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A home of their own
An innovative housing project is helping homeless people like Michael Enright get a new lease on life
Michael Enright takes a sip of coffee before setting his cup down on the kitchen table and turning his attention to the task at hand.
A sampling of his nature photography and poetry is to be featured in an exhibit entitled Focusing the Frame, and he's writing his biography for the show. Reflecting on his life, he jots down the major milestones: Born in Manitoba. Raised in Minnesota. Father of two children. University educated.
On paper, the words conjure up the image of a middle-class professional, a solid family man with a good life and a bright future - just the kind of person Enright once aspired to be. But the hard truth is that Enright's life is not as neat and tidy as those milestones might suggest. Indeed, just a few years ago, the very notion that Enright would be sorting out photos and poems for an exhibit while relaxing in his own home would have seemed more than a little unlikely.
That's because Enright has spent much of the last decade living on the streets, one of many who spend their days wandering Winnipeg, sleeping in abandoned buildings or grabbing a cot for a night at a local shelter.
That only changed in the fall of 2009 when Enright enrolled in a housing research demonstration project called At Home/Chez Soi that would eventually count 505 homeless Winnipeggers among its participants. Sponsored by the Mental Health Commission of Canada and funded by Health Canada, the initiative is testing a new approach to housing the country's mentally ill homeless, one that promises to provide homeless people like Enright with a new lease on life.
Path to homelessness
Michael Enright did not enter this world homeless. Born to a Cree mother, Enright was adopted in the 1960s by a family from St. Paul, Minnesota. In his early years, life was pretty straightforward. He graduated from high school and went on to study at the University of Minnesota. A bright young man, he obtained a degree in Medical Technology with a Chemistry minor, then landed a job working in the hematology lab at the University of Minnesota Medical Centre. He got married and had two children, a boy and a girl.
Then at the age of 27, Enright's life took a sudden twist. While working at the medical centre, he experienced feelings of depression. A doctor started him on a round of anti-depressant medication, but by the spring of that year, he had a manic episode and couldn't sleep. After three weeks, he finally wore down and, in a state of confusion, landed in hospital for six months with a diagnosis of bi-polar disorder.
After he was discharged, he decided a change of career was in order. He trained to become a commercial electrician, and worked at that until 2002 when he had another manic episode. At this point, Enright began wandering the continent, doing odd jobs. He would save money and spend it on Greyhound tickets, travelling to places like Seattle, Phoenix and Mobile, and on up to Canada. He lost track of his family.
Eventually, he landed in Squamish, British Columbia, where a woman helped him locate his birth mother, who was living in Winnipeg. "I came to Winnipeg in 2005 and met my mom and a brother and two sisters. It was good meeting them," says Enright. But he couldn't keep up with his medications, so he ended up getting sick and seeking treatment in Winnipeg. Then he was back on the road.
In 2008, Enright returned to Winnipeg to get to know his birth mother better. By this time, he was homeless, living on the street or staying at the Salvation Army shelter on Main Street. He even slept a few nights in the vestibule of a bank building, taking shelter from Winnipeg's nasty winter temperatures. He was living on hand-outs and dealing with multiple social agencies.
Then, once again, something happened to change Enright's life.
A case worker of Enright's had heard about At Home/Chez Soi and its plan to offer housing to the homeless as part of a demonstration project. He asked his hardluck client if he would be interested.
Enright jumped at the possibility of having a home of his own. His feelings about that moment, he says, are best captured by a photo he selected for the Focusing the Frame exhibit that shows a bright green caterpillar lifting itself over broken pavement.
"I wanted to get away from the bed bugs and the run-down hotels and the cold," he says about moving into his own place in February 2010. "The caterpillar is in trouble. If it doesn't find food and shelter, it won't last to become a butterfly. That was me."
A possible solution
Sad as it may be, Enright's tale is not so unusual.
It is estimated that there are over 2,000 homeless people wandering the streets of Winnipeg, sleeping in vacant buildings, spending nights in a shelter or couch surfing at friends' and relatives' homes. According to At Home/Chez Soi, the homeless come from all walks of life, and include middle-class professionals, trades people, and artists. Some are simply out of work and out of luck. Others suffer from mental health issues or addictions to drugs, alcohol or gambling, which have left them unable to function in society. As a report by At Home/Chez Soi notes, they all have one thing in common: "At one point in time, their life mattered. Now, many feel alone, abandoned and forgotten."
Enright's problems can be traced to his mental health issues. Lacking a support system and unable to stay on his medication, he seemed destined to live the rest of his life without having a home to call his own, until At Home/Chez Soi came along.
