The Role of Permanent Supportive Housing in Addressing Canadian Homelessness

Adrianna Autio

Mental health challenges and homelessness are closely linked, but this connection is often ignored. Both are urgent public health issues in Canada (Gaetz et al., 2016), marked by high rates of psychiatric disorders, substance use, and economic instability. Together, these problems make people more vulnerable and marginalized, affecting more Canadians every year (Mental Health Commission of Canada, 2022). Housing First strategies are now a key part of national and provincial efforts to help people with mental health conditions who are homeless (Goering et al., 2014).

In Canada, permanent supportive housing (PSH) is characterized by the provision of immediate, long-term, or short-term affordable housing along with flexible and voluntary support services (Goering et al., 2014). The Housing First model, utilized in projects like At Home/Chez Soi, treats housing as a basic human right and does not require individuals to be sober or in treatment before securing a home. This approach stands in stark contrast to traditional models that required individuals to "prove" their readiness through treatment completion; a clinical barrier that often abandoned vulnerable people to the instability of shelters or temporary housing during their most difficult moments (Aubry et al., 2016). Despite historical efforts to foster community integration for those living with serious mental illness (Kirby & Keon, 2006), a profound and systemic lack of investment in community-based care has directly fueled the crisis of homelessness, leaving many of our most marginalized neighbors without a safety net (Gaetz et al., 2016). While mental health challenges affect many across Canada, the burden is disproportionately heavy for those without a place to call home; alarming data suggests that up to 67% of urban homeless individuals are navigating mental health conditions, and nearly a quarter struggle with the complex intersection of mental illness and substance use (Gaetz et al., 2016; Urbanoski et al., 2017). For youth, Indigenous peoples, and women, these systemic gaps create unique and devastating vulnerabilities, making the development of compassionate, tailored interventions not just a policy goal, but a moral imperative (Klodawsky, 2009).

Research on clinical outcomes like mental health, substance use, and social integration shows mixed results (Goering et al., 2014; Stergiopoulos et al., 2015). Some Canadian studies find that PSH improves psychiatric symptoms, quality of life, and reduces hospital stays, but others see little or no difference compared to control groups. This may be because PSH programs in Canada vary widely. Some offer full on-site clinical and case management services, while others provide more flexible and voluntary support. Without standardization, it is hard to know which parts of these programs work best and for whom (Aubry et al., 2016).

Research on PSH in Canada faces several challenges. Many studies do not use random assignment, which can lead to selection bias (Goering et al., 2014). This means people with the most severe symptoms or those who have stopped using services are often left out. Also, participants may drop out because of relapse, moving, or incarceration, so results often reflect only the more stable individuals (Aubry et al., 2016).

A significant hurdle in evaluating these programs is the lack of standardized metrics to track adherence to Housing First principles, making it difficult to determine which specific program elements drive success (Aubry et al., 2016). 

Currently, Canadian policy conversations are shifting toward the cost-effectiveness and scalability of Permanent Supportive Housing (PSH). Evidence suggests these programs successfully reduce reliance on expensive emergency services, hospitalization, and the criminal justice system (Goering et al., 2014). The landmark At Home/Chez Soi study underscores this impact, revealing that for every $10 invested in Housing First, nearly $9.60 was recovered through savings in health and justice system costs for high-needs individuals (Goering et al., 2014).

Despite this progress, the inconsistency in how programs are implemented remains a persistent challenge (Aubry et al., 2016). Variations in local resources, leadership approaches, such as the preference for harm reduction over abstinence, and community engagement significantly shaping outcomes. There is a pressing need for culturally safe and trauma-informed models, particularly for Indigenous communities and women who often encounter compounding barriers to both stable housing and mental health support (Klodawsky, 2009).

Moving forward, Canadian research should prioritize robust, long-term studies that leverage representative samples and consistent fidelity measures (Stergiopoulos et al., 2015). It is critical that we deepen our understanding of underserved populations, including youth and those navigating co-occurring mental health and substance use challenges (Urbanoski et al., 2017). Ultimately, improving PSH requires a more integrated policy framework that bridges housing with mental health and addiction services. Future research must also look beyond simple housing retention to measure broader indicators of success, including community integration, personal recovery, and overall well-being (Aubry et al., 2016).

