“Simply put, a homeless person should be offered choices for housing without preconditions. Once a roof is over their heads, then our team can provide the support to foster personal recovery and maintain housing stability,” said Pio Giralico, manager of the Housing First Intensive Case Management & Strengthening Communities in Scarborough programs.
However, in today’s market, that order of operations is often turned on its head. “It's not so easy to secure housing,” Pio continued, “so, while we wait, we’ll work on some of the person’s other goals.”
The wait can be a long one. Even with CMHA Toronto’s generous housing subsidy of $1,200, the waitlist for affordable housing now stretches to 12 or more years. Given the importance of housing to long-term recovery, these gaps and delays are causing ripple effects throughout the health care system and across Toronto, a problem destined to get worse before it gets better.
Even at the beginning of COVID, the Housing First team was still able to house people, but today “due to the skyrocketing costs of rent, we haven't been able to house anyone in over six months. That's a snapshot of our reality here and now,” said Pio.
So what do people do?
“I’ve worked with one individual who is staying in a shed on a friend’s property because he doesn't have the ability to secure something right now. There are no shelter beds. Luckily CMHA does have its Safe Bed program, where people can get access to a 30-day stay, but even that is hard to get into,” said Mark Dwyer, Housing First’s clinical lead, elaborating on the many barriers people face.
One of these barriers is the self-disclosal required for accessing the Housing First mobile rent subsidy. “There is the stigma of any type of affiliation with services like ours that can sometimes be detrimental,” Mark said. “In order for the subsidies to be released there has to basically be an outing that the person is working with the Housing First service.”
Housing First maintains relationships across the city with property managers willing to rent to CMHA Toronto clients, but not all will and there is little recourse if a client is turned down.
“Every once in a while, we'll take off one hat and put on a real estate agent’s hat, trying to forge relationships [with property managers] to help speed up the process, which is still full of molasses.”
The before phase
For Housing First’s multi-disciplinary team, working with an unhoused or precariously-housed client has a before, during and after phase. These days, the primary goal of securing safe shelter is balanced against other goals: to stabilize mental health, provide options for care and encourage people to pursue them, and connect people with resources for employment and social support.
Each client will have unique needs, and Housing First – like all other CMHA Toronto programs – is client-centric and trauma-informed.
“We'll have meetings that are constantly underlined with a housing search that, unfortunately, does not go anywhere,” explains Chandra Sullivan, case manager, “so the focus for the rest of the time is how can we maximize our time to make sure that, while the housing is still an issue, your health care is at least in check. What are your other goals as far as your mental or physical health? Are there community groups that you can be a part of, do you have connections to your dentist? When was your last exam?”
For many, options for training, education and employment are high priority, so the conversation is about building a path towards those goals. “The answer really depends on the individual. The way our support looks is as complex as any individual's life. You have to be ready to meet [the client] where they're at, and it could look totally different” from one client to another, said Chandra.
The changing face of homelessness
The economic and social dynamics at play in the housing market are widening the net of who might be caught in a housing crisis.
“We're seeing people that are highly educated, professional individuals, people that you would think, ‘oh, everything is fine for this person’ and it's not,” said Mark. “People come to us and no one knows what's going on in their lives. They hide it very well. They've been doing okay for a long time and then things happen, the foundation crumbles, and everything else opens up. Before, they could hide all the issues that were going on. I consulted with one of Chandra’s clients in this situation, who was asking ‘what now? How did I manage to be in an illegal basement apartment with no lights, no water, and I’ve got to go to the washroom at a local gas station. How did I get into this?’”
Building a foundation of trust
At the heart of the work is a one-on-one relationship. “When you start with folks, they've had a distrust of the system. And that includes me, my face, right? I’m the system, and there's that distrust,” said Lou Sevilla, case manager with lived experience for Housing First. “So you're going to work on relationship-building and rapport skills. You’re going to make sure clients know we're going to do this together, we're not going to make decisions for you. You're going to be involved.”
Lou uses their lived experience to build rapport, co-create options, and gain trust, all of which supports recovery. “I always draw back from my own experience. If they're going through the mental health system currently, for example, then I look back at my own experiences, the negative and positive things I've learned, and use that as a way to support them,” said Lou. Gradually, they build up layers of the client’s own experience and draw upon it, “just constantly reminding them of the strength and resilience they’ve built up. I try to use my lived experience as a narrative to bring them hope,” they said.
The work progresses when they start to build trust with you, and they know you’re an ally. That's the work that happens whether it's 10 years or one year into the housing piece.
During and after: a critical period
Housing First is an evidence-based solution to house the homeless developed in the late 90s by psychiatrist Sam Tsemberis and now recognized internationally as a best practice. According to Pio, “If you asked Dr. Tsemberis what does ‘housing first’ mean to you, he wouldn’t call it a homelessness project, he would call it a recovery-oriented philosophy. He saw that, of those people that are homeless, 90% or more are people with untreated issues around mental health, addiction, and trauma.”
Whether or not there is a roof over people’s heads, treating the underlying mental health issues is imperative to get it and keep it there.
That’s where CMHA Toronto’s Housing First cross-disciplinary team comes in. Comprised of 12 staff including case managers, housing workers, a nurse case manager, housing workers, and a consulting psychiatrist, the team offers a holistic approach that can address the multiple, interconnected social determinants of health and provide mental health, addictions and trauma care wherever the person is in their housing and recovery journey.
“What's great about Pio’s team is that everyone has a place at the table and it's round. Everyone is listening to each other and getting knowledge,” said Mark, whether it’s Lou’s specialization in the geriatric system, tapping into nurses for primary care, or calling on addictions specialists to support that area of need. “We try to do our best to use what we have within the team as resources to improve services for our clients.”
This level of service doesn’t stop once the person is housed. As rewarding as it is to help someone secure safe housing – “It's like you're getting the keys handed to you to as much as they are getting the keys in their hand,” said Lou – the next step is to keep the person there.
The first three months is a crucial window during which people must settle into their new life. “They're now having to acclimate to a whole breadth of life responsibilities that, especially if they've been chronically homeless, they are not used to thinking about – bills, budgeting, cleaning, home maintenance. If they can get past that three-month window, then statistically they're way more likely to succeed in housing long term,” said Chandra.
This is also the period where people “have room to do work with that trauma,” Chandra adds. “The continuous work after they’re housed is crucial in so many ways, not just to keep them housed but to help them along on their journey of recovery.”
Mark adds, with respect to trauma-informed care, “we assume trauma is there; for everything else we wait. When clients come to us, we want to listen to their stories. We can’t assume what's best for people, we have to hear what the person says and work from where they're at, and then get to what is their priority. We navigate the system with people rather than doing stuff for people and telling people what they need to make a better life.”