The seeds for the research demonstration project were planted several years ago when a Senate committee chaired by Senator Michael Kirby launched the most extensive consultation on mental health ever conducted in Canada. That process eventually led to the publication of a report in May 2006, entitled Out of the Shadows at Last.
The report looked at mental illness from the perspective of both the mental health and health-care systems in Canada. Among other things, it noted that homelessness is a serious and growing problem. It estimated that there are between 150,000 to 300,000 homeless people living across the country, including many who have some form of mental illness.
A separate report produced in 2011 by the Main Street Project painted a more detailed picture of Winnipeg's homeless. It noted that as many as 75 to 80 per cent of Winnipeg's homeless are Aboriginal, and that 45 per cent of the people needing emergency shelters in the city have been diagnosed with mental illnesses such as depression, addiction, anxiety, manic depression/bi-polar disorders and schizophrenia.
The same group suffers from many physical ailments. Chronic bronchitis, anemia, foot, eye and ear problems, Hepatitis C and an increased risk of contracting tuberculosis are just some of the health issues facing Winnipeg's homeless. They can also be users of drugs such as marijuana, pain killers, crack, sedatives and solvents.
Homelessness also has an effect on the health-care system, one that can be quantified at the monetary level. Experts in the field say many homeless people end up being high-end users of the system, in many cases because they have no home. For example, the Main Street Project report noted that it costs $1,482 per day to treat someone in an acute care bed in hospital, compared to $16.37 per day to pay for a bachelor apartment. That's $491 a month in housing, compared to $44,460 a month in hospital.
The Kirby report recommended a number of actions be taken to address the plight of the mentally ill homeless. Chief among them was a recommendation to study a novel approach known as "Housing First."
Pioneered in New York in 1992, the Housing First concept differs significantly from the traditional approach to sheltering people living on the street, known as "Treatment First." Under the Treatment First approach, individuals are required to adhere to conditions such as mandatory counselling, curfews and abstinence from alcohol and drugs in order to move into supportive or transitional housing. They may also be required to take medications for mental illness.
Under the Housing First approach, people are allowed to move into a home without having to accept any conditions. This concept also favours a harm reduction approach to addictions rather than mandatory abstinence.
Health Canada, which funds the Mental Health Commission, wanted to know whether the Housing First approach would be more effective in housing the mentally ill homeless and providing other benefits and potential cost savings. In order to find out, the Mental Health Commission established At Home/Chez Soi.
The research begins
With a budget of $110 million and a five-year mandate that ends in March 2013, At Home/Chez Soi is one of the most ambitious projects of its kind anywhere in the world.
Not surprisingly, organizing the logistics of such a research project was no simple matter. Five Canadian cities are taking part in the study - Vancouver, Winnipeg, Toronto, Montreal and Moncton. Over 2,200 homeless people are included, out of which over 1,030 people are receiving housing and services.
Marcia Thomson is the Site Coordinator for At Home/Chez Soi in Winnipeg. She says the agency began laying the foundation for the project by forming partnerships with university researchers, the Winnipeg Health Region and close to 80 community organizations, including three key ones: Mount Carmel Clinic, the Aboriginal Health and Wellness Centre of Winnipeg and the Ma Mawi Wi Chi Itata Centre.
"Our first year was spent working in the community, talking about the project and how it could fit the need in Winnipeg," says Thomson. "Each of the five cities has a unique environment, and we wanted to tap into the existing service agencies who work with the homeless, in order to help our plan get legs under it. We talked about the population of homeless and how the Housing First model would work in Winnipeg. The homeless experience trauma, isolation and rejection. Many are victims of the child welfare system, and are involved in the justice system. Many are living the legacy of the Aboriginal residential school system."
As the demonstration project took shape, the division of labour became clear. University researchers would interview participants in the project and collect and analyze the data. The Winnipeg Health Region would help find homes for the homeless, while the community organizations would provide the front-line support to participants.
Eventually, more than 500 Winnipeg homeless people were identified as candidates for At Home/Chez Soi. Each one was interviewed by researchers from the University of Manitoba's Department of Psychiatry and the University of Winnipeg's Institute of Urban Studies. The candidates were then randomly divided into two groups: the first is a control group of 230 people receiving "treatment as usual" with no interventions; the second group was offered a place to live and support services based on the Housing First and harm reduction models.
"It (the enrolment process) was a long and somewhat stressful process, especially if a person was randomized into the treatment as usual group," says Dr. Jino Distasio, Associate Professor of Geography and Director of the Institute of Urban Studies at the University of Winnipeg, and co-principal investigator for the Winnipeg site. "Everyone wanted to get into housing. But as the study has progressed, we've talked with the people who didn't. They feel they're an important part of the study, helping us show what happens when intervention doesn't occur."
