Mental illness is strongly related to issues with housing and problems with housing
stability. Around 30% to 50% of homeless people have mental illness, and many
suffer from disorders that cause severe dysfunction, such as psychoses, acute distress,
and personality disorders. In 20% of the homeless, mental illness co-occurs with
substance abuse problems, and many people find themselves without reliable housing
after being deinstitutionalized (Scott, 1993). Adults with serious mental illness are 10
to 20 times more likely to experience an unstable housing situation and homelessness,
and substance abuse exacerbates that risk (Kuno, Rothbard, Averyt, & Culhane,
2000).
Housing issues and mental health have a close, two-way relationships. It’s not just
about the homelessness but also about living in an unstable and an unsafe
environment that can make the individual’s mental health worse and serve as a
constant source of stress.
Housing First approaches have tried to address these concerns by offering housing
with options for treatment and permanent rather than temporary residency options, so
the person has long-term stability (Gabriellan et al., 2018). Before examining the
positive impact of programs that provide housing alongside treatment, it’s worth
examining what happens when this is not done.
Many services provide support for individuals struggling with mental health issues
and housing issues as well. While there are resources to support individuals in
precarious situations, many of them fail to help individuals. As mentioned above, one
of the causes of homelessness is deinstitutionalization where the person is released
from the hospital, a rehabilitation facility, or a prison but have no place to go instead
(Scott, 1993). Many individuals with mental illness are not able to stay in programs
that support housing initiatives, often going to prison or becoming homeless, or
maintain low rates of social integration (Gabriellan et al., 2018). Without housing, a
person is subject to a variety of negative influences that undermine their health and
make it difficult for them to recover, maintain a good health, and protect themselves.
Mentally ill people without proper housing can experience a worsening of their physical and mental health, be victims of violence, and more (Henwood et al., 2013)
In an unstable environment, a person cannot improve their lifestyle, take medication
reliably, watch their nutrition, and engage in other behaviors that can make their
condition better and reduce the risk of severe symptoms (AHURI, 2018).
In general, many countries identify a shortage of affordable long-term housing for
people with mental illness, which has led to people overstaying in mental hospitals or
lapsing/relapsing into homelessness (AHURI, 2018).
Housing issues have a bi-directional relationship with mental health issues. Mental
health problems can lead to a precarious housing situation and viceversa. People with
mental illness tend to have higher risk factors for issues that contribute to said
precariousness, such as domestic violence, family violence, unemployment, and more
(AHURI, 2018).
What can be achieved with secure housing? First, people can focus on treatment and
rehabilitation while they have their basic needs met. They can improve their well-
being and quality of life. A review of housing first programs for people with psychiatric disabilities found that housing programs for people with severe and persistent mental illness could achieve
large effects in terms of housing outcomes, significantly reducing the number of
homeless individuals. It also led to quicker and improvements in community
functioning and improved quality of life (Aubrey, Nelso, & Tsemberis, 2015).
Stable housing can offer alternatives to hospital-based environments and is more
sustainable on the long term. Community-based services better address the needs of
varying populations and help increase quality of life. They reduce stigmatization and
are more compliant with human rights and with a respect for the individual’s
autonomy. Community-based programs are associated with better treatment
adherence, lower clinical symptoms, more stability, and vocational rehabilitation
(Padmakar et al., 2020). Another review found that ensuring adequate housing should be a treatment priority, as providing stable, permanent housing reduces harm and enables people to seek treatment voluntarily. For severe mental illnesses, an unlimited length of stay is recommended because the issue is likely to be chronic and change with time. Quality
of life deteriorates when people are moved from housing that is appropriate to their
needs and capacities. Stable housing leads to reduced hospital stays and allows the
person to seek treatment when they need it and not try to work through the symptoms
on their own for fear of becoming homeless. Stable housing in individuals with
mental illness can reduce psychiatric symptoms and increase well-being, so this
should not be considered as an afterthought or after medication. The authors of the
review go further to suggest that stable housing provides the cornerstone for a
successful treatment, enabling the person with mental illness not just to survive but to
thrive, seeking new life skills program and treatment for other issues, such as
addiction (Dunn & Kyle, 2007).
Overall, this suggests that housing is important and improves outcomes for people
with mental illness. However, further research has suggested that simply providing
housing is not enough. It is also important to provide transitional options.
