Pathways into homelessness: Understanding how both individual and structural factors contribute to and sustain homelessness in Canada

Abstract

This qualitative study examined how homeless individuals with mental illness experience pathways into homelessness. Study participants were enrolled in the At Home/Chez Soi project, a Pan-Canadian Randomized Controlled Trial comparing the Housing First approach with Treatment as Usual for homeless individuals. This inquiry is grounded in social ecological perspective, which considers interactions between individual and structural factors. Findings from consumer narrative interviews (n = 219) revealed that individual factors, such as substance abuse, relationship conflicts and mental health issues significantly contributed to homelessness, in addition to structural transitions from foster care and institutional settings into the community. Additional structural factors entrenched participants in unsafe communities, created obstacles to exiting homelessness and amplified individual risk factors. The study findings confirm the role of individual risk factors in pathways into homelessness, but underscore the need for policies and interventions to address structural factors that worsen individual risks and create barriers to exiting homelessness.

Keywords

homelessness homelessness pathways homelessness risk factors social ecological perspective

Introduction

In Canada, homelessness has been widely regarded as a crisis since the 1980s, during which it grew from a problem affecting a subgroup of single men to a crisis affecting a diverse population of men, women, youth and families (Gaetz, 2010). According to recent estimates, between 150,000 and 300,000 Canadians will experience homelessness over the course of a year (Fitzpatrick-Lewis et al., 2011; Hwang et al., 2011). In response to the homeless crisis in Canada and abroad, a myriad of studies have been conducted to examine the pathways into homelessness, particularly among individuals with mental illness and substance abuse disorders.

Most studies on pathways into homelessness emphasise either individual risk factors, such as mental illness and substance abuse, or structural risk factors, including discrimination and the lack of affordable housing (Morrell-Bellai et al., 2000; Nooe and Patterson, 2010; Shinn, 2007; Toro, 2007). However, few studies illustrate the interactions between individual and structural factors, or embed study findings in a theoretical framework that can advance the understanding of pathways into homelessness (Kloos and Shah, 2009). To extend knowledge from previous inquiries on pathways into homelessness among individuals with mental illness, qualitative findings from the At Home/Chez Soi project are presented. At Home/Chez Soi is a Pan-Canadian Randomized Controlled Trial (RCT) that compared Housing First (HF) interventions with treatment as usual (TAU) for homeless individuals with mental illness, substance abuse or co-occurring disorders.¹

Through the use of qualitative interviews, narratives were elicited from participants to better understand the lived experience of becoming and being homeless. Drawing from social ecological perspective (Bronfenbrenner, 1979; Moos, 1976), the study findings present participant perspectives regarding pathways into homelessness among Canadian adults with serious mental illness, with implications for policy and intervention.

Individual risk factors

A large proportion of individuals who experience homelessness have serious mental illness and/or substance use disorders (Lowe and Gibson, 2011; Rickards et al., 2010). Mental illness is a risk factor for homelessness, and the experience of homelessness is a risk factor for developing a serious mental illness (Bhugra, 2007). Individuals with severe and persistent mental illness are likely to experience repeated and longer periods of homelessness than other groups experiencing homelessness (Goering et al., 2011). It is estimated that up to one-third of homeless individuals have a serious mental illness, including schizophrenia, depression or bipolar disorder, and that 50% have co-occurring substance use disorders (Rickards et al., 2010). The prevalence of mental health issues and substance abuse disorders is far greater in homeless populations compared with the general public (Aubry et al., 2011; Hwang, 2001).

Childhood abuse and trauma are significant risk factors for homelessness. Homeless individuals with mental illness experience significant disadvantage, as they are more likely to be impacted by poverty, family instability and domestic violence (Sullivan et al., 2000). Kim et al. (2010) found that a history of physical and sexual trauma was significantly associated with mental health issues in a sample of homeless men. Individuals who become homeless, particularly during adolescence, identify family conflict and family violence as central contributing factors (Mallett et al., 2005).

Homeless individuals are more likely to have experienced numerous stressful life events, such as major financial crises, the loss of relationships, death of loved ones, foster care placement, psychiatric hospitalisations, abuse and sexual violence (Zugazaga, 2004). A recent study found that a sample of formerly homeless individuals with mental illness experienced an average of 8.8 adverse life events, including incarceration, suicidality, parental abandonment and the death of a mother (Padgett et al., 2012). Additionally, studies indicate that homeless individuals have smaller social networks and low levels of social support (Calsyn and Winter, 2006).

