Appropriate, affordable housing for individuals with brain injury

In addition to the physical changes experienced after brain injury, many of the following common cognitive, emotional, and behavioural symptoms/impairments can increase the chance of homelessness:

Additional contributing factors include discrimination, intimate partner violence, poverty, and systemic barriers.

Discrimination

Discrimination is often a precursor to homelessness and can continue after the fact. Discrimination is when a person is treated differently based on race, religion, ability, mental illness, age, gender, or socioeconomic status. Individuals facing discrimination often experience restricted options, difficulty accessing housing and services that contribute to their position on the streets [1].

Approximately 28 – 34% of people experiencing homelessness in Canada are Indigenous peoples. This is a percentage of the Indigenous population, which makes up 4.3% of the overall Canadian population [2].

• More information on discrimination and homelessness

Intimate partner violence

Intimate partner violence (IPV) and family violence can lead to homelessness. It is estimated that 237 people per 100,000 people are affected [3] (Statistics Canada, 2016). In some cases, it becomes necessary to leave home quickly with no supports. According to the Canadian Observatory on Homelessness:

This is particularly an issue for youth and women, especially those with children. Women who experience violence and/or live in poverty are often forced to choose between abusive relationships and homelessness. Young people that are victims of sexual, physical, or psychological abuse often end up experiencing homelessness. As well, seniors that are experiencing abuse and neglect are increasingly at risk of homelessness.” [4,5].

• More information on intimate partner violence (IPV)

Poverty

Many individuals who live below the poverty line are living paycheque to paycheque. They are at risk of being homeless, particularly if their ability to work is compromised through job loss or illness.

System failure

Sometimes Canadian systems don’t work as intended. This includes inadequate discharge planning for people leaving hospitals, corrections, and mental health and addictions facilities and a lack of support for immigrants and refugees [6]

Homelessness is not something that happens quickly and in isolation. There are usually many cascading effects that lead to homelessness and it is very rarely a choice.

Statistics on homelessness and brain injury

• Almost half of all homeless men who took part in a study by St. Michael’s Hospital had suffered at least one traumatic brain injury (TBI) in their life and 87% of those injuries occurred before the men lost their homes [7].
• Studies find that 60% of homeless individuals with TBI report sustaining multiple injuries [8].
• The majority of first TBIs occur prior to homelessness, suggesting that brain injury is a risk factor for homelessness. However, homelessness has also been found to be a risk factor for subsequent TBIs [9].
• TBIs have been linked to increased mental health problems, physical health problems, and drug problems among the homeless [10].
• Homeless individuals with TBIs appear to have worse cognitive impairment than homeless individuals without TBIs [11].
• In a study of women with TBI in Canada, poverty was found to be a significant barrier to accessing health care [12].

Advocating for affordable, appropriate housing

No one should have to choose to pay rent over food, but it happens everyday. Financial assistance in provinces is too low – especially in cities – for people to find affordable housing without sacrificing basic needs. Once a person becomes homeless, it becomes even more difficult to find housing. There is also a stigma around homelessness driven by ignorance and judgement, and that stigma can negatively affect a person’s ability to escape homelessness. This is especially true for individuals with a brain injury who may not be able to work, don’t have the cognitive abilities to manage money, or are experiencing additional challenges.

Housing programs geared towards supporting individuals with acquired brain injury (ABI) are underfunded and specialized ABI housing programs in Canada have extensive wait lists, leaving people exposed to ongoing social, emotional, and financial risks.

As brain injury is a lifelong condition, affordable housing support and strategies need to be improved to address barriers and supports across their life span. We also need to understand the path to homelessness for those living with brain injury, as it is a critical piece in the prevention strategy.

Housing First model

Housing First is “a recovery-oriented approach to ending homelessness that centers on quickly moving people experiencing homelessness into independent and permanent housing and then providing additional supports and services as needed… The basic underlying principle of Housing First is that people are better able to move forward with their lives if they are first housed. This is as true for people experiencing homelessness and those with mental health and addictions issues as it is for anyone. Housing is provided first and then supports are provided including physical and mental health, education, employment, substance abuse, and community connections.” [13]

This model focuses on providing permanent housing to individuals despite their circumstance and needs.

