Quality of life

HOMELESSNESS
Accommodation is a fundamental need for people with a mental illness as for the rest of the community. Without adequate and safe accommodation, effective treatment and rehabilitation strategies cannot be implemented (Burdekin et al. 1993; Shepherd et al. 1996; 1997). Thus, it is essential that accommodation be considered a priority when addressing the needs of people with a mental illness. This quality of life section covers issues relating to homelessness and the provision of accommodation and related services.

Definitions of Homelessness
Primary Homelessness: people without any form of accommodation, i.e. people who live on the streets.

Secondary: people who frequently move from one temporary shelter to another (ie emergency accommodation, boarding houses and shelters, temporarily staying at family and friends places).

Tertiary: people who live in boarding houses on a medium to long-term basis.

(Parker et al. 2002)

Prevalence of homelessness for people with a mental illness
The true incidence of homelessness and the prevalence of people with serious mental illness among the homeless population is difficult to assess as the population tends to be transient. Studies vary in their reporting of incidence rates. For example, Breakey (1996) found that the incidence rate of homeless people with a mental illness was between 2% to 90%. However a recent report by Welsey Mission indicated that 75% of participants in their study who were living in Sydney had a mental illness (Robinson 1998). Within this mentally ill and homeless population, the report found that 29% had schizophrenia. In Robinson's words: "These figures should be contrasted with the prevalence among the general community which is 1%. That means homeless people are 29 times more likely to suffer the effects of schizophrenia than those in the general community" (p 3).

Studies in the United States indicate an even higher prevalence of mental illness among homeless people - up to 80 per cent (Lipton et al. 1983; Marcos et al. 1990). Studies in Britain report 30-50 per cent of homeless people experience mental illness, with schizophrenia being the most common diagnosis (Koegal et al. 1988).

Compounding problems associated with being homeless
There is a high prevalence of chronic and acute medical conditions in homeless people that can further compound the problems associated with mental illness in this population (Robinson 1998). A survey of homeless people in Sydney reported that 50 per cent had at least one chronic physical illness with one in eleven having hepatitis B or C (Robinson 1998). Other problems identified in extremely high rates among homeless people include drug and alcohol misuse, limited family or other supports, and trauma (100 per cent of homeless women and 91 per cent of homeless men have experienced a severe trauma including rape, assault or witnessing murder) (Robinson. 1998).

Impact of de-institutionalisation
Despite common belief, de-institutionalisation has not significantly contributed to the increase in homeless people with schizophrenia in Australia or overseas (Virgona et al. 1993). The reasons for reaching this conclusion are (i) relatively few homeless people with a mental illness have had prolonged hospitalisation (Meltzer et al. 1991) and (ii) it has been decreases in housing and income that have contributed to an increase in homeless people with a mental illness, rather than de-institutionalisation itself. The majority of de-institutionalisation occurred in NSW from the early 1960s on, when thousands of people were discharged from psychiatric hospitals primarily to private boarding houses and a plan was set in place to create a system in which people with a mental illness would have access to community-based support. However, while the NSW Dept of Health are still working towards an optimal system, the problem is the lack of funding to optimise community care: "Under-funded, incomplete, fragmented and poorly monitored community-based services make community services inaccessible to most people. The homeless mentally ill arguably have suffered most as a result of these shortcomings, having multiple needs for intensive and ongoing support" (Parker et al. 2002).

Risk factors for and pathways to homelessness
Certain factors have been identified as increasing the risk of some people with a serious mental illness becoming homeless. These include being male, single or unemployed, and/or having:

few or no family contacts;

few or no friends and acquaintances;

poor social, planning and financial skills;

alcohol or other drug misuse;

lengthy history of mental illness;

poor acceptance of treatment;

history of brief repeating hospitalisations;

history of early discharge; and

poor discharge planning.
(Caton et al. 1995; Caton et al. 1994; Susser et al. 1991)

Individuals with the above characteristics and experiences may require specialised supportive housing and treatment services if they are to live successfully in community settings (Caton 1995).

