Summary

We began this chapter on Mental Health with the age-old riddle of, what comes first the chicken or the egg? This riddle is often posed in relation to mental illness and homelessness because the two are so closely intertwined that it can be challenging to tease them apart. Often people experience poor mental health that results in housing loss and then gets exacerbated by the stress and trauma of homelessness. Throughout this chapter, we considered the prevalence, reasons, and possible treatments for people living with mental illness and experiencing homelessness.

At the start of the chapter, we introduced you to the composite characters Arin and Tanzia who were each experiencing homelessness in their own unique way. The scenarios were presented as an entry point for thinking about the complexity of homelessness as it relates to poor mental health. We returned to these individuals’ stories again at the end to demonstrate how they can help us understand the foundational concepts of being trauma-informed, person-centred, socially inclusive, and situated within the social determinants of health as critical for understanding homelessness in Canada.

We then asked you to consider three questions along the way, with the guidance of leading homelessness researchers.

First we asked, “What is the prevalence of mental health issues for people who experience homelessness?” Here we saw a diverse range of estimates that emerge from research using different parameters for inclusion. Should we consider only people with diagnosed mental illness or should we open it up and also consider people who are generally mentally unwell? These factors shape estimates, that range as low as 10% to as high as 100%. What we know is that the rates of mental health issues are significantly higher for people experiencing homelessness than amongst those who are housed, and that despite this, their access to mental health services remains low. Homelessness is a traumatic experience that makes it nearly impossible to maintain mental wellness.

Next we asked, “Why is mental illness so high among people experiencing homelessness?” We began with the important message that people who experience homelessness live in a constant state of crisis, having to meet their daily needs without the security of a reliable place to live. The mass number of people living with mental illness and navigating service agencies was traced to historical decisions such as the deinstitutionalization of psychiatric patients at a time when cuts were being made to social housing and income supports. We saw through this section that people who experience homelessness are often isolated, lonely, and report a lack of meaningful activities in their lives. These feelings can lead to poor mental health and greatly increase the risk of suicidal ideation and suicide attempts, particularly amongst young people, and markedly those who identify as LGBTQ2S+. When people lose their housing, they often also lose the identities associated with it, like being married, a parent, or employed, which get replaced by discriminatory and harmful labels. While people who experience homelessness often show remarkable personal strength in these situations, the institutions within our society still have a long way to go in providing coordinated and integrated mental health services for them.

Finally, we asked, “What are the treatments that improve mental health, and do they work?” Throughout this chapter, we discussed many difficult realities of life for people who experience homelessness. The trauma and daily stressors of operating in a constant state of crisis create the conditions for poor mental health and possible mental illness diagnoses. We concluded, in this this last section, by taking a more hopeful approach and looking at some of the interventions that have shown promise for this population. Most notably, we saw that building relationships, the community reinforcement approach and motivational enhancement therapy, mindfulness practice and cognitive behavioural therapy, dialectical behaviour therapy, community-based population mental health interventions, and recovery education centres are all approaches that can help people who experience homelessness and are living with mental illness. Regardless of which method is used, we saw that what matters most is that it is tailored to the needs of the client and progresses at their own pace. In the final part of this section, we saw how Housing First offers people with mental illness the opportunity to identify and work on their mental health needs after becoming securely housed, through the assistance of either intensive case management or assertive community treatment. We ended this section – and will end this chapter – with the critical message that housing is the most fundamental social determinant of health and mental health. If we want to help people become mentally well, we need to begin with ensuring they have a safe and secure place in which to recover.