Structural contributions to homelessness

Research has also identified structural contributions to homelessness. A common structural risk factor for homelessness occurs as individuals transition from foster care or institutional placement into the community (Lamb, 2001; Lowe and Gibson, 2011; Nooe and Patterson, 2010). Pecora et al. (2005) found that up to 22% of children who age out of foster care become homeless within a year. Transitions from foster care and institutional settings present risk for homelessness, as many individuals receive little support for transition planning and do not acquire the skills necessary for independent living in the community (Pecora et al., 2005).

Structural contributions to homelessness also include broader sociopolitical factors. Social policies that provide financial and other support to individuals living in poverty have been found to reduce homelessness, while a lack of affordable housing increases the risk of homelessness (Gaetz, 2010; Shinn, 2007). Discrimination is a significant structural risk factor, as historically marginalised minority groups are overrepresented among the homeless population in several nations (Kauppi and Braedley, 2003; Okamoto, 2007; Philippo et al., 2007; Toro, 2007).

In their analysis of structural trends in homelessness, Kauppi and Braedley (2003) suggest that globalisation and demographic changes have contributed to the crisis in homelessness in Canada, as well as internationally (2003). In the Canadian context, Gaetz (2010) argues that global and domestic economic policies, such as trade liberalisation and deindustrialisation, have contributed to homelessness. Changes in Canadian social and housing policies and a widespread lack of affordable housing contributed significantly to the shift from homelessness as a problem affecting a subgroup of single men to a crisis affecting diverse groups (Gaetz, 2010).

Social ecological model

Studies on pathways into homelessness often dichotomise individual and structural risk factors, failing to account for the complexity of this social problem (Nooe and Patterson, 2010). Social ecological perspective posits that ‘an authentic understanding of any organism is inextricably linked with an understanding of its habitat’ (Wright and Kloos, 2006). Thus, the crux of social ecological perspective is the emphasis on understanding the person-in-context. The social ecological perspective suggests that homelessness and other social problems result from ‘interactions among risk factors, ranging from individual conditions to socio-economic structures and environmental circumstances’ (Nooe and Patterson, 2010: 105). The social ecological model has received attention in recent inquiries on homelessness, as this model presents an alternative to reductionism (Kloos and Shah, 2009; Nooe and Patterson, 2010).

From a social ecological perspective, individual and contextual systems are viewed as interactive and interdependent (McLaren and Hawe, 2005; Nooe and Patterson, 2010; Patterson et al., 2012b). The model emphasises individual agency and expects that individuals will have different reactions to structural conditions based upon previous experiences, perspectives and individual differences (Kloos and Shah, 2009). Qualitative inquiries anchored in social ecological perspective can highlight the interplay between individual and structural factors from the perspectives of individuals with lived experience.

The Housing First model

Housing First (HF) is an evidence-based intervention for homeless individuals with serious mental illness, which originated in the 1980s in New York City (Goering et al., 2011). HF provides homeless individuals with immediate access to subsidised housing of their choice without preconditions, such as sobriety or adherence to psychiatric treatment (Padgett, 2007; Tsemberis et al., 2004). Additionally, HF provides an array of support services to address needs regarding physical and mental health, addiction services, employment, social relationships and community integration.

HF is based on four central principles: (1) consumer choice over housing and support services; (2) the separation of housing and clinical services; (3) a recovery orientation; and (4) a focus on community integration. The rationale behind the HF model is that providing immediate access to housing and promoting choice is a more respectful and effective way to foster consumer engagement and recovery (Padgett, 2007; Tsemberis et al., 2004).

At Home/Chez Soi

Findings from RCTs of HF in the USA have indicated that the intervention is effective at reducing homelessness and hospitalisation and increasing housing stability and housing choice. However, given the healthcare and social policy differences between Canada and the USA, there was a need to systematically evaluate the effectiveness of the HF approach in Canada, particularly with relevant subpopulations, including Aboriginal individuals, ethnoracial groups and immigrants (Goering et al., 2011).

In 2008, The At Home/Chez Soi project was initiated with funding from the Mental Health Commission of Canada (MHCC). At Home/Chez Soi, a Pan-Canadian mixed methods Randomized Controlled Trial (RCT), implemented and evaluated the HF model in five Canadian cities: Moncton, Montreal, Winnipeg, Toronto and Vancouver. The project examined whether HF resulted in better outcomes than treatment as usual (TAU) for chronically homeless adults with high and moderate needs (Goering et al., 2011). The treatment group received the HF intervention, while TAU consisted of services that participants would normally receive in their respective cities if the project did not exist (e.g. shelters, drop-in centres, etc.). Thus, the TAU group received usual care, as opposed to no care at all. The project established a Safety and Adverse Effects Committee with diverse representation to review any reports of adverse events related to the project (Goering et al., 2011).