Permanent supportive housing, especially the Housing First model, has significantly transformed how Canada approaches homelessness among those with severe mental illness (Peng et al., 2020). While Canadian research consistently demonstrates marked improvements in housing stability, findings regarding mental health and substance use remain promising but varied (Nasmith et al., 2020).

References

Aubry, T., Goering, P., Veldhuizen, S., Adair, C. E., Bourque, J., Distasio, J., & Tsemberis, S. (2016). A multiple-city RCT of Housing First with assertive community treatment for homeless Canadians with serious mental illness. Psychiatric Services, 67(3), 275–281. https://doi.org/10.1176/appi.ps.201400587

Canadian Observatory on Homelessness. (2019). Permanent supportive housing. Homeless Hub. https://www.homelesshub.ca/solutions/housing-accommodation-and-supports/permanent-supportive-housing

Gaetz, S., Dej, E., Richter, T., & Redman, M. (2016). The state of homelessness in Canada 2016. Canadian Observatory on Homelessness Press. https://www.homelesshub.ca/sites/default/files/SOHC16_final_20Oct2016.pdf

Goering, P. N., Veldhuizen, S., Watson, A., Adair, C. E., Kopp, B., Latimer, E., & Aubry, T. (2014). National At Home/Chez Soi final report. Mental Health Commission of Canada. https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/Final%20report%20volume%201%20cross-site%20ENG.pdf

Klodawsky, F. (2009). Home spaces and rights to the city: Thinking social justice for chronically homeless women. Urban Geography, 30(6), 591–610. https://doi.org/10.2747/0272-3638.30.6.591

Kirby, M. J., & Keon, W. J. (2006). Out of the shadows at last: Transforming mental health, mental illness and addiction services in Canada. Standing Senate Committee on Social Affairs, Science and Technology.

Latimer, E., Rabouin, D., Cao, Z., Ly, A., Powell, G., Adair, C. E., & Goering, P. (2017). Costs of services for homeless people with mental illness in 5 Canadian cities: A large prospective follow-up study. CMAJ Open, 5(3), E576–E585. https://doi.org/10.9778/cmajo.20170018

Mental Health Commission of Canada. (2012). At Home/Chez Soi project: Summary of findings. https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/AtHomeChezSoi_FinalReport_ENG.pdf

Mental Health Commission of Canada. (2022). Mental health and homelessness. https://mentalhealthcommission.ca/what-we-do/homelessness/

Nasmith, T. E., Gadermann, A., Jaworsky, D., & Palepu, A. (2020). Clinically significant substance use and residential stability among homeless or vulnerably housed persons in Canada: A longitudinal cohort study. Journal of Public Health, 43(3). https://doi.org/10.1093/pubmed/fdaa018

Peng, Y., Hahn, R. A., Finnie, R. K., Cobb, J., Williams, S. P., Fielding, J. E., Johnson, R. L., Montgomery, A. E., Schwartz, A. F., Muntaner, C., Garrison, V. H., Jean-Francois, B., Truman, B. I., Fullilove, M. T., & Community Preventive Services Task Force. (2020). Permanent supportive housing with Housing First to reduce homelessness and promote health among homeless populations with disability: A Community Guide systematic review. Journal of Public Health Management and Practice, 26(5), 404–411. https://doi.org/10.1097/PHH.0000000000001219

Program and policy barriers to permanent supportive housing. (2015). National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK519603/

Stergiopoulos, V., Gozdzik, A., Misir, V., Skosireva, A., Sarang, A., Connelly, J., & Hwang, S. W. (2015). Effectiveness of Housing First with intensive case management in an ethnically diverse sample of homeless adults with mental illness: A randomized controlled trial. PLOS ONE, 10(7), e0130281. https://doi.org/10.1371/journal.pone.0130281

Tsemberis, S., Kent, D., & Respress, C. (2012). Housing stability and recovery among chronically homeless persons with co-occurring disorders in Washington, DC. American Journal of Public Health, 102(1), 13–16. https://doi.org/10.2105/AJPH.2011.300320

Urbanoski, K., Kenaszchuk, C., & Veldhuizen, S. (2017). Service use and barriers to care among homeless adults with mental illness. Canadian Journal of Psychiatry, 62(8), 569–579. https://doi.org/10.1177/0706743717711173