. The one hostel who admits her has her on a contract to come
in at 11 p.m. at night and leave at 7a.m. in the morning. The day shelter drop-in
she uses closes at 6 p.m.. In cold weather, 5 hours is far too long for someone to
be on the street. While it is important to create relationships and bring services
to where people are at, we need access to a wide range of housing options to truly
end homelessness.
In
July of this year, the Toronto Coalition against Homelessness released a report,
365 Days Have Gone By, referring to the fact that a year has passed since
the release of recommendations following an inquest into the freezing deaths of three
men on the streets of Toronto, in the winter of 1996. At the time of the inquest,
there was a reluctance on the part of the Coroner to discuss the issue of housing,
even though at the time of their deaths, all three men were homeless. The Coalition
report points out that very few of the inquest recommendations have been implemented:
most notably a need for coherent housing strategies and better access to and coordination
of a wide range of services to assist with individual needs.
One
of the men who died, Mr. Campani, was a psychiatric survivor who was discharged from
hospital with two TTC tickets and a map to Seaton house, a large hostel in downtown
Toronto. He died a year later in a makeshift lean-to under the Gardiner Expressway,
found by Street Patrol. Unfortunately, as we heard in the research this morning,
people are still being discharged with nowhere to go. We have to agree that this
is an unacceptable practice. I raise this as an issue because while Mr. Campani and
the people whose stories we heard this morning did have individualized support, what
they needed at the point of their release from hospital was a safe and secure place
to go.
As
many of us have acknowledged, we are doing our work in an environment of cutbacks
and fiscal restraints, with a government who has told us it is committed to getting
out of the housing business. At the local level we have heard of the rise of community
and resident groups that wish to rid their areas of services such as drop-ins for
homeless persons. It would be irresponsible for us as service providers to not keep
the broader social context in mind. We need to advocate for housing, while we pay
attention to individual needs.
Dianne
Patychuk - Social Epidemiologist, Toronto Public Health
As
researchers in publicly funded institutions, we have a responsibility to do what
the researchers of the Pathways study have done today, which is to present our research
in an open way to be publicly debated. A critique can then happen and can inform
the final findings and study report. Thank you for having the courage to do that.
It doesn't take a Ph.D. to recognize quality of research, and having a Ph.D. doesn't
mean you cannot still learn.
There
are two other noteworthy studies around housing and homelessness issues in Toronto:
the Street Health Report, which was based on interviews of 486 people, and the public
inquiry of the Toronto Coalition Against Homelessness.
Intensive
one-to-one service support is becoming harder and harder to fund. We have a responsibility
to use the our research knowledge to outline an approach to the bigger problem, which
is less about program development and developing institutionalized responses, than
about policy issues. The Pathways model identifies good opportunities for strategic
interventions, and as service providers, we know how to develop institutionalized
responses. It is harder to use advocacy work as one of our responses to homelessness
than program development. We have to make an effort to attack the bigger, policy
problems, despite this.
Unemployment
is a crucial, and long term issue. While unemployment rates may seem to be declining,
this is not actually due to the creation of new jobs. There are fewer people looking
for work, and fewer people employed. More of the new jobs being created are part
time. There is significant economic stress in our community, and the job situation
is not going to alleviate that economic stress in the near future.
We
are in an environment that allows homelessness to be the outcome of individual journeys.
This is an environment that assaults and attacks people with social assistance cuts,
lack of affordable housing, provincial legislation (Bills 96 and 142), cuts to social
services, and now the downloading of social housing and social service costs to the
municipal level. It is an environment that says it's okay to give people a mat on
the floor, day after day, without an alternative. Current economic and social powers
have created, not individual pathways, but a bulldozed road to homelessness, for
people to walk on during their personal journeys. We don't believe in that in Toronto.
The
Pathways model is an important model because it demonstrates that there are opportunities,
from childhood through adulthood, to influence the direction of people's lives. However,
it is clear from health inequalities research that you cannot totally undo the impact
of the early social and economic disadvantages, and the cumulative effects of social
inequalities. Research has highlighted the importance of entitlements, availability
of housing, and employment.
As
we move into the Megacity, which creates a city larger than 6 provinces and both
territories, we are like a city state. We have a great challenge and opportunity
to create a vision and policies for the new city that take responsibility for housing
and social equality. The provincial and federal governments are washing their hands
of the responsibility. This puts the ball is in our court and we have to take leadership.
