The following articles appeared in the October 2018 edition of Parity: Mental Health, Disability, Homelessness.
Introduction; Mental Health, Disability and Homelessness
by Jenny Smith, CEO, Council to Homeless Persons
Deinstitutionalisation was predicated on the assumption that social housing would be available for all those living in the community with psychosocial disability. It also assumed that Centrelink incomes would retain their value. It assumed the availability of adequate: housing, employment, income, clinical services and psychosocial support. In combination, they would underpin a decent quality of life and social inclusion for those living with psychosocial disability.
Sadly, the reality has not lived up to this vision. In contrast, the experience of mental illness and related disability today is frequently a fast track to poverty. Living with psychosocial disability too often means reduced access to employment, and hence income at poverty levels. The combined impact of psychosocial disability and low income makes it impossible to compete for housing in our ridiculously tight rental market.
Hence it is no surprise that so many people living with psychosocial disability cycle in and out of homelessness.
It is also increasingly understood, that homelessness itself is bad for our mental health. Homelessness directly creates mental health issues, or exacerbates and magnifies pre-existing mental health conditions. It is not hard to understand how the experience of homelessness, or even being at risk of homelessness, can trigger a whole range of mental health problems. The ontological insecurity of homelessness alone is sufficient to produce anxiety and depression. Add in coping with stigmatisation and the daily effects of ongoing social exclusion and marginalisation, and the nexus between mental health and homelessness is not at all hard to understand and appreciate.
The Federal Government has announced that a new ‘psychosocial disability’ stream will be added to the National Disability Insurance Scheme (NDIS). This is a clear acknowledgement that to date, the NDIS has largely not responded appropriately to psychosocial disability, particularly for those people whose psychosocial disability was not judged to be permanent.
Simultaneously, existing mental health supports through the Personal Helpers and Mentors Program and in some jurisdictions community mental health psychosocial support services have been dealing with the prospect of that funding being rolled into the NDIS scheme and hence available to a narrower target group.
In this context, it is important that the Victorian Government has announced ‘$50 million over two years for a new psychosocial support model for clients of the clinical mental health service system who are not eligible for the NDIS or are waiting for their NDIS plan to begin.’
Both these announcements represent a welcome recognition from government that the NDIS needs to do better with psychosocial disability. Far greater dedicated resources need to be allocated to the mental health and disability sectors to assist them to be able to cope with the growing demand for their services.
Concern about the capacity of our current service systems to cope with mental health issues and psychosocial disability has been further highlighted by the recent undertaking by the Victorian Government to hold a Royal Commission into mental health service provision should it be re-elected in late November 2018.
The Council to Homeless Persons has long advocated for a ‘housing first approach’; the provision of safe, secure and affordable housing to end the homelessness of those experiencing chronic or long-term homelessness, many of whom have also experienced mental illness and related psychosocial disability. This housing represents the stable foundation that makes possible the provision of the ‘wrap around’ individualised services that both get and keep housing. Housing security underpins effective mental health interventions.
Specialist Homelessness Services Clients with Mental Health Issues
by Carol Kubanek, Housing and Homelessness Reporting and Development Unit, Australian Institute of Health and Welfare
People living with mental health issues are more likely to experience homelessness compared to all Specialist Homelessness Services (SHS) clients.1 Those with severe mental illness are more likely to experience higher housing stress and live in unstable housing compared to all people with a mental health issue.2, 3
The number of clients with a current mental health issue seeking assistance from SHS has increased at an average rate of 12 per cent per year since 2012–13, increasing from about 48,600 in 2012–13 to 77,600 in 2016–17. Various factors, including increased identification and community awareness of mental illness, may have resulted in an increased recognition by individuals of their own mental health issues and reporting of mental illness by SHS clients.
SHS Clients With Current Mental Health Issues
In 2016–17, an estimated 77,600 people (27 per cent of all SHS clients) who sought SHS services reported a current mental health issue, of whom 18 per cent were Indigenous, 60 per cent were female, and 45 per cent were aged between 25 and 44.
Half of all SHS clients (50 per cent) who reported a current mental health issue needed long-term housing assistance compared with 35 per cent of all the SHS clients. About 37,000, or 48 per cent of clients who reported a current mental health issue, needed short-term or emergency accommodation.