At Home/Chez Soi research will make a cost comparison of the effects on the health-care system, looking at what it costs to keep a mentally ill person in a home, compared to serving their needs on an emergency basis at a hospital or other service agency, says Dr. Jitender Sareen, Professor of Psychiatry and Psychology at the University of Manitoba's Faculty of Medicine, and Director of Research and Anxiety Services in the Department of Psychiatry at the Health Sciences Centre.
"The group of people we are studying are highly vulnerable," says Sareen, who is the other co-principal investigator for the Winnipeg site. "People (who are homeless) are more likely to die than the average person in Winnipeg. The homeless have a high rate of illness, mortality, suicide and hospitalization. They are high consumers of resources."
Recruitment into each group was finished in June 2011, with 275 people randomly selected for the housing and service side of the program. All project participants are interviewed every three months for a two year period following enrolment. Researchers look at their physical health, mental health, social wellbeing, housing stability and ask about their life stories and life goals.
"We ask participants questions regarding their housing and vocational history/ activities, perceived housing quality, landlord relations, mental health, physical health, quality of life, food security, health, social and justice service use, community integration, mobility history and trauma history," says Corinne Isaak, research associate with the Department of Psychiatry at the University of Manitoba's Faculty of Medicine, and research coordinator for the Winnipeg At Home/Chez Soi project.
By the end of the project, researchers will have a good idea of how participants fared under the Housing First approach, including whether they were able to stay in their home for an extended period of time, stay on their medications, or learn to control their addictions. As a recovery program, the goal of At Home/Chez Soi is to help people lead a better, safer and healthier life.
Unlike participants who are housed, the treatment as usual group is tracked only by the researchers. Interviewers meet people at social service agencies, shelters, meal programs, project service team centres and coffee shops. Interviewers also go to Health Sciences Centre and other city hospitals, as well as the Selkirk Mental Health Centre. They have access to most of the judicial institutions in and around Winnipeg, says Isaak. "Typically the location is wherever the participant feels comfortable and has easy access to," she says, adding that the follow-up rates for the housed and the treatment as usual groups are similar, at around 90 per cent.
The road to recovery
Soon after being enrolled in At Home/ Chez Soi, Enright was moving into his new home - the back half of a duplex in Point Douglas.
His new place came with the basics: a bed, table and chairs, cooking and bathroom gear, plus some living room furniture. It was spare, but compared to the homeless shelter, it was spacious, it was clean, and it didn't have bedbugs. Simply put, it was home.
"The best part was that I could get my dog, Mandy, from where she was staying on a farm in Altona," he recalls during an interview in his home as he rubs an affectionate hand over Mandy's head, while her pup, Pete, crowds in. "Dogs aren't allowed in the shelters, and it was too much to ask her to live on the streets. It was just a start for me, but it meant so much."
As a member of the Housing First group, Enright was enrolled with the Wi Che Win service team run by Ma Mawi Wi Chi Itata Centre - one of three agencies providing front-line services to the 275 Housing First clients. The other service teams are the Assertive Community Treatment (ACT) team, operated by Mount Carmel Clinic, and the Ni Apin team, run by the Aboriginal Health and Wellness Centre of Winnipeg.
All the teams include people with "lived experience," meaning they either have been homeless or are a relative or friend of someone who has lived on the streets. Some have battled addictions and/or mental health issues. They know what it takes to survive on the streets and can relate to the people in the program.
The front-line worker's job is to coach a case load of 15 people into maintaining their housing, while learning to get illnesses under control. They sit with people, sometimes without talking, patiently waiting until the client feels ready to share some of their life experiences, concerns and what they want to do with this opportunity. They find their clients in jails, in hospitals, in the depths of despair and in towering rages. They liaise with landlords, and talk with workers in agencies such as Employment Income Assistance, Justice and Child and Family Services. They inform people about the options available to them to deal with their addictions and life traumas, such as detox programs, addictions counselling, talking with Elders, learning about their culture and attending sweats.
The ACT team works with 97 participants, mostly First Nations or Métis, many who have severe mental health issues. The teams' spirit name is "Wiisocotatiwin," which means "working to help others find their cherished gifts." Corrine Warkentin, Program Manager, says, "Our participants are gifted people." Many are artists and poets. They are educated, have held jobs and raised families.
The ACT team supports participants in the area of justice, housing, life skills, and emotional, spiritual, mental and physical health. The team incorporates traditional values and healing in working with participants, through sharing circles, traditional ceremony and other teachings. ACT is made up of a psychiatrist, program manager, team leader, nurses, peer support, housing, justice and family support workers. But what makes the team unique is the trauma worker. Warkentin says the trauma worker is needed because many of the participants are survivors or intergenerational survivors of residential schools and the child welfare system. "We're working with deeply traumatized people who have experienced much abuse," she says. "They are amazing and resilient people and have survived so much."
Ni Apin works with 79 project participants, who they refer to as "constituents" and uses the medicine wheel as a basis for how to teach people to walk their own journey to health, using both contemporary and traditional healing methods. Ni Apin has a drop-in centre with a kitchen, computers and a clothing depot, plus the services of five support advocates, a housing procurement specialist, and a psychologist. A cultural advisor is available one day a week.
"All our constituents are Aboriginal," says Darlene Hall, Executive Director of the Aboriginal Health and Wellness Centre of Winnipeg. That compares to 55 to 65 per cent of clients reported to be Aboriginal on the other two teams. "We use a ‘made-in-Winnipeg' model that uses holistic methods which incorporate traditional and contemporary methods," says Hall.
Ni Apin's variation on the medicine wheel shows constituents where they start on the wheel and where they can progress to. "People can look back to where they were six months ago, and see their progress. It gives them a sense of accomplishment. It's all about learning balance in their lives," says Hall, adding that Ni Apin will offer classes in literacy and pre-employment skills in 2012, as people learn to overcome their addictions and are ready to move forward.
Ni Apin support advocates try to touch base with each of the 15 people on their list once a week. Hall says they spend a lot of time looking, because many of the formerly homeless people find that living in a small apartment is too lonely, so they often go out and seek their friends. Support advocates look for them in the shelters, food banks, medical clinics and other places they know their constituents like to hang out, says Hall.
Wi Che Win is responsible for 99 project participants. They use an intensive case management system, with five case managers working five days a week. They offer a drop-in with a kitchen, the services of a psychologist, and cultural events such as sweats and elders' teachings. They have women'sonly and men's-only groups. Their goal is to build a community that will last long beyond the At Home/Chez Soi project.
"Our program is set up to follow the seven sacred teachings, as a complement to western medicine," says Betty Edel, Program Manager of Wi Che Win. "Rather than treating mental illness with medication only, we seek to help people work through their personal traumas as well as the issues that arise sometimes from the impact of societal systems on marginalized people. We are in a reciprocal relationship, where we are walking on a journey with them, not leading or pushing. Wi Che Win means ‘walk with me' and we are here to support each other."
Wi Che Win case managers also spend 80 per cent of their time in the community, talking with the people they have in housing, working with various social and health agencies, and acting as advocates.
"So many people judge the homeless," says Edel. "We try to be patient and accepting of people, knowing that it is not our journey. We are just being honoured by being allowed to walk with someone for a while. We assist a person to find a home, and share with them the expectations on them of their neighbours and landlord. We accept and understand that it is a learning process, which means sometimes things work out and sometimes they don't."
Edel doesn't remember Elders talking specifically about mental illness as if it was something to deal with on its own. Instead, they spoke about finding balance in our mental, emotional, physical and spiritual state of being. When a person does not have a home, they are out of balance. Wi Che Win provides the supports to work through pain and trauma and come out the other side, on a journey that is directed by the person.
"There are people with biological problems, such as manic depression and schizophrenia, which can be treated medically. It is our job to ensure we are open to, and walk with people, as they look at all areas of their lives. In order to do that, we must look at the past and deal with it so we can move forward. We are here to share resources to help people heal themselves," she says.
The story so far
The At Home/Chez Soi research demonstration project ends in March 2013. At that time the research will be analyzed to determine whether Housing First works better than the Treatment First approach.
But there are early indications that the Housing First approach has much to recommend. For example, the service teams say 170 project participants have been able to maintain their housing for an extended period of time, a remarkable retention rate for the population in question, according to Carla Kematch, who is a project consultant with At Home/ Chez Soi in Winnipeg.
Then there are the personal stories. Kematch speaks of how one participant cried when his move-in was complete because he couldn't believe that he had a home. Another 30-year-old man who had been homeless for most of his life was living under a bridge in -30 C weather. He has been successfully housed, has connected with family and friends, and can manage his own medication. Others have decided to put themselves into treatment.
A report by At Home/Chez Soi outlined some of the thoughts expressed by participants. For example, some clients commented on the "independence, safety and belonging" they felt from having their own home. Others said having their own place gave them a sense of "privacy, dignity and safety."
