Dr. Tim Aubry: Why is mental illness so high among people experiencing homelessness?

In this video, Dr. Tim Aubry explains that some people are more vulnerable to becoming homeless because of their mental health problems. He notes that once a person experiences homelessness, their mental health often gets worse due to the poor living conditions. Dr. Aubry notes that part of the way we think about mental health today involves substance use, which is more commonly related to single adult and youth homelessness, than family homelessness. He argues that mental illness is high among people experiencing homelessness because they are in a crisis situation, trying to survive every day, and they have the stress and uncertainty of not knowing how they will get out. This video is 3:21 in length and has closed captions available in English.

Dr. Nick Kerman: Why is mental illness so high among people experiencing homelessness?

In this video Dr. Nick Kerman explains how the history of deinstitutionalization in Canada in the 1970s and 1980s led to the closure of psychiatric hospitals, resulting in a large number of people who had nowhere to go for support. He notes that the effects of these policy decisions have been seen through decades of over-representation of people with serious mental illness in the homeless population. Dr. Kerman discusses the complex relationship between mental illness and homelessness, noting that mental illness can be a pathway into homelessness but can also be a consequence of the victimization and trauma that often result from homelessness. Dr. Kerman concludes by noting that two of the basic building blocks of mental health – sleep and nutrition – are often compromised as well for people who are sleeping in shelters on an ongoing basis. This video is 6:00 in length and has closed captions available in English.

Dr. Cheryl Forchuk: Why is mental illness so high among people who experience homelessness?

In this video, filmed at a hospital during the COVID-19 pandemic, Dr. Cheryl Forchuk explains that the question of why mental illness is high amongst people experiencing homelessness is complex because it is a “chicken and egg” scenario of considering what comes first. She notes that we need to consider the perfect storm of policy changes that occurred when the Federal government withdrew from funding social housing, income supports were reduced, and deinstitutionalization closed psychiatric facilities with no housing provisions. Dr. Forchuk argues that people who experience mental illness are the most discriminated and stigmatized group in society and that people who become homeless often lack the social supports that might keep others with the same issues housed. Dr. Forchuk concludes by noting that addiction issues can also be a “chicken and egg” situation, such that if a person does not have an addiction issue prior to homelessness, they are likely to have one afterward. This video is 3:21 in length and has closed captions available in English.

Social isolation and loneliness are both causes and consequences of being mentally unwell. They are also risk factors for suicidal ideation (i.e. considering suicide) and for committing suicide. This is evident from a body of research on homelessness and mental health. For instance, a study of 455 people who were formerly or currently homeless showed that 16% reported suicidal ideation and 7% had attempted suicide (Gentil, Grenier, & Fleury, 2021). The same study showed a complex association with mental health disorders and substance use. Notably, suicidal ideation was higher for those with generalized anxiety disorder, substance use disorders, and schizophrenia spectrum and other psychotic disorders (Gentil et al., 2021). Higher rates of suicide attempts were reported by those with higher functional disability, more frequent hospitalizations, and those with substance use and mental health disorders (Gentil et al., 2021).

Amongst youth, the risks of suicidal ideation and attempts have been found to be even higher. Researchers conducting the first national survey on youth homelessness collected 1,103 responses from young people accessing homelessness services in 42 communities across Canada and found that 42% reported at least one suicide attempt and 85% were in high psychological distress (Kidd, Gaetz, & O’Grady, 2017). These risks were particularly evident amongst those who experienced homelessness for the first time at an early age, were female gender, and identified as lesbian, gay, bisexual, transgender, queer or questioning, or two-spirit [LGBTQ2S+] (Kidd et al., 2017). The second survey, conducted four years later, included 1,375 youth accessing homelessness services in 49 communities and found that 35% reported at least one suicide attempt and 33% had a drug overdose that required hospitalization (Kidd et al., 2021). Dr. Kaitlin Schwan was a researcher on the national youth homelessness survey project and lead author on a proposal for improving mental health care for these young people in Canada (Schwan, Kidd, Gaetz, O’Grady, & Redman, 2017). Here she speaks more about the findings and the implications homelessness has for the mental health of young people.