The RCT measured housing outcomes (e.g. housing stability, differences in types of shelter, housing quality), service use and cost outcomes (e.g. health service use, justice service use, cost analysis), and social and health outcomes (e.g. quality of life, community functioning, health and substance related outcomes). The research officially ended in March 2013. The overall findings of the At Home/Chez Soi project are detailed elsewhere (Mental Health Commission of Canada National Final Report, 2014)

The qualitative component of the research, upon which the current study is based, entailed face-to-face narrative interviews with consumer participants in both the intervention and TAU groups within the five research sites, as participants became involved in the study (at baseline) and again at 18 months. The current study details pathways into homelessness, as described by At Home/Chez Soi participants during the baseline consumer narratives interviews.

Methods

The research questions guiding this study are:

How do the participants describe pathways into homelessness?

How do the participants make sense of continued homelessness, including barriers to exiting homelessness?

Recruitment and participants

Participants were recruited through community agencies serving homeless individuals, such as shelters, drop-in centres, outreach teams, mental health teams, inpatient programmes and criminal justice programmes (Goering et al., 2011). The overall study sample consisted of 2234 participants in both the intervention and TAU groups.

Across the five research sites, the research teams randomly selected approximately 10% of the overall sample to participate in the baseline narrative interviews. The research teams then made purposeful adjustments to the final narrative interview sample to ensure a diverse cross-section of participants in terms of gender, age and race/ethnicity. Participants were required to be 18 years old or above (or 19 years old or above in Vancouver), to have the status of absolutely homeless or precariously housed, and to have a mental disorder with or without a co-occurring substance use disorder, based on DSM-IV criteria. In the study, individuals who were characterised as experiencing absolute homelessness lacked a regular, fixed, physical shelter to stay for more than seven nights, and had little likelihood of obtaining accommodation in the upcoming month. Individuals who were absolutely homeless may have been discharged from an institution, prison, jail or hospital with no fixed address (Goering et al., 2011). Precariously housed individuals had a primary residence of a Single Room Occupancy, rooming house or motel/hotel. Additionally, precariously housed individuals had experienced two or more episodes of absolute homelessness within the past year (Goering et al., 2011).

In total, 219 baseline consumer narrative interviews were conducted between December, 2009 and June 2011. More males (61.6%) were interviewed than females (36.1%) and transgendered persons (2.3%). Of the participants, 83.1% were born in Canada, while 16.9% of participants were born in other nations. The mean age was 41 years old, and ethnicity was representative of the full study sample (22% Aboriginal and 25% from ethnoracial groups).

Of the participants interviewed at baseline, 90.9% had been hospitalised for a psychiatric problem for more than six months within the past five years. Participants reported recently experiencing a major depressive episode (52.1%), a manic or hypomanic episode (16%), PTSD (27.3%), panic disorder (25.1%), a mood disorder with psychotic features (22.4%), a psychotic disorder (32%), substance dependence (50.2%), alcohol dependence (32.9%), alcohol abuse (18.3%) and substance abuse (26%).

Study sites

Metropolitan Vancouver is Canada’s third largest urban area, with a census metropolitan area (CMA) population of 2,313,328 (Statistics Canada, 2011). Vancouver, with a census subdivision population of 603,502, is also home to the infamous downtown Eastside, where homelessness, drug addiction, and other health and psychosocial problems are rampant and highly visible. The 2008 Metro Vancouver Homeless Count found 1372 people who were homeless in the City of Vancouver (Patterson et al., 2012a). The interaction between precarious housing and illicit drug use has been found more prevalent in Vancouver compared with other Canadian cities, such as Toronto (Fischer et al., 2005). Low-income housing options in Vancouver for individuals with mental illness and substance use problems are typically in congregate settings (City of Vancouver, 2011).

Winnipeg is the capital and largest city (CMA population 730,018, census subdivision population of 663,617) in the province of Manitoba (Statistics Canada, 2011). Winnipeg has the largest population of First Nations people living off reserve (25,970). While there has never been a census of homelessness in Winnipeg, it has been reported that there are at least 350 people living on the streets and 1900 people who use shelters on a temporary basis (Isaak, 2012).