• Some people need affordable independent housing options that do not have extensive wait lists.
• Some people need supported living where they may have a room or an apartment but have access to supports as needed.  This is essential for those with memory impairments and organizational challenges.
• Some have complex medical needs and require full-time care, but are in a long-term care facility with seniors with Dementia and Alzheimer’s. While their medical needs are provided for, this does not meet their need for socialization and engagement with peers in any meaningful way.

For those living with brain injury, supports need to be put in place to ensure housing is secured and sustainable over the long-term. Supports should include:

• Access to mental health and other health care supports
• Addiction services specific to those with brain injury
• Affordable childcare
• Community engagement
• Help with filling out forms – health cards, income taxes, available subsidies, etc.
• Help with organization – paying bills, opening mail, budgeting, planning, etc.
• Mediation and dispute resolution supports
• Supports for victims of intimate partner violence

Housing first in action: At Home/Chez Soi project

The At Home/Chez Soi project was a $110 million government-funded project by the Mental Health Commission of Canada to explore housing-first approaches to assisting the homeless population in Canada. The project was four years long – 2 years of active participation with 2 years of follow-up – and covered the cities of Winnipeg, Toronto, Vancouver, Montreal, and Moncton. There were over 2,000 homeless participants with mental health challenges. Along with the focus on mental health, the different cities had their own smaller focuses [14]:

• Vancouver, British Columbia – people also experiencing problematic substance use
• Winnipeg, Manitoba – urban Indigenous population
• Toronto, Ontario – ethno-racialized populations, including new immigrants who do not speak English
• Montréal, Quebec – included a vocational study
• Moncton, New Brunswick – services in smaller communities

This project provided housing to people experiencing homelessness along with various mental health service models to determine success rates and more. 66% of the participants had reported a brain injury, or an instance of trauma/unconsciousness that could have led to a brain injury. At Home/Chez Soi showed that Canada could make positive strides to ending homelessness by using a housing-first model. The following findings were shared in the final report.

Over the two years of the study, participants in Housing First spent an average of 73% of their time in stable housing compared with 32% in treatment as usual (TAU). In scientific terms, these differences are considered to be highly significant; that is, there are large differences between the groups. Specifically, since the study used a randomized design and all other characteristics that could result in stable housing were equivalent between groups except the intervention, the finding can be reasonably and confidently attributed to the provided housing [15].

• Housing itself was motivating to participants, since it inspired people to behave in a way that would maintain their homes and allow them to reclaim their lives.
• Housed participants from the HF group reported more choice over where they lived, including the choice to live in a place where they felt safe, and in some cases away from previous problematic social circles.
• Housed participants in the HF group often expressed a feeling of stability and permanence [16].
• Participants had lower uses of emergency shelters and emergency hospital services.
• HF participants had improved eating and health habits because they had a place to store food (self-reported).
• All participants reported less contact with the justice system.
• Every $10 invested in Housing First leads to between $3.42 – $9.60 average reduction in costs of other services.
• Quality of participants’ daily lives changed from being survival-oriented to being “more secure,” “peaceful,” and “less stuck,” which enabled them to move forward in their lives

Any solution for homelessness will require a collaborative approach of all levels of government, community organizations, private companies and, most importantly, the input of those living with brain injury.

The difference between social housing vs. affordable housing

Many people use the terms’ social housing and affordable housing as if they are the same – but they have different meanings. Social housing is housing that is subsidized by the government and made available to low-income households.

Affordable housing is defined by the Canadian Mortgage and Housing Corporation as, “including housing provided by the private, public, and non-profit sectors. It also includes all forms of housing: rental, ownership, and co-operative ownership, as well as temporary and permanent housing.”

Housing reports and resources

• National Final Report of the At Home/Chez Soi project
• More information about At Home/Chez Soi from the Mental Health Commission of Canada
• Canadian Housing First Toolkit

How to advocate for appropriate, affordable housing

Advocacy for appropriate, affordable housing happens at several levels. There needs to be more education of the public on the housing plight in Canada; outreach to the National Housing Strategy council advocating for appropriate housing for brain injury survivors; and large-scale advocacy from organizations to government departments.

Ways to advocate for appropriate, affordable housing include:

• Writing to your local government representatives
• Sharing research and information about housing with your network
• Signing petitions for organizations
• Contact your local brain injury associations to see if they are involved in any initiatives

Resources

• Learn more about initiatives from the Canadian Observatory on Homelessness
• Canadian Housing and Renewal Association
• Right to Housing

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