Homelessness was perceived as a Aspecial interest issue at a provincial level. The
municipal government cannot deny the importance of this issue because it is visible
on the street.
Affordable,
good quality rental housing of diverse types, close to basic services, is needed
throughout the Greater Toronto Area. Access to social assistance should be based
on need, not on the willingness of municipal taxpayers to contribute. We must recognize
the importance of jobs. There is a big gap between existing services and the need
for services in many areas. We need to show the costs of not preventing homelessness
and the costs of social and economic inequalities. We have seen repeatedly, in public
health that prevention saves lives and reduces costs. We must act now.
1. I refer everyone to the Rupert Pilot Project Report, which was about assisting
over 500 people labeled Ahardest to house. The Rupert Pilot Project examined working
with private and non profit landlords to provide effective housing and support services.
We need to make a clear statement on the housing issue. Housing is a critical issue
for people labeled seriously mentally ill, and this has to be clearly communicated
to the provincial and federal governments. This study clearly acknowledged that mental
illness is not a major causative factor in homelessness in Metro Toronto. This is
important. One of the awful things that happens to homeless people is that they get
pathologized, labeled or dismissed as choosing to live on the street, or being crazy,
drunk ne'er do wells. This study gives us ammunition to say otherwise.
In addition, we have to reject the policy direction at senior levels of government,
in terms of abandoning very successful programs that produced hundreds of thousands
of units of housing stock and various supports. There is a lot of academic heft behind
this study. I hope that you investigators are honest to your research, and will stand
shoulder to shoulder with the homeless, anti-poverty advocates, housing providers,
municipal politicians and others who are engaged in a struggle at this moment to
convince policy makers that housing programs are needed not just for a Afringe group,
but a whole population. The authors of the study need to stand in solidarity with
the homeless and allies of the homeless in terms of the broader struggle for affordable
housing.
This conference and the Pathways study should make a clear statement to the federal
and provincial governments that they need to get back into the housing business;
that the starting point is to go back to the programs they have abandoned, and to
move on from there.
2.
I feel an overwhelming sense of frustration. One of the sources of this frustration
is the title of this conference. I work as an outreach worker: every day I walk the
paths with people into homelessness. I know those pathways very well. I really wish
we were talking about the pathways out of homelessness. There is a difference
in making that the title of this conference. We need to talk about those.
Everyone knows that we are not fighting a War on Poverty. We have a war on poor people,
which is driving the numbers of homeless people up. The average citizen in our town
has a sense of that, and is worried about that. What kind of a city or country will
we have when we tolerate an attitude that poor people have done something wrong and
should be punished? We should be thinking instead of a pathway out of homelessness,
and there are many gates blocking that pathway. For example, I spent a good part
of this morning trying to delay a discharge to the street. I spent a good part of
this week struggling to find housing for my client, suitable for his needs. I have
one vacancy to work with. I need something to offer. Houses and homes will not be
built out of words. They are bricks and mortar issues which need to be talked about
much more than they are.
A helpful aspect of this report is that it attempts to help us understand that people
have many kinds of health issues, and we should not get caught up in the myths perpetuated
by the system. We need to understand that homelessness is a poverty issue. We must
recognize that people who are forced to live out on the street eat terribly. They
are very tired. They have lost hope. The health system has not made itself very accessible
to these people. Not only is it inaccessible, but there is legislation pending that
will make it even more difficult for people to get health service. Clinicians, you
need to make your voices heard around issues like the new health card legislation,
which will make it more difficult for homeless people who can't keep identification,
who don't have health cards, or who get them and lose them, to get health service.
We need to come together to say, firstly, let's build; and secondly let's create
the roads out of homelessness.
3.
I'm Bob Burnett. There is a myth out there that we can't build safe, affordable comfortable
housing with today's rules, with the money that is currently available. I would like
to help dispel that myth and meet some other people who want to carry on from this
good groundwork and go out there and build housing.
4.
I want to address the notion of protests. Protests are something we have a moral
obligation to make: we have to scream as loudly as we can. We cannot accept people
dying on the streets, and we have a responsibility to talk about this, as workers.
The notion of programs is fine, to a point. But consider situations where you have
a program teaching people to manage their money. How do people Amanage $520.00 per
month? How do you tell someone who cannot afford to pay their rent, and cannot afford
to eat, that it's about managing your money? We must be really careful about the
kinds of programs we set up. We must also be careful about where we offer those programs.
