Homelessness is everyone's problem
July, 2009
First multi-site randomized trial of housing interventions in Canada
One cold day in March after work, Julian Somers went for an early evening walk. From his office at SFU's downtown Harbour Centre campus he strolled down Hastings street to check out one of the city's new homeless shelters. Vancouver's recently elected mayor and council were determined to solve the shameful situation where thousands of homeless people must sleep on the streets of the city that tops the ranks of the world's best places to live. Somers, an associate professor in the faculty of health sciences, specializes in the treatment of drug addicts and is a member of SFU’s Centre for Applied Research in Mental Health and Addiction. As he walked through the familiar desolation of Vancouver's downtown east side he thought, "We don't do addiction treatment very well," and he could not help remembering his own father who lived and died on those same streets.
Somers is the principal investigator for the Vancouver site of the $110-million five-city Canadian Multi-site Research Demonstration Project in Mental Health and Homelessness, sponsored by the Mental Health Commission of Canada in partnership with Health Canada. The other cities are Winnipeg, Toronto, Montreal and Moncton. Co-investigators include UBC/Providence Health Care Leadership Chair in Addiction Research Michael Krausz, and UBC Professor/Director of the Centre for Population Health Promotion Research James Frankish. "There has never been a multi-site randomized trial of housing interventions," says Somers. The project will use a Housing First approach pioneered in cities such as New York and San Francisco. It focuses on immediately providing housing to the homeless, together with needed supports and assistance. The four-year budget for Vancouver is about $23.5M.
About 80% of the funding is earmarked for housing and services for the homeless. The other 20% goes toward collecting data and producing new knowledge. In Vancouver, of 500 participants about 300 will get rental support for at least two and a half years. They will also receive ongoing health support matching their individual needs. The subjects, who must all meet defined criteria for homelessness, will be recruited in two groups. One cohort of 200 with less severe mental health issues will be divided into a control group of 100 who will receive usual care (e.g. existing housing and support services) while a second group of 100 will get housing coupled with a type of therapy called Intensive Case Management. Another group of 300 with more severe mental disorders will be divided into three: 100 for controls who will continue with usual care, another 100 who will get housing with a type of care called Assertive Community Treatment, and a third group of 100 who will be placed in an apartment-type setting with onsite intensive support.
Somers was heading to the homeless shelter on that cold evening because he wanted to understand how it was operating and who was using it. Who was getting in? Who wasn't? Were the residents young or old? The shelter had been open for about two months. By talking to people in the street Somers learned that if they came back to the shelter before 7:00pm the next day they get the same cot as the night before. "That's what people are doing," says Somers. They get two meals a day at the shelter. They hand in their dirty clothes, have a shower and get a fresh set of clean clothes laundered by shelter staff. "After the meal, I noticed that people would sit together in groups. There's an obvious sense of community, they share a bond like any human social group," says Somers. Some of them looked great, like people arriving home from work, according to Somers. "But they didn't look like that two weeks before," he adds.
Looking at Somers, a well-educated 30-something triathlete, it's hard to imagine his own personal connection with Vancouver's homelessness problem. "My dad lived in an SRO hotel for a number of years but had no support," says Somers. An only child, Somers rarely saw his dad who left the family home when Somers was eight years old. After obtaining a BA in Psychology from SFU, Somers received graduate degrees from the University of Washington in Seattle. The venerable SFU Psychology professor Bruce Alexander was one of Somers' mentors. His theory of addiction does not point to the individual addict, but rather examines the society where they live. "What do you do when a society is formed around factors other than strengthening communities and finding people a place in those communities?" says Somers. This is a key question he hopes to answer in the current study. Using focus groups, the research team has been asking the homeless themselves for guidance. What do they think the research questions should be? "Homeless people with mental disorders are grossly disenfranchised. They have no voice and few avenues for support," says Somers. What's more, the stigma towards the homeless and mentally ill held by some health care providers can be a major obstacle to better care.
"You'd think health care worker's should know better, but some actually don't," says Michael Krausz, UBC professor of psychiatry and co-investigator on the project. Our current health care system is designed to help integrated people, not those at the margins of society. "Though we don't know much about treating the homeless, they make up 10% of all visits to the emergency room at St. Paul's Hospital in downtown Vancouver. That's about 1,800 per year," says Krausz who works at St. Paul's. He believes that if the homeless received better health care support, they would take care of themselves. And being healthier, their future care costs would be significantly reduced as well.
One day, when he was a teenager, Somers rushed from his Point Grey home home in response to a call from someone in his father's downtown east side apartment. He arrived to find his dad unable to move, conscious but drunk and choking. "He had tried to hang himself”, says Somers, but his father didn't die on that occasion.
"I believe giving people housing is a good thing, but the nature of the support given must put an emphasis on choice, choice for housing and for health services," says Somers. He believes that if the homeless are given a range of choices, individuals will develop their own array of supports. "We cannot predict what each individual will do, or what's relevant for them," he says.
Somers' father ultimately developed Korsakoff's syndrome due to alcohol poisoning. He was hospitalized and died. "My dad's story is the same as many others. He was a self-educated Irishman, involved in local theatre, he was literate, had a house in Point Grey, and it wasn't just one single thing, but a series of events and missed opportunities that put him on a trajectory terminating in in precarious housing, untreated illness, and premature death," says Somers.
At the homeless shelter people have finished their dinners and are sitting in groups watching TV or talking. They look relatively happy, but Somers wonders: what's next? If this shelter is stabilizing lives, what do we do? We have no next step, no apartments for these people, no social community. When he looks at the faces of the homeless he sees a profound feeling of longing. "You sense the absences in their lives, their health needs, post-trauma stress, a longing for opportunities such as a job, a place to live, friends, clothing and food," he says.
Somers worries about the future, even four generations out. Considering the current financial crisis with failed mortgages and people being displaced from homes, he says, "Such problems could become more common. Either we will allow all these disenfranchised people to increase, or we have to shift our thinking from, 'Here take this,' to 'Here are your choices.'" Somers would like to see the homeless have a chance to live in Kitsilano or Point Grey, as well as the downtown East side. Bruce Alexander's theory says all members of society have contributed to the problem, so Somers feels everyone has some obligation to the homeless. "You could say, too bad, it's their tough luck, or their bad choices, but that's not enough," he says. "As a society we need to build a social scaffolding to reclaim these lost people. A scaffolding of new social ideas, a framework of thought, so people can be guided in their social behaviour and actions. That's the ultimate goal of the study."