Addressing homelessness in people with a mental illness
Thorough assessment of an individual can help identify whether they will require additional services and supportive housing after they leave an inpatient setting. Research indicates that identifying people at risk and planning for their discharge will improve their accommodation situation and consequently their mental health (Caton et al. 1994; Lipton et al. 1983). Assertive outreach case management, daytime drop in service, traditional outpatient services and psychosocial residential rehabilitation have all been shown to improve the accommodation situations and decrease psychiatric symptoms in people with mental illness including schizophrenia (Starrfield et al. 1995; Hawthorne et al. 1994).

ACCOMMODATION
Key principles in the provision of accommodation for people with schizophrenia:

Conduct a comprehensive and early assessment of the person's accommodation needs.

Provide a range of accommodation options that reflect a diversity of needs.

Provide flexible, appropriate and well co-ordinated support services that aim to ensure stable tenancy.

Develop partnerships between government departments, non-government organisations and private organisations to ensure the provision of a range of effective accommodation and related services.

Assessing accommodation needs
The type and level of accommodation and support required by an individual with a serious mental illness needs to be accurately identified. While not every person with a serious mental illness will need accommodation services, it is still essential to assess each individual's situation to determine what, if any, services they require. While assessment tools have been developed specifically for housing and supported accommodation, an individual assessment that considered all the person's needs (i.e. not just their diagnosis) is equally effective (Weir 1997). An individual's accommodation needs must be addressed proactively before a crisis occurs. Thus, an early and comprehensive assessment should be conducted in the initial stages when the Individual Service Plan is being developed.

Types of accommodation
A number of accommodation options that provide varying degrees of support are available for people with a mental illness. There is no one preferred model for housing provision, as long as the person is involved in the planning of their housing and support, and is provided with options and flexible services which can vary with their changing needs (Weir 1997).

What people with a mental illness want in their housing:

to live in a home with low behavioural demands (residence should be a home not a treatment facility); and

to make daily decisions themselves rather than by the staff.
(Owens et al. 1996; Weir 1997)

Homes should be homes, not residential treatment settings (Ford et al. 1993). This is contrary to the standard practice of combining treatment and living needs in a residential service (Brown et al. 1991; Weir 1997). There also needs to be community integration, not segregation based on diagnosis, and people with schizophrenia should be viewed as members of the community as opposed to 'program residents' (Weir 1997).

Supported accommodation
Supported accommodation is defined broadly as housing provided to mental health service consumers who require regular clinical and/or tenancy support. It is based on principles of consumer choice, integrated community housing and flexible services (Carling 1993). People with mental illness are assisted in gaining housing and are then provided with the services and supports that they want and need (Brown et al. 1991).

Many people with a mental illness and their families prefer supported accommodation and there has also been national and state policy shifts toward this model throughout Australia and internationally (Weir 1997; Carling 1993).

Accommodation types
1. Independent housing is available in the form of property owned by the individual, public housing, non-government organisations, private rental accommodation or premises kept for people with mental illness as part of the Departments of Housing and Health's special accommodation programs. People with schizophrenia can be assisted in these independent settings through rent subsidies and a range of clinical and tenancy support from government departments and non-government organisations (Weir 1997).

2. Boarding houses are privately owned and provide reasonably priced accommodation. Boarding houses must be licensed to operate and are regulated by the Ageing and Disability Department. Most of these facilities provide full board and lodgings, and minimal supervision or support.

3. Halfway houses provide ongoing assessment, active treatment and rehabilitation, often in a therapeutic community. The residents maintain the house. These houses aim to prevent continual re-admissions to hospital and develop social skills.

4. Group homes provide relatively independent living in the general community, with groups of people who have a disability living in the same residence. The Departments of Housing and Health generally own and administer these facilities, and organise the provision of support and psychosocial rehabilitation.

5. Hostels provide supervision for residents. The accommodation may be partially or fully serviced. Residents are responsible for provision of their own meals, and maintenance of some house areas.

6. Respite and crisis beds in cottages or units provide very high support as an alternative to hospitalisation or a break from usual accommodation (NSW Departments of Health and Housing 1997). Emergency accommodation facilities are also available for people who find themselves homeless and/or in some kind of danger

Accommodation support services
Regardless of the type of accommodation a person with a mental illness chooses, relevant support services should be available to them where necessary (Simmons 1997; Korman et al. 1996). The type of support services that an individual requires can be identified in initial and ongoing assessment procedures. Services should be of high quality, flexible and sensitive to the culture, gender and age of the individual (Weir 1997).