Are we going to come accept that people live in subways? The kind of support we want
is in housing. Anybody who thinks that you can get your life together while you're
in a hostel, day shelter or on the streets needs to do a real reality check, and
that includes the researchers who put this project together. If you don't recognize
this, you will have ignored the questions brought up today.
5.
I would like to address notion of social protest as well. There was a good example
of social protest in France. Some years ago, the prostitutes in Paris organized to
get some laws changed, and threatened to march on clients' homes. The whole city
became involved in the protest, and it was a successful, grassroots campaign. The
laws were changed. There was also a successful grassroots effort in Toronto last
year, to get the Coroner's Inquest into the deaths of the three men.
I'm
concerned that protest is devalued as a form of communication. Protest is a traditional
recourse of the poor and socially isolated. If there is only one authorized way to
speak, then you silence people by saying that their way of speaking is not authorized
nor should it be listened to. For people who don't have letters after their names,
speaking out of turn, arguing, and being impolite are ways of being heard. They are
messy and embarrassing, but they are a way of being heard.
I would also remind you that regarding mental illness, one common form of torture
is to deprive people of sleep and food. That makes you crazy and breaks you down.
I don't know why people find it surprising that homeless people are broken down and
tired, and not always polite, friendly and articulate. Socially isolated people should
not be assumed to be unable to analyze their own situations. There has been an attitude
today that homeless people are social problems and are unable to participate in solutions.
There are no presenters speaking from a position of what it means to be studied and
talked about as a social problem. There is a message from researchers that the only
way to hear from homeless people is in a study where their knowledge is presented
through anonymous, case examples.
The Task Force on Homelessness and Addictions, which has 5 participating agencies,
is currently conducting a study funded by the Trillium Foundation. The project is
sloppy and messy, because it is being done in a participatory action format. Everyone
involved, from the people on the task force to the steering committee, has experienced
homelessness, addiction, or some other form of extreme stigmatization. We did not
accept current research instruments as a given. With input from academics, we created
a new research instrument, in conjunction with homeless and addicted and socially
isolated people. They have a lot to say about their situation, and they proposed
a lot of solutions. That data is incredibly rich, and was arrived at quite economically.
Ms. Donner thanked the panelists and the audience.
Dr. Paula Goering
This
day was built into the Pathways Project from the beginning, because the research
team recognized we needed broader input, particularly with regard to the policy recommendations.
We
will be reviewing the questions, discussion and feedback, and developing with assistance
from our Project Advisory Board, a set of final recommendations that will go into
the proceedings and be a part of the study report. Housing will be emphasized in
our final recommendations, as has been reinforced by today's discussion. We welcome
anyone who wishes to participate in the final recommendations.
Thank
you to the project researchers, conference coordinator Catherine Riley, rileyc@cs.clarke-inst.on.ca,
moderator Gail Donner, and the conference participants.
Following the conference, the Pathways Project Advisory committee and other interested
stakeholders convened to make recommendations regarding future action. The policy
implications of the study findings touch on a variety of domains (e.g. housing, income,
supports treatment etc.). Although our study highlights mental health issues, we
also gathered information about individual and societal factors and determinants.
In the end, while the information regarding mental health has important and controversial
implications, study results also underline the importance of other factors, such
as the lack of meaningful work and income, the lack of affordable, decent housing
and childhood histories of poverty and abuse.
As
described in the Bibliography compiled by the project, numerous recommendations addressing
homelessness have already been made by various organizations and coroner's inquests.
In particular, recent reports by the United Way and Community Mental Health Association-
Ontario Division provide comprehensive and timely policy recommendation. Rather than
generating another long list of all relevant recommendations, we have focused upon
identifying pressing needs for action for specific levels of government.
There
are also numerous local groups and agencies who have demonstrated great charity,
energy and determination in their efforts to help persons who are homeless. We feel
that recommendations aimed at municipal, provincial and federal levels need to be
emphasized. The structural determinants of homelessness such as high unemployment,
lack of affordable housing, poor educational achievement and childhood poverty are
obvious areas where government intervention is required.
Federal Level
The
magnitude of the housing crisis demands a return of CMHC to the provision of social
housing. Specific population needs (aboriginal, refugee, for example) also justify
federal commitment and intervention.