Changes in the Rate of Assistance/Service use by Clients
The rate of SHS service use by clients who presented with a mental health condition increased from 21 people per 10,000 of the population in 2012–13 to 32 people per 10,000 in 2016–17 (Table 1).
In 2016–17, the SHS clients who reported mental health issues and accessed SHS services were more likely than other groups to return to SHS for additional support during the year (2.4 support periods per client). On average, they received a median of 68 days of support, almost twice as many days as all SHS clients. Six in ten SHS clients (61 per cent) with mental health issues were ‘returning’ clients, that is, they had received support from SHS at some time in the previous five years.4\\
Improvements in Homelessness and Housing Outcomes
For clients with a current mental health issues and whose support had ended (around 50,000), nearly 25,000 (or 50 per cent of clients) were homeless at the beginning of support. By the end of the support, the rate had decreased to 37 per cent.SHS clients who are considered homeless include those with ‘no shelter or improvised/inadequate dwelling’ (rough sleepers), those in ‘short-term accommodation’, as well as those in a ‘house, townhouse or flat — couch surfer or with no tenure’ (couch surfer). Some clients who were homeless at the beginning of support had moved into more stable housing by the end of support, and vice versa.
• around 39 per cent of the clients who were homeless at the beginning of support were housed at the end of support
• 32 per cent of rough sleepers were housed at the end of support
• 41 per cent of couch surfers were housed at the end of support.
Clients with a current mental health issue who presented to agencies housed, but at risk of homelessness, were also assisted to maintain housing.
• For these clients, 85 per cent of clients ending support were assisted to maintain housing.
Demand for Mental Health Services
Mental health services − including psychological, psychiatric and mental health services − was one of the most commonly reported specialised services needed by all SHS clients
in 2016–17. Of those clients with a mental health issue, about 30 per cent (23,000 clients) reported needing mental health services. These needs were mostly met, with around 45 per cent (10,500 clients) provided with services and about 24 per cent (5,500 clients) referred for services.
Additional Vulnerabilities — Complex Needs
Many people who seek assistance from SHS, and who experience both homelessness and mental health issues, have additional vulnerabilities. Of the 77,600 clients reporting a current mental health issue, over half (53 per cent or about 41,100 clients) reported additional vulnerabilities:
- 29 per cent (or about 22,500 clients) had experienced domestic and family violence
15 per cent (or about 12,600 clients) reported problematic drug and/or alcohol use
10 per cent (or about 7,500 clients) reported all three vulnerabilities (domestic and family violence, problematic drug and/or alcohol use and mental health issues).
The integration of services for those experiencing multiple vulnerabilities — mental health, homelessness and problematic drug and alcohol use — responds to the needs of clients experiencing mental health issues. Clients have a preference for all-inclusive services where staff at agencies have a full understanding of the needs of the clients and where services delivered across agencies worked together to assist clients.5
Further studies across data collections could review the complex needs
of clients with mental health issues and identify which services would effectively improve the outcomes of these clients.
* All SHS clients include those who are homeless as well as those at risk of homelessness.
Australian Institute of Health and Welfare (AIHW) 2017, ‘Specialist homelessness services annual report 2016–17’ AIHW, https://www. aihw.gov.au/reports/homelessness- services/specialist-homelessness- services-2016–17/contents/contents
Robinson C 2003, ‘Understanding
iterative homelessness: the case of
people with mental disorders’ Final Report No. 45, Australian Housing and Urban Research Institute, https://www.ahuri.edu. au/__data/assets/pdf_ le/0014/2219/ AHURI_Final_Report_No45_Understanding_ iterative_homelessness_the_case_of_ people_with_mental_disorders.pdf
Psychiatric Disability Services of Victoria (VICSERV) 2008, ‘Pathways to Social Inclusion: Housing and Support’, VICSERV. https://www.mhvic.org.au/images/PDF/ VICSERV_publications/pathways_full.pdf
Australian Institute of Health and Welfare (AIHW) 2017, op cit.
Flatau P, Hall S, Thielking M, Clear A and Conroy E 2014, ‘How integrated are homelessness, mental health and drug and alcohol services in Australia?’ Australian Housing and Urban Research Institute (AHURI) Research and Policy Bulletin, issue no.182 pp. 1–4.