There are two broad types of support that may be required by people with a mental illness: (i) clinical support; and (ii) tenancy support. Clinical support aims to treat symptoms and behaviours associated with the mental illness. The nature of clinical support is decided when developing the Individual Service Plan. It is usually provided by a mental health worker and may be co-ordinated by the case manager (Weir 1997).

Tenancy support is concerned with the activities of daily living and social requirements of the individual. Services can include cleaning, social outings, conflict resolution between house members, house repairs and maintenance, and help with household chores like shopping, washing and paying bills. Tenancy support can be provided by non-government organisations or government departments such as Home and Community Care (Weir 1997). There are elements of tenancy support that are intrinsically part of the work of a mental health team. However, use of the mainstream agencies should be the ultimate goal.

There is a need for a co-ordinated blend of clinical and tenancy support so that stable housing can be ensured for people disabled by mental illness. Non-government organisations, government departments and other service providers are all responsible for co-ordinating and providing tenancy support.

The Schizophrenia Fellowship of NSW offers low-level supported accommodation for people living with a mental illness. To find out more, contact our NESB Community Development Officer.

The Schizophrenia Fellowship is also working with some of its carer members to develop a new model of supported accommodation for their family members living with mental illness. The Project's vision is for a partnership between the Office of Community Housing and the carers, through the Fellowship, to establish a group of one bedroom units with a common room, where the tenants will have support from the local mental health team as well as their families. To find out more, contact the Schizophrenia Fellowship on (02) 9879 2600.

References

For a list of references for this quality of life section on homelessness and accommodation, click here.

To ensure the information presented here is in line with current research and best practice, this section will be updated regularly, so make sure you bookmark this page and return often. If you would like to be alerted to updates automatically, join our free mailing list. We also encourage you to email us with your views on the 'quality of life' content, whether you are a consumer, carer or mental health professional. The Guidelines were developed using a collaborative approach and we would like to ensure that any updates to this section are also carried out in a collaborative manner, so your views are very important to us.

This section on 'quality of life' proudly sponsored by:

SFNSW Inc...Locked Bag 5014 Gladesville NSW 1675...ph: 02 9879 2600...fax: 02 9879 2699...Email: admin@sfnsw.org.au