Dr. Kaitlin Schwan: The stress of youth homelessness

In this video, Dr. Kaitlin Schwan discusses the results from a survey conducted by the Canadian Observatory on Homelessness with 1,100 youth experiencing homelessness across Canada. She notes that many young people report huge increases in health challenges, such as lacking a place to rest and wash, experiencing high rates of stress, and not recovering from illness as quickly. Dr. Schwan explains that this survey showed high rates of nutritional vulnerability and that 30% of respondents indicated they did not have access to clean water on a daily basis. She further notes that mental health and addictions challenges were found to be high, with 42% having attempted suicide and 85% in high symptom distress categories. Dr. Schwan explains that despite public misconceptions, these youth are much more likely to be the victims of crime than the offenders. She concludes by arguing that all of these conditions make it difficult for young people to be healthy and well, which is why we need to focus on successfully exiting them out of homelessness and into secure housing. This video is 4:31 in length and has closed captions available in English.

Dr. Alex Abramovich: LGBTQ2S youth, stigma, and mental health supports

In this video, Dr. Alex Abramovich explains that LGBTQ2S+ youth experiencing homelessness face high levels of stress and stigma, which has a negative effect on their mental health. He notes that amongst this population there are significantly higher rates of depression, anxiety, substance use, suicidality, and suicide completion compared to heterosexual and cisgender youth. Dr. Abramovich is clear to note that these mental health challenges stem from the daily stigma, discrimination, and violence these youth experience in society, and not from their gender or sexual identities. He concludes by arguing that more specialized mental health assessments and supports are needed for this population of young people. This video is 1:37 in length and has closed captions available in English.

Social support is key to people’s well-being. Without a strong network of friends, family, or community members, individuals often feel isolated and lonely. This message was clear in a study conducted with 76 youth experiencing homelessness and residing across 8 shelters (Gauvin, Labelle, Daigle, Breton, & Houle, 2019). Researchers found that youth who had not attempted suicide perceived more social support (both tangible assistance and guidance) whereas those who had attempted suicide reported using more non-productive coping strategies like keeping to themselves, isolation, and self-blame (Gauvin et al., 2019). Humans are social beings and having others to turn to is critically important for mental wellness. There is a pervasive and deeply harmful stigma associated with experiencing homelessness that serves to keep people isolated, subsequently decreasing their already poor mental health.

Even when people move out of homelessness and into secure housing, one of the biggest challenges they continue to face is reintegrating into the community around them. Research with youth transitioning out of homelessness in Toronto demonstrates that as young people work through this transition and seek to be more socially integrated, they grapple with their identity (Thulien, Gastaldo, McCay, & Hwang, 2019). This sense of inclusion can be challenging as they follow a non-linear path, from the street to social integration, that can leave them feeling bogged down, confused, and exhausted by the competing aims of feeling integrated and trying to meet their basic needs (Thulien, Gastaldo, Hwang, & McCay, 2018). Dr. Naomi Thulien and her team have studied the pathways young people take in exiting homelessness and the mental struggles of trying to feel connected and socially included through the process. In the next video, Dr. Thulien discusses this research further.

Dr. Naomi Thulien: Loneliness, social isolation, and relationship building

In this video, Dr. Naomi Thulien argues that relationship building is critically important in supporting people experiencing homelessness and should be actively cultivated. Without trusting relationships, she notes, support can unravel. Dr. Thulien explains that loneliness and boredom are linked to homelessness, poor mental health, and addictions in an existential kind of way. She notes that trying to keep busy is a reminder of how socially isolated people can be and changes the way they experience the passing of time. Dr. Thulien concludes that housing people is important, but we must also ensure they have meaningful activities to fill their time. This video is 7:08 in length and has closed captions available in English.

How well integrated a person feels within their community is dependent on a range of factors related to the housing itself, such as the neighbourhood safety and location, whether people are using substances, and the housing quality (Ecker & Aubry, 2017). However, community integration can also be related to personal factors, such as whether a person feels they have meaningful activity in which to engage that helps prevent boredom (Marshall, Keogh-Lim, Koop, Barbic, & Gewurtz, 2020a). In the preceding video, Dr. Thulien spoke about the kind of existential boredom that people can experience once they are housed but have no meaningful activities to fill their time. There is limited research on boredom and homelessness, but a scoping review has found themes related to coping strategies, the impact of boredom, the environment as a determinant, and possible interventions (Marshall et al., 2020b).

