3. What are the treatments that improve mental health, and do they work?

Homelessness is always a difficult issue to consider, and this chapter is particularly challenging because it highlights all the daily struggles that lead to poor mental health outcomes. At this point we have seen that there are high rates of mental health issues, with estimates as high as 100% of people who experience homelessness being affected. We have seen that these high rates are caused by trauma, discrimination, social isolation, loss of identity, and a lack of mental health services to support people. This is a dire picture. However, people do recover from mental illness and from homelessness so the discussion cannot end there. Instead, we need to consider what approaches work to treat mental illness and to help improve mental well-being overall. We invite you now to consider what you have learned about the causes of poor mental health and see if you have ideas on what treatments might help. You may use the space below to record your thoughts. 

 

How to complete this activity and save your work: Type your response to the question in the box below. When you are done answering the question navigate to the ‘Export’ page to download and save your response. If you prefer to work in a Word document offline you can skip right to the Export section and download a Word document with this question there.

 

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).

aqua icon for website linkYou can learn more about this study from this research snapshot!

Research Snapshot Stergiopoulos et al.pdf (camh.ca) 

There are many interventions that have shown promising outcomes for people who are experiencing homelessness and impacted by mental illness. The research literature discussed above points to 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 interventions that have shown some effectiveness in helping people experiencing homelessness with mental illness. 

 

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Brakenhoff and Slesnick (2018) importantly note that, “Regardless of the chosen intervention, service providers must ensure youth who are homeless are given the space to identify treatment goals that are meaningful to them. While progress may be slow given the extensive challenges these youth experience, research has demonstrated that with the right tools and support, change and behavioural improvement is possible, even for the most vulnerable youth” (pg.14). The need for individuals to set their own goals and their own pace is true for youth as well as for adults. In the next video, Dr. Sean Kidd discusses these interventions and the importance of tailoring the support to an individual’s self-identified needs in further detail. 

 

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.

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

  1. The mental health treatments that work are the same for people who experience homelessness as for those who are housed, but there are more complex considerations.
  2. There are a set of conditions upon which our standard interventions, such as psychotherapy, psychosocial interventions, and medications, are understood to work. The premise is that there are other conditions met, so that they can be effective, to improve that person’s life, make them feel better in mind and body, and more able to do stuff that they want to do.
    • For example, a person who has spent the night somewhere unsafe and is exhausted and hungry is not going to be mentally well enough for a treatment like Cognitive Behavioural Therapy.
  3. When addressing mental health challenges for people experiencing homelessness there is no one size fits all approach, but rather many different things that can be done as part of a complex intervention.
    • Helping a person to stabilize, making sure they have enough to eat, a safe place to sleep, and supportive social contacts are important.
    • Housing First can help provide shelter in a timely manner, without readiness requirements, to help the person achieve the level of stability needed.
    • Some people may be dealing with very challenging symptoms and need medication as an important initial step.
  4. While the foundational pieces are being put in place, it is sometimes possible to have early conversations to help people get ready for future treatments, such as psychosocial interventions, supported employment, cognitive behavioural therapy, and psychotherapy.
  5. What is needed is a careful assessment of the spectrum of factors, to tailor a person’s supports to their needs, and offer them in an order that works for them.
  6. The mental health sector for people experiencing homelessness is profoundly underfunded. Funding greatly influences what we can offer and its effectiveness.
    • In physical medicine there is greater use of algorithms to direct the course of treatment for specific conditions.
    • In mental health treatments for people experiencing homelessness, we often know what we should be doing, what we can do, and what works. We just cannot do it because of the lack of people to do the assessments and treatments, in a sequence that recognizes the complex issues.

 

The lack of funding for mental health systems in Canada reduces the capacity for people who need treatment. Dr. Kerman and Dr. Kidd (2020) have argued that embedding mental health recovery within a quality improvement framework would increase leverage for systems change and create advancements in recovery practice. They point to the Triple Aim, with the goals of improving healthcare outcomes, quality, and costs as all being relevant within the context of mental health systems and in working towards the integration of a social determinants of health lens (Kerman & Kidd, 2020). We have identified the social determinants of health as a foundational principle throughout this book because they are central for understanding what contributes to people’s health and well-being on a broad level. Certainly, one of the most important social determinants is whether people have safe, secure, and affordable housing. We present the next video about “My Place Supportive Housing in Vernon, British Columbia” to demonstrate the critical importance of housing as a social determinant of mental health. As you watch it, we encourage you to reflect upon how housing has improved the mental well-being of the tenants in the video. 

 

 

In the chapter on Politics, Policy, & Housing in Canada we looked at the rise of Housing First as a targeted intervention for people who have severe mental illness and experience chronic homelessness. The underlying idea is that people need housing as a starting point, without having to demonstrate they have met housing-readiness requirements. Advocates had been arguing for this approach since the 1980s but the program as we know it today was shaped by Dr. Sam Tsemberis and Pathways to Housing in New York. In Canada, the effectiveness of Housing First was evaluated by a multi-year, multi-site study known as the “At Home / Chez Soi” project funded through the Mental Health Commission of Canada (Goering et al., 2014). Housing First has been widely adopted (and at times adapted) as a means of housing people with mental illness. As a brief refresher on Housing First, we invite you to watch this video created by the Homeless Hub that explains how this approach is recovery-oriented and implemented to help people experiencing homelessness move rapidly into permanent housing. 

 

 

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.