			Homelessness & Accommodation HOMELESSNESS Accommodation is a fundamental need for people with a mental illness as for the rest of the community. Without adequate and safe accommodation, effective treatment and rehabilitation strategies cannot be implemented (Burdekin et al. 1993; Shepherd et al. 1996; 1997). Thus, it is essential that accommodation be considered a priority when addressing the needs of people with a mental illness. This quality of life section covers issues relating to homelessness and the provision of accommodation and related services. Definitions of Homelessness Primary Homelessness: people without any form of accommodation, i.e. people who live on the streets. Secondary: people who frequently move from one temporary shelter to another (ie emergency accommodation, boarding houses and shelters, temporarily staying at family and friends places). Tertiary: people who live in boarding houses on a medium to long-term basis. (Parker et al. 2002) Prevalence of homelessness for people with a mental illness The true incidence of homelessness and the prevalence of people with serious mental illness among the homeless population is difficult to assess as the population tends to be transient. Studies vary in their reporting of incidence rates. For example, Breakey (1996) found that the incidence rate of homeless people with a mental illness was between 2% to 90%. However a recent report by Welsey Mission indicated that 75% of participants in their study who were living in Sydney had a mental illness (Robinson 1998). Within this mentally ill and homeless population, the report found that 29% had schizophrenia. In Robinson's words: "These figures should be contrasted with the prevalence among the general community which is 1%. That means homeless people are 29 times more likely to suffer the effects of schizophrenia than those in the general community" (p 3). Studies in the United States indicate an even higher prevalence of mental illness among homeless people - up to 80 per cent (Lipton et al. 1983; Marcos et al. 1990). Studies in Britain report 30-50 per cent of homeless people experience mental illness, with schizophrenia being the most common diagnosis (Koegal et al. 1988). Compounding problems associated with being homeless There is a high prevalence of chronic and acute medical conditions in homeless people that can further compound the problems associated with mental illness in this population (Robinson 1998). A survey of homeless people in Sydney reported that 50 per cent had at least one chronic physical illness with one in eleven having hepatitis B or C (Robinson 1998). Other problems identified in extremely high rates among homeless people include drug and alcohol misuse, limited family or other supports, and trauma (100 per cent of homeless women and 91 per cent of homeless men have experienced a severe trauma including rape, assault or witnessing murder) (Robinson. 1998). Impact of de-institutionalisation Despite common belief, de-institutionalisation has not significantly contributed to the increase in homeless people with schizophrenia in Australia or overseas (Virgona et al. 1993). The reasons for reaching this conclusion are (i) relatively few homeless people with a mental illness have had prolonged hospitalisation (Meltzer et al. 1991) and (ii) it has been decreases in housing and income that have contributed to an increase in homeless people with a mental illness, rather than de-institutionalisation itself. The majority of de-institutionalisation occurred in NSW from the early 1960s on, when thousands of people were discharged from psychiatric hospitals primarily to private boarding houses and a plan was set in place to create a system in which people with a mental illness would have access to community-based support. However, while the NSW Dept of Health are still working towards an optimal system, the problem is the lack of funding to optimise community care: "Under-funded, incomplete, fragmented and poorly monitored community-based services make community services inaccessible to most people. The homeless mentally ill arguably have suffered most as a result of these shortcomings, having multiple needs for intensive and ongoing support" (Parker et al. 2002). Risk factors for and pathways to homelessness Certain factors have been identified as increasing the risk of some people with a serious mental illness becoming homeless. These include being male, single or unemployed, and/or having: few or no family contacts; few or no friends and acquaintances; poor social, planning and financial skills; alcohol or other drug misuse; lengthy history of mental illness; poor acceptance of treatment; history of brief repeating hospitalisations; history of early discharge; and poor discharge planning. (Caton et al. 1995; Caton et al. 1994; Susser et al. 1991) Individuals with the above characteristics and experiences may require specialised supportive housing and treatment services if they are to live successfully in community settings (Caton 1995). Addressing homelessness in people with a mental illness Thorough assessment of an individual can help identify whether they will require additional services and supportive housing after they leave an inpatient setting. Research indicates that identifying people at risk and planning for their discharge will improve their accommodation situation and consequently their mental health (Caton et al. 1994; Lipton et al. 1983). Assertive outreach case management, daytime drop in service, traditional outpatient services and psychosocial residential rehabilitation have all been shown to improve the accommodation situations and decrease psychiatric symptoms in people with mental illness including schizophrenia (Starrfield et al. 1995; Hawthorne et al. 1994). ACCOMMODATION Key principles in the provision of accommodation for people with schizophrenia: Conduct a comprehensive and early assessment of the person's accommodation needs. Provide a range of accommodation options that reflect a diversity of needs. Provide flexible, appropriate and well co-ordinated support services that aim to ensure stable tenancy. Develop partnerships between government departments, non-government organisations and private organisations to ensure the provision of a range of effective accommodation and related services. Assessing accommodation needs The type and level of accommodation and support required by an individual with a serious mental illness needs to be accurately identified. While not every person with a serious mental illness will need accommodation services, it is still essential to assess each individual's situation to determine what, if any, services they require. While assessment tools have been developed specifically for housing and supported accommodation, an individual assessment that considered all the person's needs (i.e. not just their diagnosis) is equally effective (Weir 1997). An individual's accommodation needs must be addressed proactively before a crisis occurs. Thus, an early and