Boredom is something we all inevitably face. You may have found yourself at times having nothing to do and wondering how to fill the time or, dare we say it, sitting through a class that does not hold your interest (of course not this one!). This kind of boredom is common and not what we mean here. Many people who experience homelessness do not have activities, like work, to fill their time. They also often lack money to engage in leisure activities. With endless time, limited social contacts, and no money to spend, the hours stretch on. People may continue to use service agencies, and many spend time volunteering, but these require transportation which also costs money.

Dr. Sean Kidd: Why is mental illness so high among people who experience homelessness?

In this video, Dr. Sean Kidd explains that people have different experiences and trajectories of homelessness, but that a common factor driving people’s physical and mental health outcomes is the social determinants of health. He notes that for many people who experience homelessness, their challenges began while they were housed. For youth this is often in the form of trauma or neglect within the home or school. For adults, this may be related to job loss, divorce, and/or mental health and addictions issues. Dr. Kidd notes that when a person loses their housing they also often lose their identities such as tied to being employed, someone’s spouse, or a homeowner. These identities may be replaced with assumptions that they are now dangerous, lazy, and/or a criminal. These labels create new mental health challenges that lead to a vicious cycle. Dr. Kidd concludes that this cycle demonstrates the importance of homelessness prevention, so people’s problems do not become compounded. This video is 4:53 in length and has closed captions available in English.

Dr. John Ecker: Mental health challenges and supports

In this video, Dr. John Ecker explains that mental health challenges can happen prior to homelessness, as a result of homelessness, or in combination. He notes that structural and systemic failures need to be considered, such as inadequate mental health and financial supports, as well as the lack of coordinated discharge practices from hospital. Dr. Ecker explains that experiencing homelessness can be traumatic and have negative consequences for physical and mental health. He concludes by noting that we must also recognize the strength and resourcefulness of people who experience homelessness, and the importance of the social bonds they create with others, which can help buffer mental health challenges. This video is 3:18 in length and has closed captions available in English.

People who experience homelessness face tremendous adversity but still show remarkable resilience, strength, and positivity despite these hardships (Shankar, Gogosis, Palepu, Gadermann, & Hwang, 2019). We set out in this section to identify why mental illness is so high among this population and found that there are many complex reasons. While we may be tempted to ask the chicken and egg question of what comes first, the reality for many people is that they cannot be so easily teased apart. People may be mentally unwell and have difficulties maintaining their housing as a result. Once in shelter, moving between temporary accommodations, or on the street, the stress of living in a constant state of crisis makes their mental health worse.

Historically when people were mentally ill they would be sent to live in an asylum. These places, while deeply problematic, created a new problem when they closed in the 1970s and 1980s. Deinstitutionalization occurred as they closed their doors and moved people out into the community with the notion that they could receive pharmaceuticals and mental health treatment outside the hospitals. However, this occurred at the same time the Federal government stopped funding new social housing, creating a lack of affordable places for these patients to live, and Provincial governments decreased the income supports they would provide. These policies and decisions created a situation that left mass numbers of people unhoused, living in deep poverty, and without access to the same levels of mental health services.

This sense of disconnection from society and social supports has carried through to the current day. Having people that one can count on – whether family, friends, or support workers – is critical to good mental health. However, when people experience homelessness they often feel isolated and cut off from others. As we saw in this section, this social exclusion leads to high rates of suicidal ideation and suicide attempts. This is particularly true for young people, with those who identify as LGBTQ2S+ at the highest risk. People who experience homelessness often feel a deep sense of loneliness and express the need to find meaningful activities to fill their time. The sense of boredom that accompanies homelessness, and which follows people even after they are housed, can weigh heavily on their minds, and ultimately threaten their housing security.

When people lose their housing they also lose the sense of identity that is tied into it, like being a homeowner, spouse, parent, or worker in a particular job. Not only do people lose the identities they have, but they are often substituted for stereotypes such as that the person must be a criminal or dangerous because they are homeless. The loss of identity and the discrimination that people face is a key reason why mental illness is so high among this population. In the time since the deinstitutionalization movement, we have continued to see institutional failures, yet amidst these conditions, many people who experience homelessness demonstrate remarkable personal strength. The question we need to ask is not what comes first, mental illness or homelessness, but rather how we can help make both better so that we do not need to wonder at all.