 

 

In comparison, assertive community treatment is similarly designed to assist people who have high acuity and complex support needs but is conducted as a team-based approach. In this model, a diverse team of professionals works to support the various needs clients may have. The principles of an assertive community treatment team include that they work collaboratively to deliver mental health services to a group of consumers, that consumer needs direct the delivery of care, service is targeted to the population most in need, the team works assertively and flexibly to provide outreach rather than expecting consumers to come to services, and the treatment is designed to prevent hospitalization and help consumers live successfully in the community (Government of British Columbia, n.d.). The following video was created by Gwen Haworth and shows how assertive community treatment is used as a model of care in RainCity Housing’s program in Vancouver. 

 


What do you think?

human head with light bulb as brain graphicIntensive case managers work with a smaller caseload of clients than traditional case managers and provide their clients with more frequent and on-going support. Assertive community treatment is done by a team of diverse professionals who provide different types of support to clients who have complex needs in the community. What do you think the benefits of each approach are? Why do you think some Housing First programs use intensive case management while others use assertive community treatment? 


 

Dr. Nick Kerman has conducted research on Housing First and mental health recovery. He and his team examined predictors of recovery for people with mental illness using longitudinal Housing First data and found that the most effective interventions were aimed at preventing chronic homelessness, strengthening social networks, increasing community involvement, and providing case management services (Kerman, Sylvestre, Aubry, & SchĂźtz, 2019). Dr. Kerman and his team further found through a multi-site randomized controlled trial that Housing First is effective in helping people with mental illness, who frequently use emergency hospital services, to become stably housed (Kerman et al., 2020). In the next video, Dr. Kerman discusses the evidence base and role of intensive case management and assertive community treatment in helping people with mental illness move into secure housing. 

 

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.

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

  1. There are a wide range of treatments for mental health problems, but they often fall into two categories of individual treatments, such as counselling, and medication.
  2. In 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.
  3. Once people are housed, there are different intervention approaches that can be beneficial based on their support needs.
    • Assertive community treatment [ACT] is an evidence-based intervention that works for people with higher levels of support needs.
      • ACT is done by a multi-disciplinary team that goes into the community to meet people where they are at and connect them to services and supports.
      • These teams commonly involve a range of professionals including nurses, occupational therapists, social workers, psychiatrists, peer support workers, psychologists, and addictions counselors.
      • This support model operates 24/7, which is beneficial for people with serious mental illness and/or other complex needs.
    • Intensive case management [ICM] has been shown to be beneficial for individuals who have less complex support needs.
      • In ICM a person who is experiencing homelessness or is newly housed is paired with one or more case managers who help facilitate connections to other providers and services in the community.
      • ICM also supports clients in daily living skills, such as budgeting, grocery shopping, cooking, and attending appointments.
      • ICM has been shown to be effective in helping people stay housed and live the lives they want in the community.
  4. When talking about mental wellness it is important to recognize the importance of preventing mental health problems and promoting positive well-being.
    • We need to know more about how to address the limits in our public systems and help people thrive after exiting homelessness.

 

Ponka et al., (2020) have conducted a systematic review of the effectiveness and cost-effectiveness of different case management intervention styles on the health and social outcomes for people experiencing homelessness. Among their conclusions was that intensive case management significantly reduced the number of days a person spent homeless, and that assertive community treatment had promising effects on housing stability and was more cost-effective than more traditional case management styles. We invite you now to learn more about how these different case management styles compare for helping people with mental illness move out of homelessness, in this section’s featured reading below. 


Featured Reading:

open book graphicPonka, D., Agbata, E., Kendall, C., Stergiopoulos, V., Mendonca, O., Magwood, O… & Pottie, K. (2020). The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review. PLoS ONE, 15(4): e0230896. 


Housing is a key social determinant for health and mental health. You may be sick of us saying that, but we persist in repeating ourselves because it is true, and we want you to remember it. We have seen that Housing First has become an increasingly popular approach for connecting people with housing and offering supports through intensive case management or assertive community treatment. Dr. Tim Aubry was a lead researcher on the original At Home / Chez Soi study and has continued to conduct evaluations of the Housing First approach. We conclude this section with a video of Dr. Aubry discussing what the research shows about the effectiveness of Housing First for helping people who have mental health issues become securely housed. 

 

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.

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

  1. Community mental health treatments and programs are proven to be effective for people experiencing homelessness who also have mental health issues.
  2. Assertive community treatment [ACT] is the program with the most effective results for people experiencing chronic homelessness.
    • ACT was initially created to help people leave psychiatric institutions, as part of the deinstitutionalization movement, and is now a standard part of Housing First.
    • ACT is a wrap-around service for people with high level needs, that is inter-disciplinary, and involves helping people set goals and connect with mental health and physical health services.
  3. Intensive case management [ICM] is another community mental health approach that is effective for people with lower support needs.
    • In this model, one or more case managers act as a person’s primary support.
  4. Even before they were used in Housing First, research showed these two approaches were effective in helping people successfully exit homelessness.
    • Combined with Housing First supports, such as rent supplements and ensuring housing meets people’s needs, these interventions are up to 85% to 90% effective at helping people with mental illness exit chronic homelessness.

 

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.

 

Podcast: What are the treatments, and do they work? (14:54)

Click the link below to listen to all of the researchers answer the question “What are the treatments, and do they work?” in audio format on our podcast!

 


 

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Understanding Homelessness in Canada Copyright © 2022 by Kristy Buccieri, James Davy, Cyndi Gilmer, and Nicole Whitmore is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, except where otherwise noted.

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