comprehensive assessment should be conducted in the initial stages when the Individual Service Plan is being developed. Types of accommodation A number of accommodation options that provide varying degrees of support are available for people with a mental illness. There is no one preferred model for housing provision, as long as the person is involved in the planning of their housing and support, and is provided with options and flexible services which can vary with their changing needs (Weir 1997). What people with a mental illness want in their housing: independence; privacy; safety; to live alone; to live in a home with low behavioural demands (residence should be a home not a treatment facility); and to make daily decisions themselves rather than by the staff. (Owens et al. 1996; Weir 1997) Homes should be homes, not residential treatment settings (Ford et al. 1993). This is contrary to the standard practice of combining treatment and living needs in a residential service (Brown et al. 1991; Weir 1997). There also needs to be community integration, not segregation based on diagnosis, and people with schizophrenia should be viewed as members of the community as opposed to 'program residents' (Weir 1997). Supported accommodation Supported accommodation is defined broadly as housing provided to mental health service consumers who require regular clinical and/or tenancy support. It is based on principles of consumer choice, integrated community housing and flexible services (Carling 1993). People with mental illness are assisted in gaining housing and are then provided with the services and supports that they want and need (Brown et al. 1991). Many people with a mental illness and their families prefer supported accommodation and there has also been national and state policy shifts toward this model throughout Australia and internationally (Weir 1997; Carling 1993). Accommodation types 1. Independent housing is available in the form of property owned by the individual, public housing, non-government organisations, private rental accommodation or premises kept for people with mental illness as part of the Departments of Housing and Health's special accommodation programs. People with schizophrenia can be assisted in these independent settings through rent subsidies and a range of clinical and tenancy support from government departments and non-government organisations (Weir 1997). 2. Boarding houses are privately owned and provide reasonably priced accommodation. Boarding houses must be licensed to operate and are regulated by the Ageing and Disability Department. Most of these facilities provide full board and lodgings, and minimal supervision or support. 3. Halfway houses provide ongoing assessment, active treatment and rehabilitation, often in a therapeutic community. The residents maintain the house. These houses aim to prevent continual re-admissions to hospital and develop social skills. 4. Group homes provide relatively independent living in the general community, with groups of people who have a disability living in the same residence. The Departments of Housing and Health generally own and administer these facilities, and organise the provision of support and psychosocial rehabilitation. 5. Hostels provide supervision for residents. The accommodation may be partially or fully serviced. Residents are responsible for provision of their own meals, and maintenance of some house areas. 6. Respite and crisis beds in cottages or units provide very high support as an alternative to hospitalisation or a break from usual accommodation (NSW Departments of Health and Housing 1997). Emergency accommodation facilities are also available for people who find themselves homeless and/or in some kind of danger Accommodation support services Regardless of the type of accommodation a person with a mental illness chooses, relevant support services should be available to them where necessary (Simmons 1997; Korman et al. 1996). The type of support services that an individual requires can be identified in initial and ongoing assessment procedures. Services should be of high quality, flexible and sensitive to the culture, gender and age of the individual (Weir 1997). There are two broad types of support that may be required by people with a mental illness: (i) clinical support; and (ii) tenancy support. Clinical support aims to treat symptoms and behaviours associated with the mental illness. The nature of clinical support is decided when developing the Individual Service Plan. It is usually provided by a mental health worker and may be co-ordinated by the case manager (Weir 1997). Tenancy support is concerned with the activities of daily living and social requirements of the individual. Services can include cleaning, social outings, conflict resolution between house members, house repairs and maintenance, and help with household chores like shopping, washing and paying bills. Tenancy support can be provided by non-government organisations or government departments such as Home and Community Care (Weir 1997). There are elements of tenancy support that are intrinsically part of the work of a mental health team. However, use of the mainstream agencies should be the ultimate goal. There is a need for a co-ordinated blend of clinical and tenancy support so that stable housing can be ensured for people disabled by mental illness. Non-government organisations, government departments and other service providers are all responsible for co-ordinating and providing tenancy support. The Schizophrenia Fellowship of NSW offers low-level supported accommodation for people living with a mental illness. To find out more, contact our NESB Community Development Officer. The Schizophrenia Fellowship is also working with some of its carer members to develop a new model of supported accommodation for their family members living with mental illness. The Project's vision is for a partnership between the Office of Community Housing and the carers, through the Fellowship, to establish a group of one bedroom units with a common room, where the tenants will have support from the local mental health team as well as their families. To find out more, contact the Schizophrenia Fellowship on (02) 9879 2600. References For a list of references for this quality of life section on homelessness and accommodation, click here. To ensure the information presented here is in line with current research and best practice, this section will be updated regularly, so make sure you bookmark this page and return often. If you would like to be alerted to updates automatically, join our free mailing list. We also encourage you to email us with your views on the 'quality of life' content, whether you are a consumer, carer or mental health professional. The Guidelines were developed using a collaborative approach and we would like to ensure that any updates to this section are also carried out in a collaborative manner, so your views are very important to us. This section on 'quality of life' proudly sponsored by: