Sylvestre, J., Nelson, G., & Aubry, T. (Eds.). (2017). Housing, citizenship, and communities for people with serious mental illness: Theory, research, practice, and policy perspectives. Oxford University Press.
Reviewed by Nick Falvo, PhD
Nick Falvo is Director of Research and Data at the Calgary Homeless Foundation.
Three Ontario-based researchers have edited a very good book on supportive housing for persons with serious mental health challenges. This 395-page, 17-chapter tome discusses history, types of supportive housing, cost considerations, theory, experiences of other countries, frontline practice and tenant considerations. I highly recommend it.
Here are some key things to know about it:
- Chapter 3 reviews three studies comparing two different models of supportive housing. The studies in question compare tenant outcomes (i.e., housing stability and life satisfaction) between scattered-site supportive housing and single-site supportive housing. With the former, landlord and professional staffing support are performed by different entities, and only a small percentage of the building’s units are occupied by people with mental health challenges. With the latter, both the landlord and professional staff support are provided by the same entity, and the entire building is comprised of people with mental health challenges. The chapter argues that outcomes have been found to be very similar in both types of housing.
- There are variations of each of the approaches to supportive housing discussed above. For example, in Calgary, HomeSpace Society serves as landlord while partner agencies provide professional staff support to tenants; however, all tenants in HomeSpace’s permanent supportive housing buildings are from the same client demographic (e.g., and almost all of them have mental health challenges). In that respect, HomeSpace is a bit of a hybrid of the two main models contrasted in Chapter 3.
- Chapter 3 is especially relevant to the Calgary Homeless Foundation (CHF). In its early years, CHF had a strong focus on the scattered-site approach—in part because it can take longer to develop single-site supportive housing (and CHF needed to act quickly to address rising homelessness). Over time, however, CHF decided to go beyond the scattered-site approach for three reasons. First, it realized that there simply wasn’t enough affordable housing stock in the city (especially during periods of very low rental vacancy rates) so newly-developed housing was required. Second, CHF found that 24-7 staff support was required for some very complex clients. And third, developing new units from scratch offers very specific design components that were found to be needed for complex clients (e.g., staff offices, communal space). Today, CHF continues to see the value in a variety of approaches to supportive housing.
- Chapter 5 provides excellent material for local officials doing program evaluation. CHF will soon be developing a new logic model (in partnership with community stakeholders) and material in this chapter provides very helpful background information for that undertaking. For example, the chapter discusses the theory of change—an essential concept in program evaluation. According to John Burrett, who has been contracted by CHF to help us on our logic model: “A program’s theory of change is the set of actions to be taken and the expected outcomes of those actions, and a set of assumptions and theoretical/experience based relationships and mechanisms that connect the actions and expected outcomes.” In other words, why is it that you think Program X will result in Outcome Y, and what evidence do you have to support that view?
- Chapter 8 will be of great assistance to new researchers searching for the best methodological approach to their work. Indeed, researchers (including master’s and PhD students) typically have to demonstrate how they’ll carry out original research. This chapter serves as a guide for them, offering a variety of possible approaches to studying supportive housing for persons with mental health challenges. I was particularly intrigued by an approach whereby researchers study which particular locations of communities give supportive-housing residents a sense of belonging (as reported by residents). One example of such a study can be found here—it found that, of all settings in the community, the resident’s actual home was the location deemed by residents to be most important.
- Chapter 10 provides a useful history of supportive housing. It discusses the institutionalization of people with mental health challenges throughout Canada in the 1800s—that is, it discusses the placement of tens of thousands of individuals into psychiatric hospitals. It further discusses deinstitutionalization, a process that essentially reversed this. In Canada, deinstitutionalization began in the 1950s; and by the mid-1970s, approximately two-thirds of psychiatric beds had been removed. Not surprisingly, there were major implementation challenges with this, hindered in part by the fact that many of the boarding homes into which patients were relocated were operated on a for-profit basis with limited staff support. Many former patients were subsequently readmitted to hospital. (At CHF, we find that placing persons with mental health challenges into the right kind of supportive housing results in cost savings to both health and justice systems. We’ll be releasing this research in the near future.)
- Chapter 10 also provides an interesting history of forced sterilization, which was especially prevalent in Alberta. It notes that forced sterilization of some mental health patients didn’t end in Alberta until the early 1970s (in fact, Alberta was the first jurisdiction of the former British Empire to legislate involuntary sterilization in 1928). Indigenous women in Alberta were disproportionately targeted by this legislation.
- The book misses an opportunity to discuss why supportive housing for persons with mental health challenges gets more attention (and more resources) in Canada than supportive housing for other marginalized groups. There are many types of supportive housing. It’s a policy approach that’s been designed specifically for the frail elderly, youth (including for LGBTQ2S+ youth specifically), Indigenous peoples, and veterans; it’s also been designed for persons with substance use challenges, developmental disabilities and HIV/AIDS. Yet, most public policy attention on supportive housing pertains to persons with mental health challenges (and that was also the focus of this book). I wish the authors had tried to explain why this one group is prioritized over the others.
- Chapter 4 argues that the single-site approach is more expensive than the scattered-site approach, but doesn’t account for the equity built up over the long term with the single-site approach. That’s a bit like saying that renting is cheaper than paying a mortgage, without accounting for the fact that after you finishing paying off a mortgage, you own the asset. It’s true that with the single-site approach, on-site staff support typically costs more (in part because tenants typically have more complex needs). But with single-site approaches, a non-profit entity typically ends up owning the building. Such asset accumulation is very important for non-profit entities, as it reduces operating costs over the long term (i.e., after the mortgage is paid off) and allows the non-profit to leverage the asset (e.g., borrow for an additional building against the asset). I’m personally aware of no research that compares the long-term (i.e., 25-50 years) costs of single-site vs. scattered-site approaches.
In Sum. This is a ‘must read’ for researchers who have a strong interest in supportive housing. It also serves as a useful reference book. Each chapter is very well organized, allowing readers to quickly identify the material for the task at hand. Many of the chapters serve as very useful stand-alone chapters.
I wish to thank Alex Abramovich, Tim Aubry, Carla Babiuk, Vicki Ballance, John Burrett, Brian Davis, Candice Giammarino, Martina Jileckova, Lisa Ker, Bernadette Majdell, Jedd Matechuk, Gautam Mukherjee, Geoff Nelson, Shane Rempel, Greg Suttor, John Sylvestre and Matt Vermunt for assistance with this review. Any errors are mine.
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 However, it’s worth noting that research finds that tenants, when surveyed, indicate a strong preference for the scattered-site approach over the single-site approach. A 2017 meta-analysis on this question is available here.