Toronto has the largest urban population in Canada, with a CMA population of 5,583,064 and a census subdivision population of 2,615,060. Of Toronto’s population, 46% are immigrants (Statistics Canada, 2011). Immigrants are becoming one of the fastest growing subpopulations among the homeless in Canada, due in part to difficulties securing employment and discrimination (Enns, 2005). The diversity of Toronto’s population contributes to the complexity of the problem of homelessness (Hwang et al., 2012). The Street Needs Assessment conducted in Toronto in 2009 estimated that there were more than 5000 homeless people in Toronto on that night (Kirst et al., 2012). Toronto is considered to be a ‘service rich’ urban centre, with a large array of shelters, drop-in centres, street outreach services and supportive housing programmes (Hwang et al., 2012).

Located in the province of Québec, Montréal is Canada’s second largest metropolitan area. Montreal has a CMA population of 3,824,221 and a population of 1,649,519 in the census subdivision of Montreal (Statistics Canada, 2011). The number of people in Montréal who were homeless for at least part of 2005 was estimated at 30,000 (‘Cadre canadien en matière de logement 2005’, in RAPSIM, 2008, as cited in McAll et al., 2012). In Montreal, several government departments provide particular services and support, and partnerships exist between the community and public sectors (Fleury et al., 2014).

Moncton, the largest city in New Brunswick, is one of the fastest growing cities in Canada with a population 69,074 in the city of Moncton and 138,644 in the CMA of Greater Moncton (Statistics Canada, 2011). The number of homeless individuals who received services from shelters in the Greater Moncton area in 2006 was 946. Relative to the other sites, Moncton is the most resource deprived in terms of housing and community mental health services (City of Moncton, 2009, as cited in Prevost et al., 2012). In rural Moncton, the lack of transportation to support services is a barrier. Halfway houses and long-term nursing homes are often used by homeless individuals in rural areas, many of which are not designed for individuals with mental health problems (Prevost et al., 2012).

Study design and data collection

In-person, individual narrative interviews were collected from participants at baseline, before or shortly after they were enrolled in the project, using a Baseline Consumer Narrative Interview Guide. Sample questions included: What was life was like before you started living on the streets or in a shelter?; How did you first become homeless?; Please tell me about any barriers that have stood in the way of your attempts to find and keep housing. Interviews were conducted in offices affiliated with the project, service agency offices, participants’ apartments and public settings. Interviews lasted between 45 and 90 minutes, and field notes were written following the interviews. All interviews were audiotaped and transcribed verbatim.

After receiving REB approval, informed consent was obtained from all participants as they were initially screened for project eligibility, and prior to the start of the baseline narrative interview. Participants were informed that the purpose of the interview was for them to tell their stories regarding living on the streets and in shelters, and within the mental health system. The participants were assured that a decision not to participate would not affect their housing or services. The participants were compensated through a cash honorarium of between $20 and $30 for their time and transportation expenses.

Several measures were taken to ensure rigor and data quality. All interviewers were trained on how to administer the Baseline Consumer Narrative Interview Guide. Site research coordinators listened to initial audio interviews and provided feedback to interviewers. In addition, the National Research Team randomly reviewed five audio and transcript files per site to ensure quality and to provide further feedback. The National Team used a quality control checklist to ensure that all questions and probes were asked during the interviews. Comments were also provided regarding the clarity of the interviewer’s questions, building rapport and avoidance of judgement or bias (Kvale, 1996; Mack et al., 2005).

Coding and analysis

The site teams used procedures for coding that are consistent with constant comparative analysis and grounded theory (Charmaz, 2006; Strauss and Corbin, 1990). Initially, the researchers performed a line-by-line coding procedure to identify central concepts, and then these codes were transformed into higher level categories by grouping similar codes into thematic categories (Charmaz, 2006). NVivo and other qualitative data analysis software were used to facilitate the coding process. To ensure analytic rigor, the research teams independently coded several transcripts and met to discuss the preliminary codes. Research team members continued to double code several transcripts to compare the accuracy of the codes and to refine them, as needed. Each site then provided a detailed report of the findings, using a template that was developed by the National Team. The National Team evaluated and synthesised the findings from each report, culminating in a national report of the At Home/Chez Soi baseline narrative analysis. This article is based on key findings of the national report, which described cross-cutting themes from the baseline participant narratives across the five research sites (Piat et al., 2012).

Results

Four central themes emerged regarding the pathways into homelessness and barriers to exiting homelessness. Participants emphasised the importance of individual factors and the manner in which they interact to influence homelessness (Theme 1). Some participants indicated that structural transitions from foster care and institutional settings significantly contributed to their pathways into homelessness (Theme 2). Findings also revealed that structural factors created barriers to exiting homelessness, leading to a sense of entrenchment (Theme 3). Structural factors further amplified and exacerbated the individual risk factors (Theme 4).

Theme 1: Interplay among individual factors

The participants described the manner in which several individual factors, including substance abuse, trauma, family conflict and violence, relationship problems and mental health symptoms interacted and eventually led to homelessness. Many participants explained several factors that contributed to the initiation of their substance abuse. They went on to describe the negative events that resulted from their substance abuse, eventually leading to homelessness. Some participants indicated that the problem of substance abuse was intergenerational in nature:

I was born addicted to heroin. My aunt’s a drug dealer, my mum’s a junkie, so … I tried it and I liked it.

For many participants, substance abuse was triggered by and linked with experiences of trauma and loss. For example, one participant reported that the tragic loss of her daughter led to her substance abuse problems, and to eventual homelessness:

My daughter died. She was killed by a drunk driver. And it just sent me over the deep end and I ended up blowing a million and a half dollars over the last 10 years. I totally lost it. I didn’t care about anything.

Additionally, participants described how substance abuse contributed to relationship instability and loss:

I was working and I had a girlfriend and I planned on marrying her … I had a good full time job and I was, you know, I had responsibilities and pretty much ran a factory … I was production coordinator, and the girl, she’s beautiful and loved me and all that stuff, but the booze finally took over that.

Many participants described substance abuse and relationship problems as interrelated factors that culminated in homelessness:

Yeah, it’s usually drugs and alcohol [that leads to homelessness]. I would say [drugs and alcohol] would be like 90 percent and 10 percent would probably be like interpersonal relationships, you know, living with a friend, get into a fight, you know, a girlfriend …

So it was my addictions that brought me down and unhealthy relationships with men. That was because I trusted them, believed in them and they just like lied to me …

Participants also reported that severe family conflict and violence was a precursor to homelessness. For many, family conflict and violence escalated during adolescence. Participants ran away or were kicked out of the home:

My father was an alcoholic truck driver, very cruel, very mean … I mean, he broke my arms, he broke my collar bone, he fractured my skull, he locked me in a foot locker, he beat me with my own guitar … just crazy. I started running away from home when I was probably nine … by the time I was 13, I was on my own.

Additionally, participants described the interplay between family conflicts and substance abuse. For many, substance abuse continued or worsened once they began living on the street:

I was kicked out at age 16 to live on my own. And at the time, I was drinking alcohol and stuff and living on my own, and I spent the cheque and everything and I got put on the … out to my friends there on the street.

The experience of mental health symptoms also played a role in initial homelessness. Like the trajectories above, mental illness was not identified as an isolated experience, but was described as an experience that interacted with other factors, such as relationship problems and substance abuse. As many participants explained, a number of stressors and losses contributed to the development of mental health issues and eventual homelessness:

A lot of stuff contributed to my mental health problems: relationships, kids, people passing away when you’re not there, other things. Stuff that you weren’t there for when you could have been. There are lots of things. I can’t really pinpoint each one. It just builds up and builds up, right? And then you’ve got your own thing to handle that you’re not letting anyone know about, so it all just builds up and comes out.

Mental health issues contributed to relationship strain and to the loss of social support:

The lowest point was when my mom had to, to let me go. I had to start living on the streets … yeah, it was the lowest point. I had no job. I had no money. I had to live on the streets and at the homeless men’s shelter.

Participants also spoke about an important link between mental health issues and substance abuse, both of which contributed to homelessness. For some, substance abuse was a means of coping with mental health symptoms:

I felt like there was something wrong with me because the first time I did cocaine – I was 14 – it felt like the missing part of me … it made my thoughts and feelings clearer.

Similarly, for other participants, the experience of mental health issues contributed to substance abuse, which then led to homelessness:

I bounced around for a while, I got heavily into pills and because I was depressed, I didn’t see a way out and I was young, my source of income was gone and then slowly bit by bit I couldn’t afford housing anymore so then I went into a shelter.

Other participants believed that their substance use led to the development of mental health symptoms, and to eventual homelessness:

After I started using drugs like marijuana and I started drinking, then I just became very psychotic. Like it all escalated since then.

Theme 2: Transitions from foster care and institutional settings

Participants emphasised the contributing structural role of problematic transitions from foster care and institutions (including group homes and juvenile justice settings) into the community. Participants reported experiencing frequent moves between the homes of different family members, foster homes or institutional settings.

In the context of foster care, many participants described the difficulties associated with being separated from particular family members or siblings. In particular, Aboriginal participants in Winnipeg frequently discussed conflicts related to foster care.

They put me in a house with a family of more than six children, mother, father. Worse, they put my younger brother with another family. He [the husband] drank every weekend … the woman [the wife] ran into the attic all the time because she did not want to fight with him.

Numerous participants described being abused while in foster care:

At the age of five, I was in a foster home until the age of 18. It was not easy … there’s not a day that I was not beaten by my foster mother, and worse, from age five until 18, my foster father molested me.

Aging out of foster care marked a key trajectory leading to homelessness. Participants exited foster care without continued support from their foster families, and lacking concrete plans for transitioning to independent living in the community or to other supportive care settings.

I was living in foster homes. And it was okay in foster homes but after I was 18, they kicked me out and I was on my own, they didn’t teach me nothing. It was more like ah, you know, you’re 18 so get out and, you know, we don’t want to know you anymore.

Participants who transitioned from institutional environments also described lacking the skills necessary to be successful in the community. Many reported being released from institutional environments without concrete plans or assistance in preparing for this transition:

Cause when you get out, after, like you do more than five years, you don’t know how to live out here … you know, I didn’t know how to go to the Welfare Office and fill out a form.

Theme 3: Becoming entrenched: Substandard housing, unsafe and drug-involved neighbourhoods

While the majority of participants described the interplay of individual factors, they also described structural factors and processes that sustained homelessness. These structural factors presented barriers to securing stable and adequate housing. Participants described how structural factors, including poverty, lack of affordable housing, stigma, racism and discrimination trapped them in dilapidated, unsafe and drug-involved neighbourhoods. This led the participants to experience a sense of entrenchment, and further marginalised them from mainstream community life.

Once the participants became homeless, they described how difficult it was to secure housing due to their perceptions of structural barriers:

I was homeless for almost three years. I did get kicked out of my place for no reason, but I said, Okay, I’m going to try to figure out, like what is it to be homeless? How can we get out of homelessness? It’s not an easy thing to do. As soon as you get outside and you get kicked out, you turn around and there’s nothing! There’s nothing around! It took me two years to find a place. I passed through two winters. There was some shelters and everything … But the system makes it very hard to get back on your feet.

Poverty and financial strain significantly limited access to housing for participants. The housing that the participants were able to afford was described as unsafe and undesirable, as they were exposed to violence and heavy drug activity. Some chose to leave unsafe housing for shelters or the street:

My room was getting broken into and all my stuff was getting stolen … and uh, people – there were drug dealers that lived above me, and they were assaulting girls upstairs and I could hear it perfectly, you know? I just left whatever I had there and I never went back … cause I was too scared.

Many participants cited the lack of affordable housing as an additional barrier to exiting homelessness. Housing that was in their price range was substandard and undesirable:

Nobody wants to be homeless. There’s not enough housing in this area. You go looking for minimum 375 and all you’re going to find is cockroaches and bedbugs and all that kind of stuff so … I’ve tried it.

Participants also reported that stigma, racism and discrimination created barriers to securing housing, further exacerbating their experiences of marginalisation. Being identified as a homeless person isolated the participants from the mainstream community:

I’m an outcast. All the time, you’re not part of the community. Even being on welfare and going to the bank, you don’t feel a part of the community … people still look down on you and you can’t do anything.

Additionally, many experienced discrimination as they attempted to find housing, as a result of their homelessness or welfare status:

[The landlord] said, ‘Oh, you’re on a junkie’s pay plan’. He was all, ‘Buddy, if you’re on welfare, you’re on some sort of dope and I don’t want that in this house, or your friends’.

Some participants identified racial and ethnic discrimination as factors that contributed to continued homelessness, as membership in marginalised groups created additional barriers to securing housing:

Being Aboriginal and homeless in Winnipeg sucks. You know, I hate to say it, but it’s the truth. You can have three Aboriginal homeless people and one white homeless person, and that white homeless person will get the help before the other three. And they’ll get a home before us, they’ll get help before us, and you know, it’s like people like to say it’s not true, but it happens everyday.

Theme 4: Structural amplification of individual risk

Participants also described how structural factors leading to entrenchment in substandard housing and problematic communities exacerbated the individual risk factors and behaviours that initially led to homelessness. Some reported that living in communities with heavy drug activity worsened their substance abuse problems:

People get into a trap. You know, welfare – they only pay so much, right? And what are you going to do? If you’re stuck downtown, and that’s the only place you can afford, and what’s around you? Drugs. So what do you do? Your next door neighbour does it. You’re just in a trap and you can’t really get out.

Because services tend to be centralised in unsafe neighbourhoods, homeless individuals are forced to spend time in these areas, thus creating further risk:

I won’t go there [Main and Hastings] if I don’t have to … It’s not good. It makes me aggressive. Like, one look makes me want to start drugs. I think, Oh my God, I can’t wait, I can’t wait to get out of this.

Additionally, the experience of being homeless forced participants to attend to their immediate survival needs. As many explained, while they struggled to find shelter and to protect themselves from the elements, their overall condition suffered:

If [housing] is unstable then my health is poor because then the primary concern for me is that housing I have to get … especially in the dead of winter. So, I have to let go of my physical and mental health as well, eh? Until I get the home again.

Discussion

This study demonstrates the interplay between individual and structural factors in pathways into homelessness, as described by individuals with lived experience. While the themes described above were consistent across the five research sites, each site highlighted contextualised sub-themes. For instance, participant narratives from Vancouver emphasised the intergenerational cycle of poverty, abuse, mental illness and substance abuse. In Montreal, female participants in particular described histories of abuse that contributed to their predicament. Aboriginal participants in Vancouver and Winnipeg reported histories of housing instability in early life, due to moves on and off a reserve, as well as continued experiences of discrimination from landlords. Participants in Montreal reported relying on homeless peers to inform them about support services in the city, while participants in Moncton described how a general lack of services, particularly in rural areas, made it difficult to exit homelessness.

As the social ecological model suggests, risk factors for homelessness must be understood in context, by focusing on interactions across multiple levels of analysis (Toro et al., 1991). The majority of participants viewed interacting individual factors as most salient regarding their pathways into homelessness. Participants highlighted how interactions between multiple individual factors contributed to significant accumulating risk. The emergence of interacting individual factors regarding pathways into homelessness is consistent with previous findings, which suggest that homelessness is a process rather than the result of a single precipitating event (Martijn and Sharpe, 2006).

Participants described child abuse and family violence as contributing individual factors that in some cases worsened substance abuse. Many reported running away from home or being kicked out of the family home during adolescence, which is consistent with previous research (Williams and Stickley, 2011). The participants articulated that their mental health issues developed as a result of the accumulation of stress and personal loss. The presence of mental health symptoms contributed to the loss of relationships and social support, also worsening substance abuse for some. Substance abuse also interacted with relationship problems and mental health symptoms. Substance abuse was often triggered by the experience of trauma and loss, a finding that has been described in previous studies (Lowe and Gibson, 2011; Williams and Stickley, 2011). Further, substance abuse contributed to relationship strain and instability, and ultimately to the loss of social support.

Although the individual factors emerged strongly in the data, many participants described how the structural factor of transitioning from foster care and institutions, including jails and psychiatric hospitals, contributed to homelessness. Aboriginal participants in Winnipeg frequently described adverse experiences related to foster care, while participants across all of the research sites commonly described experiences of institutionalisation. Those who aged out of foster care described being ill prepared to transition back into the community, a sentiment that was also expressed by individuals transitioning from institutional placement. Participants described the lack of supports and plans for successful transitions. As other studies have indicated, transitioning from foster care and institutions into the community is a common trajectory leading to homelessness, as foster youth have few connections with supportive adults and are often ill prepared for independent living (Pecora et al., 2005; Zugazaga, 2004).

Notably, participants described structural factors as most influential to prolonged and continued homelessness. The interplay between individual and structural factors emerged as participants described the manner in which structural factors amplify the individual factors that initially contributed to homelessness (see Toro, 2007). The experience of poverty and a lack of affordable housing significantly constrained the mobility of participants, consistent with findings from previous studies (Morrell-Bellai et al., 2000). This resulted in further isolation from the community and continued marginalisation. Some participants described leaving their housing due to concerns about violence and drug activity. Others described the system and welfare in particular as a ‘trap’ that kept them in unsafe neighbourhoods with significant drug activity. The stigma of homelessness isolated participants from mainstream society through discrimination in the housing market, and by prohibiting meaningful community inclusion. For some enthnoracial and Aboriginal participants, the experience of racism and discrimination created an additional barrier to exiting homelessness.

Strengths and limitations

This study is the first of its kind in Canada, providing a Pan-Canadian analysis of pathways into homelessness, from the perspectives of individuals with lived experience. The large sample (n = 219) includes individuals from diverse racial and ethnic backgrounds. The narrative interview protocol successfully elicited rich, storied accounts of the lived experiences of homeless individuals who experience mental illnesses and substance abuse. The perspectives of these individuals elucidated the many factors that they perceived to most significantly contribute to and sustain homelessness.

There are several limitations to the study. Because interviews provide a space for the interviewer and interviewee to jointly construct a narrative (Patterson et al., 2012b), it is difficult to interpret the extent to which each social interaction may have shaped the narratives that were elicited. The narrative data were not triangulated with other sources or methods. An additional limitation is that the sample represents a subgroup of the homeless population: individuals with mental health and substance abuse problems. Thus, findings may not generalise to the increasingly diverse population of homeless individuals in Canada (Gaetz, 2010). Further, as participants described their lived experiences, individual factors, such as substance abuse and relationship problems may be more salient to them, as opposed to more macro-level structural factors. Other research methodologies can more appropriately describe the relative influence and weight of different factors. The contribution of this study, however, was to provide a better understanding of how individuals who experience homelessness perceive the role and interplay of individual and structural factors in leading to and sustaining homelessness.

Conclusion

Consistent with the social ecological model, social policies and interventions must address the pervasive structural issues and contexts that keep individuals homeless in order to effectively serve those with significant and complex individual risk factors. Evidence suggests that policy changes in Canada contributed to the homelessness crisis (Gaetz, 2010). A gradual reduction in spending on affordable and social housing in Canada began in the 1980s, culminating in the dismantling of the national housing strategy in the mid 1990s. The federal housing policy shifted from direct investment in housing to a focus on lowering interest rates and providing tax incentives to encourage home ownership (Bunting et al., 2004; Gaetz et al., 2013). This reduction is spending was exacerbated by the significant decline in affordable housing, rising unemployment and increasing socio-economic polarisation. Socio-economic polarisation continues in Canada, with a receding middle-income population and a higher distribution of individuals at either end of the income range (Hulchanski, 2010). Upper income households have benefited from this change, while lower income households have faced considerable economic strain and precarious employment opportunities (Bunting et al., 2004). According to the Wellesley Institute (2010), Canada is falling behind other advanced economies on a number of housing-related measures, such as poverty, income inequality and public expenditures on affordable housing.

Recent policy changes mark modest steps in the right direction. The federal government renewed the Homelessness Partnering Strategy (HPS), a programme that partners with communities, provinces, territories, federal departments and private and not-for-profit sectors in efforts to address homelessness. Specifically, the Government of Canada’s Economic Action Plan 2013 is refocusing HPS funds on programmes using the HF approach, given the strong evidence of the effectiveness of HF in reducing chronic homelessness in Canada (Mental Health Commission of Canada National Final Report, 2014).

As a policy strategy, the refocus on HF shifts the response to homelessness away from temporary and emergency provisions, such as shelters, to long-term, permanent housing. The basic premise of HF is that housing individuals immediately without preconditions helps to alleviate their immediate and ongoing survival struggles, allowing them to address the individual risk factors that contributed to initial homelessness (Tsemberis et al., 2004). Some components of the HF approach assist homeless individuals in overcoming structural barriers to exiting homelessness. For instance, rent subsidies reduce the burden of housing costs, and support services promote community integration.

Modest reinvestments in housing, provincially and nationally (Gaetz, 2010), the development of strategic plans for ending homelessness and research funding to evaluate effective interventions have also marked positive steps toward addressing homelessness in Canada. However, the need remains for a long-term, well-funded housing strategy at both the national and provincial level that prioritises affordable housing. National and provincial governments must also support local responses to housing and homelessness, including comprehensive plans for ending homelessness, which can more effectively account for contextual factors and specific community needs (Hulchanski, 2010).

In research, practice and policy, it is critical to move beyond dichotomous perspectives on homelessness as an individual or structural phenomenon to a transactional view consistent with social ecological perspective. Multifaceted responses are needed to support homeless individuals as they attempt to both ‘manage the transitions in their lives and to overcome systemic inequalities’ (Enns, 2005: 119). Social ecological perspective provides a lens for understanding homelessness in Canada as a complex social issue that warrants a coordinated response across sectors, levels of government and society.

Footnotes

Acknowledgements

We thank Jayne Barker, PhD, and Cameron Keller, Mental Health Commission of Canada National Project Leads, approximately 40 researchers, and the five Site Coordinators and numerous service and housing providers, as well as persons with lived experience for their contributions to this research.

Funding

This research has been made possible through a financial contribution from Health Canada. The views expressed herein solely represent the authors.

Notes

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