Promising practices in delivering housing and support interventions to the chronically and episodically homeless with FASD CAEH20 15

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1 Promising practices in delivering housing and support interventions to the chronically and episodically homeless with FASD CAEH20 15 Christine A. Walsh, PhD

2 Research Team: Dorothy Badry, PhD; Christine A. Walsh, PhD, Meaghan Bell, MA & Kaylee Ramage, MSc A partnership between: Funding provided by:

3 FASD FASD is an umbrella term to describe the range of physical and/or mental disabilities that can result from prenatal exposure to alcohol (Alberta Seniors and Community Support PDD Program, 2010, p. 4). It is recognized as a diagnostic category in the DSM 5- Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE) (American Psychiatric Association, 2014).

4 Consequences of FASD Failure in school, family stress/breakdown, challenges with keeping a job, difficulties in daily living including managing finances and housing. Greater involvement in the justice system and child welfare system. Greater risk for abuse and other forms of exploitation including gang involvement. Higher rate of addictions and co-morbid conditions- other mental health problems.

5 Homelessness in Calgary In Calgary, homelessness grew by 800% between 1992 and 2008 and declined by about 2% by According to the Calgary Homeless Foundation s (CHF) most recent point-intime count estimates (October 2014), over 3500 people experience homelessness on any given night in Calgary.

6 Homelessness and FASD Although often invisible people with FASD share similar issues between those facing homelessness including: Addictions Mental health problems Criminal justice and child welfare system involvement Poverty Low educational attainment Limited housing programs are available to support the needs of individuals with FASD

7 Service Needs Homeless serving sector: Identify individuals who have this FASD Recognize co-occurring disorders Access appropriate supports for clients (which may include getting a diagnosis) Training to deliver FASD-informed care Individuals with FASD: Access appropriate supports(which may include getting a diagnosis) Receive FASD-informed care Stable housing

8 Study Rationale Limited understanding of individuals with FASD within the homeless population Lack of understanding of effective interventions and specific needs for homeless persons with FASD

9 Purpose Develop an enhanced understand FASD within the single, adult, episodically and/or chronically homeless population Understand the impact of FASD in adult, homeless populations on service utilization, program compliance, and housing outcomes Understand the issues from the perspectives of individuals with FASD who have experienced homelessness and those in the practice and policy arenas who serve this population.

10 Methodology Multiple-methods study Literature Review (FASD/Promising Practices for care) Environmental Scan (local service providers and supports) Analysis of Homeless Management Information System (HIMS)data (demographics, service utilization, etc.) Qualitative interviews with: chronically homeless adults with diagnosed/suspected FASD (N = 16) key informants from service and policy sectors (N = 19)

11 Inclusion Criteria for Participants Adults 18 and older Suspected/ diagnosed with FASD Experience with or at risk for homelessness (chronic or episodic)

12 Life History Screen Screens clients for adverse life-course outcomes typically found in FASD Designed to guide follow-up assessments and treatment planning Childhood History Maternal Alcohol Use Education Criminal History Substance Use Employment & Income Living Situations Mental Health Day-to-day Behaviours (Grant et al., 2013)

13 HMIS: Demographic Profile ( ) 60 of 1806 (3.3%) of interviewed clients in housing programs disclosed that they had FASD 37% female and 63% male 40% are in age range of years 77% were chronically homeless continuously homeless for a year or more, or have had at least four episodes of homelessness in the past three years) 22% were episodically homeless homeless for less than a year and has had fewer than four episodes of homelessness in the past three years 38% had a recent release from a correctional facility versus 16% in the overall HMIS population 62% had experiences in foster care versus 19% of overall HIMS population

14 Demographic Profile of Participants Category # (%) # (%) # (%) Gender Male 9 (52.2%) Female 7 (43.8%) Age Average 40.7 years Range years Level of Education Less than Grade 12 6 (37.5%) Grade 12 or greater- 10 (62.5%) Children With Participant 3 (27.3%) Adult Child 3 (27%) Not with Participant 4 (36.4%) Child Welfare System (child/youth) Yes 8 (50.0%) No 8 (50.0%) Criminal Justice System (adult) Yes 11 (68.8%) No 5 (31.2%) Mental Health Issues Yes 10 (62.5%) No 6 (37.5%) Addictions Issues Yes 15 (93.8%) No 1 (6.2%) Physical Disability Yes 8 (50.8%) No 8 (50.8%) Income Supports Yes 13 (81.2%) No 3 (18.8%) Housing Situation Housed 13 (81.2%) Homeless 3 (18.8%) Length of Homelessness Average 12.5 years Range 1 to 24 years

15 Themes: Participant & Key Informants Interviews 1. Systems challenges for housing individuals with FASD 2. Challenges of understanding FASD as a disability 3. Vulnerability of homeless women with FASD 4. Systems involvement of individuals with FASD & homelessness 5. Addictions & mental health 6. Critical supports 7. The impact of diagnosis 8. Hope, resilience, & success

16 1. Systems challenges for housing individuals with FASD [The worker] just says, Go get a job I said Look lady, it s the first time in years I ve had a home. I just got out of jail, I don t really have any resume that s relevant and recent and I m facing some health issues and I m in recovery right now from my drug addictions She said, well you had a job last year. I said, Yeah, I did. I was doing really well last year but I still didn t have a home and I wasn t making enough to get a home. It killed me and I ended up using again. (Adult with FASD experiencing homelessness)