Canada,
unlike the United Kingdom or the United States, has no national policy pertaining
to homelessness. Health Canada should recognize that within a social determinant
model, homelessness is clearly a health concern. They should also take a lead role
in convening the appropriate players to develop a national policy.
Provincial
Level
MINISTRY OF HOUSING
The
Ministry of Housing has created a vacuum by abdicating responsibility for social
housing. The urgent need for more social housing is not being addressed. The provision
of emergency shelter, transitional housing and discharge from legal or medical institutions
all presume the existence permanent housing spaces.
There
is also a need for supported housing to ensure lasting community tenure. By tailoring
support to the needs of different subgroups (including persons with severe substance
abuse problems, for example), services that fit the needs, are sensitive to tenants'
rights and are cost-effective can be provided.
Tenant
advocacy services should be reinstated so that unnecessary, and often illegal, evictions
can be avoided.
MINISTRY OF COMMUNITY AND SOCIAL SERVICES
Cutbacks
of welfare office personnel should be reversed. Welfare workers should also have
special training to maintain respectful attitudes and reduce misunderstandings that
result in failed access to entitlements. Eligibility guidelines based on disability
should be reconsidered so that those with substance abuse problems are not automatically
disqualified.
The
needs of youth should also be given priority since they represent a significant subgroup
within the newly homeless population. Failure to intervene at this stage can have
long-lasting secondary effects (e.g., children born to women without housing or support,
long term homelessness, lost opportunity for employment training, etc.). Children's
Aid Society resources need enhancement to reduce the long term consequences of childhood
abuse.
MINISTRY
OF HEALTH
Intensive
case management, capable of brokering and providing services, has been shown to help
persons with complex needs access and maintain care. Outreach models such as that
embodied in the Assertive Community Treatment team approach constitute current "Best
Practice" for homeless persons with severe mental illness with or without concurrent
substance use problems and should be expanded.
For
others who have mental health problems but are less disabled, new and flexible models
of care should be developed to facilitate the delivery of services. Counseling and
casework should be more available in hostels and drop-ins. On site consultation from
mental health specialists provides an essential back-up resource as does a well-organized
crisis response system. Preventative interventions that are targeted to the special
needs of the various newly homeless subgroups need to be developed, implemented and
evaluated.
Substance
use increases the risk for many serious problems. For example, substance use, including
cocaine, was associated with HIV status and was prevalent among the subgroup that
refused to use shelters. There is thus a particular need for the development of new
approaches and services for those with dual disorders (mental illness plus substance
abuse). The merged mental illness and addictions corporation should be encouraged
to work with community agencies to develop new initiatives that provide a variety
of treatment options. An example of flexibility in program development is the shift
in residential substance abuse treatment from zero tolerance paradigms to harm reduction
models which allow for controlled use of substances while clients are in treatment.
MINISTRY
OF CORRECTIONS
Heavy
involvement with the legal system was evident, particularly among those with substance
use problems and shelter refusers. The enhancement of court diversion programs and
the development of release management programs with substance abuse and mental health
treatment components are recommended.
Municipal Level
The
downloading of services from the province to the municipality will likely cause considerable
turbulence. The Megacity Transition Committee has recommended the formation of a
Homelessness Task Force that has been endorsed by the new Mayor. Given the emphasis
on fiscal restraint and cost evaluation of civic efforts, the Task Force could use
a business plan approach to illustrate how current spending to prevent homelessness
will result in long term savings. The Task Force should take advantage of the opportunity
to coordinate the various community interests to promote and protect services. In
addition, access to services can be streamlined by avoiding a "silo" approach
that separates housing and welfare provision.
Mayor
Lastman will need to actively participate in the process he initiated by striking
the Homelessness Task Force. Strong leadership is required to ensure that the recommendations
of the Task Force get implemented. Strong leadership is also needed to revive the
flagging commitment of the provincial and federal levels of government in their areas
of responsibility (social housing stock, employment training etc.). Continued Megacity
support for innovative housing programs, for income maintenance programs and for
improved access to health and mental health services is essential.
Summary
The
recommendations of the Pathways to Homelessness Advisory group reflect the broad
and inter-connected needs of persons who are homeless. They also bespeak the necessity
of cooperation and planning between different interest groups and various government
agencies. This is the most consistent theme of previous documents focusing on the
needs of the homeless population. The findings of the Pathways Project offer additional
empirical evidence underlining the need for constructive alliances to both help those
who are homeless and prevent others from becoming so.