The report noted that some participants felt the project gave them a chance at "restarting their life." Others felt their lives were improving to the point where "some are thinking about going back to school or making changes in their lives to ‘keep my place.'"
Tina Shumilak is one of five support advocates at Ni Apin. She has been working with her constituents for two years, connecting them with counselling services and being an advocate on their behalf.
"Four of my people have maintained their housing for a year. One man volunteers in the community, making bannock and crafts. He's living in an apartment downtown, sees his doctor, and is very independent," she says. "We're learning so much about how to help people living on the streets get out of that life. (At Home/Chez Soi) is giving people a foundation, a place where they can live and start over. Having their own home gives people respect."
It's not all smooth sailing. The report noted that one participant worried that without the structure one finds in a shelter, she might fall back into depression and drinking.
Nonetheless, Kematch says the early indications are that the project's approach has made a difference in the lives of its people, a fact that she attributes to the hard work of all those participating in the program. "I want to pay homage to the landlords and all the community teams," she says. "Huge barriers are coming down in the community."
While the project has been able to secure housing, it hasn't always been easy, given Winnipeg's excruciatingly low rental market of 0.8 per cent.
"It's such a struggle to find suitable housing. None of us would live in some of the houses and apartments we've found," says Warkentin. "More needs to be done about funding, building and renovating sustainable housing into which homeless people can be moved."
It's impossible to pay the rent and buy food on $485 a month in Winnipeg. Yet that's what each person who is housed receives in the At Home/ Chez Soi project. Employment Income Assistance provides $285 a month for every person who is not employed, and At Home/Chez Soi provides $200 in a "portable housing benefit," as each person has been identified as having some form of mental illness. "We have to subsidize the rent for all our participants," says Gabby Desjarlais, an intensive case manager at Wi Che Win. "All our participants are getting some food from food banks and going to the shelters for some meals."
Gangs are another problem. They prey on the vulnerable. There are instances where gangs have identified and pushed out a project participant from their home, in order to use it as a base for selling drugs and prostitution until the police are notified.
The project participants themselves can be a challenge to house. Some invite others to live with them, including extended families or people they know from the streets. Parties get out of hand, with people arrested for drunken behaviour and damage to suites. Others have intense medical needs, and cause disruption to their fellow apartment dwellers just by the number of times an ambulance needs to be called.
"Sniff (use of solvents) is the hardest to work with," says Hall. "We have some people who have been housed, and rehoused, because they continue to use solvents. And they invite their friends in for a party, and get thrown out by the landlord."
Still, these are small problems compared to what has been achieved. "This is the year when we hope to see real improvement in our people," says Hall about 2012. "By having a home, they can work to get their addictions and illness under control. They can move forward, learning new skills."
A brighter future
There is no question Enright has been helped by At Home/Chez Soi. New skills are helping him move forward, giving him focus. His role in the Focusing the Frame exhibit was a part of the process.
About 50 people turned out to the opening night of the exhibit, which was held at the United Way building on Main Street last November. The exhibit was designed to provide project members like Enright with a chance to visually express their experience of being housed. A dozen project participants were given cameras and guidance by local photographer Stan Rossowski, who helped them tell their stories through photos.
Enright found the exercise rewarding. "I worked with Stan and the others, getting the exhibit going. We wanted to show what it means to be homeless, and then to be given a home," says Enright. Not only did he learn about digital photography, he also enjoyed the opportunity to be creative and have his work viewed by others.
Enright believes At Home/Chez Soi has helped him turn a corner in his bid to regain the kind of life he once had. Now that he has his own kitchen, he can prepare his own meals and eat a healthier diet. Sleeping in his own bedroom is far superior to roughing it on the street or on a cot with many others in a shelter.
Still, he has a ways to go. He doesn't work full-time, although he has picked up work here and there with Manitoba Green Retrofit, a social purpose enterprise that was launched to support landlords working with At Home/Chez Soi.
In the meantime, Enright spends much of his day simply doing what it takes to stay alive. He visits Siloam Mission for meals and company, walking his dogs, and walking to counselling. "I go to Ma Mawi to talk to their psychiatrist and also the Union Gospel Mission for counselling. Also, I go to a dual-diagnosis group at the Micah House on Main Street. If I start feeling bad, I know I have to go to talk to someone about it, or it will get really bad."
It's been a long road home for Enright.
"Now that I have a place of my own, I can work on my problems," he says, looking at a print of his green caterpillar photo hung on the wall at his home, his beloved dogs nearby. "My goal is to stay well, to pay my rent and keep my little pack together."
Susie Strachan is a communications advisor with the Winnipeg Health Region.
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