17 2. Challenges of understanding FASD as a disability If you re working with a client who has FASD and you don t understand where the trouble is coming from, what possibly could be happening here, then your work will be for naught almost for sure It just doesn t make sense for us to keep providing a service that doesn t meet their needs. (Key Informant-Service Provider)

18 3. Vulnerability of homeless women with FASD They sexually abused me I m lucky I just made it through everything. I wish things would have been different. Then I ended up in prostitution made money to survive basically. I was in a super abusive relationship and I got away and I drank. (Women with FASD experiencing homelessness)

19 4. Systems involvement of individuals with FASD & homelessness Having gone from home to home and for some reason never really belonging anywhere You end up asking a question within your soul, Why are they not keeping me, why am I not staying here, why am I not welcome here anymore? (Adult with FASD experiencing homelessness)

20 5. Addictions & mental health [Some] agencies they ll hold their place while they re in the addiction [treatment program] and then they come back to their place, their clothing. If they slip and use, they re right back into addiction but their place is held for them. Other places will just say You re out of here and all of their belongings get thrown out. It s like you have no value. You start all over again. (Key Informant-Service Provider)

21 6. Critical supports Flexibility in rules They were taking him from a housing program he had been at for two years, and the maximum you could stay at that place is two years so he needs to go to independent housing now. But nobody knew that he had an FASD assessment You re setting him up [for failure] so let s put the [assessment recommendations] in place and transition him in a way that s going to be helpful. Financial management They get them on AISH and we just create $1600 a month of vulnerability, not service If you manage their money, you take away half of their problems because you remove that vulnerability. Harm reduction We re going to have to get used to a harm reduction conversation If we can help agencies have conversations with the FASD population based upon what s doable, I m probably going to also have an opportunity to have conversations with you about [other positive changes]. Cultural supports I started going to these sweats and I started feeling better and better about being in there I just found the ability to take stuff and process it in the way that works for me.

22 7. The impact of diagnosis You take the basic needs of any human being, finances so they can have food and housing. As soon as they have that diagnosis, then they become somebody who is eligible for AISH [Assured Income for the Severely Handicapped] which gives them the dignity to be able to have a meal on their table and a roof over their head. (Adult with FASD experiencing homelessness)

23 6. Critical supports Guest management A lot of folks [with FASD] have trouble saying no to anybody so they let anybody in The biggest thing that works is [at the front] they can say No, that person is not allowed in this building so if you want to be with them you have to go out of the building. So it keeps their housing a safe place to be. Life skills intervention There s always [the need] to assess the person s ability to live independently and then putting different interventions in place. Social networks We can t be the only person in the circle and the support system. Even if it s just somebody taking them for coffee who is a family member or friend, [it] will give them something to do in that time when they have nothing to do. Comprehensive supports People are very different and some folks maybe need day-to-day support in every area.

24 8. Hope, resilience, & success I m just happy. I m content just to do what I gotta do to survive each day right now I got my ladder, I m climbing up and the rung breaks and I fall back to the bottom. I get another ladder, I start climbing up again, again it breaks and I fall back to the bottom again. So I m trying to find a nice sturdy ladder I can climb out of right now. (Adult with FASD experiencing homelessness)

25 Recommendations 1. Increase Awareness of FASD Systems involving adults with FASD who are experiencing homelessness need to become informed about FASD in order to support this population. 2. Training and Education in FASD-Informed Practice Mandatory training in the signs of FASD and the relevant issues, challenges and barriers that individuals with FASD may struggle with is necessary for frontline workers in the homelessserving sector. 3. Screening for FASD Screening is necessary to determine the need for referral for assessment and possible diagnosis. 4. Complex Case Management Approach including Assertive Outreach This invisible and often unrecognized population has complex needs which require assertive outreach and case management to promote stability. 5. Supports for Prevention If appropriate, women should be referred to Parent-Child Assistance Programs for mentorship and intensive support.

26 Recommendations 6. FASD-specific Housing There needs to be increased capacity for supporting individuals with FASD to acquire and maintain housing. 7. Enhance Cultural Supports Access to cultural connection is critical for Aboriginal peoples if desired. 8. Gender Based Supports for Women s Health Women with FASD are at high risk for victimization which this needs to be addressed through safety planning and assertive outreach. 9. Advocacy Advocacy for this population is necessary across multiple sectors. 10. System Navigation Significant gaps in the service sector exist in reference to this population, a system navigator could mitigate this and provide the necessary supports in accessing service.

27 Questions Christine Walsh:

28 Selected References Alberta Seniors and Community Supports, Persons with Developmental Disabilities program: Operational Program Policy: Community Inclusion Supports Framework (2007). Retrieved from 02-2, American Psychiatric Association (2013). Diagnostic & Statistical Manual 5 of Mental Disorders. (5th edition). Arlington, VA: American Psychiatric Publishing. Online: Calgary Homeless Foundation. (2014). October 2014 point in time count report. Gaetz, S. (2010). The struggle to end homelessness in Canada: How we created the crisis, and how we can end it. The Open Health Services and Policy Journal, 3, Grant, T.M., Brown, N.N., Graham, J.C., Whitney, N., Dubovsky, D. & Nelson, L. (2013). Screening in treatment programs for Fetal Alcohol Spectrum Disorders that could affect therapeutic process. International Journal of Alcohol and Drug Research, 2(3), doi: /ijadr.v2i3.116 Scott, S. (2007). All our sisters: Stories of homeless women in Canada. Peterborough, ON: Broadview Press.