Like all of the questions in this book, this question does not have a simple answer. What treatments work will depend on many variables, such as an individual’s personal history, what diagnoses(s) they have, and their willingness or ability to engage in treatment. Therefore, we cannot point to one approach and say it is the answer for everyone. What we can say is that there are a range of approaches that may work for people individually or in combination and that the foundation of success must be based on social determinants, such as having housing, proper nutrition, adequate rest, and a livable income. As we have seen, social support is also a critical piece of mental wellness for people experiencing homelessness and developing intimate relationships can help contribute to their recovery (Ecker, Cherner, Rae, & Czechowski, 2018).

The research literature points to a number of mental health approaches that have shown some effectiveness in helping people experiencing homelessness and housing vulnerability to improve their well-being. Brakenhoff and Slesnick (2018) for instance have argued that the community reinforcement approach and motivational enhancement therapy have been shown to be among the most promising interventions for mental illness and substance use problems. The community reinforcement approach is guided by the assumption that people continue to use substances because they are reinforced to do so through their environment, and that people can recover if they shift the focus such that non-substance using behaviours are more reinforcing (Brakenhoff & Slesnick, 2018). Motivational enhancement therapy is premised on the belief that everyone has the ability to change but that people have different levels of motivation, and so this intervention is structured to encourage behavioural change by increasing people’s motivation (Brakenhoff & Slesnick, 2018).

Mindfulness practice has grown from cognitive behavioural approaches and helps train people to identify their automatic thinking patterns and then to challenge them (Brown & Bender, 2018). Individuals can improve their mental well-being and promote more adaptive functioning by changing their negative automatic thoughts and improving their emotions and behaviours (Brown & Bender, 2018). Another related evidence-based intervention that has shown promise with people experiencing homelessness and mental illness is dialectical behaviour therapy (DBT), which is designed to treat a range of conditions including mood and anxiety disorders, self-harm practices, and suicidality (McCay & Aiello, 2018). Dialectical behaviour therapy is premised on the notion that conditions arise through inadequate emotion regulation due to biological factors and/or interpersonal circumstances like exposure to trauma (McCay & Aiello, 2018).

The dialectical behaviour therapy approach is comprised of cognitive behavioural approaches and acceptance-based practices that come from the Zen school of Buddhism, emphasizing the need for therapeutic acceptance, and a focus on changing maladaptive coping mechanisms (McCay & Aiello, 2018). In the video that follows Dr. Marsha Linehan, creator of the dialectical behaviour therapy approach, describes how she draws upon Zen practice to help people develop core mindfulness skills.

Population mental health interventions that exist in the community have not been documented in the same way as controlled public health interventions, but we can extract findings from quasi-experimental interventions that meet scientific standards while also showing promise of positive impacts on mental health equity (Simpson, Furlong, & Jetha, 2018). For instance, while there is limited research on the personal recovery needs of community-dwelling Canadians with mental illness, one multi-site cross-sectional study has shown that adults who receive community-based mental health supports in an urban setting reported high levels of empowerment, hope, and optimism about the future (Barbic et al., 2018). However, the same participants also reported low levels of perceived connectedness, identity, and meaning in life, suggesting that recovery-oriented patient report outcomes offer a complex picture of how these patients view their well-being and treatment needs (Barbic et al., 2018).

An increasingly recognized approach for promoting mental wellness in the community is that of recovery education centres, like the Supporting Transitions and Recovery Learning Centre in Toronto (Durbin et al., 2019). Reid et al., (2020) conducted a qualitative study with 20 people involved in the recovery education centre and learned that the process of recovery was supported through factors such as a judgement-free environment, supportive relationships, mutuality and role modelling, deconstruction of self-stigma, and reclaiming one’s power (Reid et al., 2020). As we have seen in the previous section, people who experience homelessness often feel isolated, discriminated against, and as though they have lost their sense of identity. The recovery education centre helped these individuals to improve their self-esteem, confidence, sense of empowerment, interpersonal skills, and ability to self-advocate (Reid et al., 2020).

Dr. Sean Kidd: What are the treatments that improve mental health, and do they work?

In this video, Dr. Sean Kidd discusses the complexity of treating people who are experiencing homelessness and have mental health problems. He explains that while the treatments are the same, there are fundamental conditions that need to be met for the person to be able to engage in treatment. He notes that these conditions can be met in different sequences, depending on the person’s needs but may include factors such as safe and secure housing, nutritional security, medication, and supportive social contacts. Dr. Kidd explains that while the foundational pieces are being put in place, it is possible to have early conversations to prepare people for treatments such as psychosocial interventions, supported employment, cognitive behavioral therapy, and psychotherapy. He argues that what is needed is careful assessment of the spectrum of factors to tailor a person’s supports to their needs, provided in an order that works for them. He concludes by highlighting the under-funded nature of mental health care for people experiencing homelessness and noting that funding greatly influences what we can offer and its effectiveness. This video is 5:43 in length and has closed captions available in English.