People who were given transitional housing were found to had fewer hospital and
crisis admissions and fewer homelessness days than those who did not. They were
also more likely to be employed and living independently a year after completing the
transitional program (Roman, McBride, & Osborne, 2006). Transitional housing also
was found to lead to more positive outcomes for drug use, criminal activity, and
depression. People who engaged in a transitional housing program were more likely
to be later living stably and less likely to be hospitalized (Roman, McBride, &
Osborne, 2006).
In general, it is clear that there is a research-based paradigm shift for offering people
with mental illness transitional and then stable housing within a community with the
necessary support. This appears to improve their outcomes, reduce homelessness, and
enhance quality of life and community integration.
There are significant issues in providing housing, and a common one is the issue of
people with comorbid disorders and substance abuse problems and those who do not
have substance abuse problems. Many of the existing community services and
housing options are oriented towards people with addiction, and it may be assumed
that many individuals who are homeless or require housing support also have some
form of substance abuse problem.
It is important to note that substance abuse problems have a high correlation with
schizophrenia, mood disorders (like depression and bipolar), and other disorders, in
particular, anxiety problems, phobias, and post-traumatic stress disorder. However, it
is true that there are also people who only show one of these conditions or who
present severe mental illness without having substance abuse problems and viceversa
(Quello et al., 2005, Winklbaur et al., 2006).
When a person with mental illness receives a diagnosis, having a comorbid illness can
make it more complicated. Comorbid disorders may be underdiagnosticated (Oiesvold
et al., 2013) and, as a result, not addressed in treatment and not taken into account
when finding a housing or support program for the patient. For example, a person
might be immediately diagnosed with a substance abuse problem but the comorbid
depression may not be noticed, so the person will not receive specific treatment as
they enter into a new system. In addition, they might be directed to services that are
focused on substance abuse problems but not really able to treat or accommodate the
special needs of a person with another diagnosis. So, the first issue that can be
identified in this case is that the person does not receive the treatment they need and
might help them.
If the problem is not diagnosed further down the road, there can be more issues in
regards to housing. The person might be offered options that are connected to the
diagnosis they do have and not provided with additional support or treatment to
address the needs for their other diagnosis, in particular, if they are placed in
transitional housing directed towards a specific population, for example, people with
substance abuse problems.
The second issue that might appear in this situation is that the person who does not
have a substance abuse problem might not be in the right community for them or the
best one. One of the useful aspects of supported and transitional housing is the
possibility to engage with other people who have similar experiences and hurdles.
Research suggests that a community of others can be significant for recovery, a
principle that helps form self-help and advocacy groups. Engaging with other people
who have a similar experience can help reduce symptoms, increase self-esteem,
facilitate recovery through building a community of people who understand and can
share ideas, advice, and informed support. Additionally, the individual can find
themselves also being able to help others, which is empowering (Markowitz, 2014).
This means that an individual placed with people who have different experiences and
needs might miss out, to a degree, on this community and see that what others feel or
think is not the same thing. Identifying comorbid disorders and taking them into
account can help people find a better housing option, as it is not the same thing to
have schizophrenia, to have a substance abuse problem, or to have both schizophrenia
and a substance abuse problem at the same time. It is important to note that different
problems require different types of support and treatment, and there are specific
evidence-based strategies for each disorder.
Housing and an adequate diagnosis and treatment are important for individuals with
mental health issues. Something that can be as significant is the support of their
families, especially in cases where the person is young.
People with severe mental illness identify families as a very significant presence in
their lives, more so even than mental health professionals, and this is true even among
individuals who live independently. Families can be instrumental in supporting
recovery by offering affection, belonging, emotional support, and an active
involvement. They can individuals with their independent living and be a positive
resource (Piat et al., 2011).
However, not all families are ready to assume the role of emotional support and be a
positive presence in the person’s life. Many individuals with mental health issues
have experienced abuse, neglect, or emotional difficulties within their families
(AHURI, 2018). If families want to become involved, they might first need to learn
new patterns and new ways of engaging with the person. The support of mental health
professionals can be especially important in this case through psychoeducation and
family therapy that changes the established dynamics and create better interactions.
Families might need to change to help the members with mental illness. If they are
motivated and willing to become involved, it is possible to help the person and
provide a lot of emotional support for recovery and supported living.
Mental illness may be chronic but it does not have to be severe. With the right
resources, stability, treatment, and support, individuals can live happier, healthier
lives and become independent. Quality of life can increase a lot for people who have
stable, long-term housing after a transitional program, who have the support of their
families, and who have received the correct diagnosis and treatment.
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