Housing in itself is a critical social determinant of health and mental health. However, what Housing First offers is an additional level of wrap-around supports based on people’s own self-identified needs. This means, for example, that if a person believes their substance use is a problem in their lives they can request support for substance use, or if they wish to return to school and earn a higher education they can request education supports. Research has shown that employment is associated with an increase in recovery for some people in the context of Housing First (Yazdani et al., 2020). The key aspect is that people have choice not only in their housing but in the type of supports they receive. It is important that residents within these housing programs be able to foster their own pathways to recovery with the recognition (as we so often say throughout this book) that when it comes to housing and supports one size does not fit all (Montgomery, Mossey, & McCauley, 2019).

In the chapter on Social Work we examine the role of case management in supporting people who are experiencing homelessness. Within the Housing First approach, there are two models of case management that are commonly used – these include assertive community treatment [ACT] and intensive case management [ICM]. Both approaches are designed to assist people who have high levels of support needs. According to the ICM Toolkit developed by Employment and Social Development Canada (2018), “Providing Housing First intensive case management to high acuity clients is a complex process. Each agency, area and client population has its own unique strengths and challenges, and each program will need to be flexible, innovative and responsive. Housing First intensive case management is a constantly changing process, with ongoing learning at every stage. This important work provides vulnerable individuals with housing, support, dignity and safety, and will empower them to live the best life possible and reach their inherent potential” (pg. 38).

Intensive case management provides a higher level of on-going support compared to the more traditional case management approach discussed in the chapter on Social Work. These case managers will help people who have severe mental illness and/or addiction issues to become and remain stably housed by assisting with their daily support needs. For example, an intensive case manager may accompany a person to medical appointments, help them create a budget for their household, go grocery shopping with them, and help them to ensure their home is properly cared for. They may also need to advocate for individuals who have severe mental illness and as result of previous behaviour have been banned from service agencies or parts of the community. Their key role is to offer on-going and (as the name suggests) intensive levels of support. The following video from the Canadian Mental Health Association of Toronto shows how they use intensive case management to support clients in their Housing First program.

Dr. Nick Kerman: What are the treatments that improve mental health, and do they work?

In this video, Dr. Nick Kerman explains that there are a wide range of treatments for mental health, that generally fall into the categories of individual treatments and medication. He notes that within the context of homelessness, it is important to recognize that the best way to promote wellness and treat mental health problems is to get people into safe and secure housing. Once housed, Dr. Kerman explains that assertive community treatment [ACT] and intensive case management [ICM] are two evidence-based approaches that improve wellness, depending on the person’s level of support needs. Dr. Kerman concludes that when talking about mental wellness it is important to recognize the importance of preventing mental health problems and promoting positive well-being. This video is 4:25 in length and has closed captions available in English.

Dr. Tim Aubry: What are the treatments that improve mental health, and do they work?

In this video, Dr. Tim Aubry explains that community mental health treatments and programs are proven to be effective for people experiencing homelessness who have mental health issues. He identifies assertive community treatment [ACT] and intensive case management [ICM] as the two approaches that most effectively support people to exit chronic homelessness, with the approach determined based on the person’s level of support needs. Dr. Aubry notes that these approaches have a long history of demonstrated effectiveness. When paired with Housing First supports, such as rent supplements and housing choice, they show success rates as high as 85% – 90%. This video is 3:52 in length and has closed captions available in English.

In this section we examined the question of what treatments exist to help people and whether they are effective for people experiencing homelessness. We found through the literature and researcher interviews that there are many different approaches that have shown promise. Most notably these include the community reinforcement approach and motivational enhancement therapy (Brakenhoff & Slesnick, 2018), mindfulness practice and cognitive behavioural therapy (Brown & Bender, 2018), dialectical behaviour therapy (McCay & Aiello, 2018), community-based population mental health interventions (Barbic et al., 2018; Simpson et al., 2018), and recovery education centres (Durbin et al., 2019; Reid et al., 2020). These are all clinical interventions that can help people who experience homelessness and are living with mental illness.

Along the way, we heard the message that what matters more than the specific approach used, is that the intervention is tailored to the expressed needs of the individual. People may be at different levels of willingness and ability to engage in therapeutic practices because of factors like inadequate housing, a lack of rest, poor nutrition, and low social support. These are key reasons why we have heard – and argue strongly – that housing is a primary social determinant of health that needs to be addressed for people to get well. This is the premise of Housing First, which connects people with housing and then provides support through either intensive case management or assertive community treatment, depending on the needs and wishes of the client.

We have seen throughout this chapter that people who experience homelessness often have poor mental health. This may begin while they are housed or may be the result of the trauma and stress that characterize many people’s experiences of homelessness. While there are different pathways to recovery, and they must be traversed at each individual’s own speed, it is promising to know that there are interventions and approaches that have shown success. It is important that we continue to seek ways to improve the mental health of people experiencing homelessness, and this must begin with providing safe, secure, and affordable housing.