Social Housing and People with Mental Health Difficulties
Most of us will experience temporary mental health difficulties at some stage in our life. Stresses from work or relationships can lead to poor concentration, mood swings or disturbed sleep. We can usually manage these short term difficulties ourselves.
Some people have long-term mental health conditions, although often negative symptoms are only experienced from time to time, and in between people live a normal life. Sometimes these conditions may be caused or made worse by social issues or situations, such as difficult relationships, social stigmas or financial worries.
Mental illness is defined by Mental Health Ireland as ‘severe and distressing psychological symptoms to the extent that normal functioning is seriously impaired’. The symptoms can include depressed mood, anxiety, obsessive thinking, delusions or hallucinations. Some form of professional medical or psychological help is usually needed to manage and recover from a mental illness. A stable housing environment and a job are also important elements in recovery.
In this guide, we will use the term ‘mental health difficulty’ to refer to a significant or enduring mental health condition.
The ‘Vision for Change’ policy document notes that about one in four adults will experience psychological difficulties during their lifetime that would benefit from expert intervention. About one in four GP visits relate to mental health difficulties.
Mental health difficulties can affect people of all ages and social background. They can affect people to different degrees, with some people requiring constant support and supervision, and other people thriving on occasional supports. Some people with a serious mental health difficulty may have had a history of long-term hospitalisation. Some will need to spend periods in residential care from time to time. Some people with mental health can fully recover with appropriate treatment. Others may find that their conditions are likely to reoccur.
Social Housing Supports
People with a long term mental health difficulty are more likely to have a low income or rely on social welfare than the rest of the population. People with mental health difficulties are also more vulnerable to homelessness.
While most people with mental health difficulties live in owner-occupied accommodation, social housing is next in importance for them.
A home is much more than a physical building. Suitable, stable housing is a key support to someone with a mental health condition. A suitable home in a supportive community can give someone a safe and secure environment, and is important for recovery and maintaining good mental health. The quality of accommodation, its location, and security of tenure are all important aspects that contribute to other supports to recovery, like good access to public transport and to employment.
International research has found that stable housing can be a pre-condition to successful participation in psychiatric treatment. Having a home helps people to recover from and manage their mental health difficulties.
Social housing is more than just a physical building. A local authority provides other services to tenants, including adaptations, and tenancy sustainment services.
Supports and training for staff
Managers should also be mindful of the importance of adequate training for staff to cope with potentially stressful or difficult situations, and of their duty of care in that regard. Staff who find themselves in such situations without adequate training and support may be vulnerable to excessive stress and risk to their own mental health.
Housing Strategy for People with Disabilities
The National Housing Strategy for People with Disabilities states clearly that housing for people with disabilities falls within the remit of housing authorities. Protocols have been developed to link the provision of housing for individuals with disabilities with the provision of required social supports from the health service.
The strategy sets out as one of its nine aims
“To address the specific housing needs of people with a mental health disability, including through the development of frameworks to facilitate housing in the community, for people with low and medium support needs moving from mental health facilities, in line with good practice.”
There are a number of pieces of legislation that affect provision of social housing for people with mental health difficulties.
Equal Status Acts 2000 – 2011
The Equal Status Acts 2000-2011 prohibit discrimination in the provision of goods and services on a number of grounds, including disability. The definition of disability in these Acts includes mental health disabilities.
Discrimination in the provision of accommodation is prohibited, with some exemptions. Accommodation can be refused where it would be reasonable to conclude the outcome would be a substantial risk of criminal or disorderly behaviour, vandalism or damage. More formally put, ‘A person providing accommodation or related services, can refuse service or accommodation to a person if a reasonable individual, having the knowledge and experience of the provider, would form the belief that the provision of service or accommodation to the customer would produce a substantial risk of criminal or disorderly conduct or behaviour, or damage to property in or around the area where the service or accommodation is provided.’
The Department of the Environment, Community and Local Government provide a reference list of relevant housing legislation on their website www.environ.ie. The Department is currently developing a voluntary regulatory code of practice to regulate the operations of Approved Housing Bodies. The Residential Tenancies (Amendment) Bill 2012 provides for statutory regulation of Approved Housing Bodies, though this has not been enacted at the time of publishing.
The Housing (Miscellaneous Provisions) Act 2009 provides a role for local authorities as a gateway to different housing options, including local authority housing, voluntary sector social housing, and the Rental Accommodation Scheme.
Disability Act 2005
This Act says that mainstream public services should include people with disabilities. It also requires that goods or services procured by public bodies shall be accessible to people with disabilities, unless that would not be practicable, would not be justified for cost reasons, or would result in unreasonable delays. When Local Authorities are acquiring or leasing properties for social housing, they should consider the accessibility of those properties.
UN Convention on the Rights of Persons with Disabilities
Ireland has signed this Convention, and plans to ratify it. The Convention has a number of provisions that relate to housing, in particular
- 19 - Living independently and being included in the community
- 28 (d) - Access by persons with disabilities to public housing programmes.
Good principles of customer service
People with mental health difficulties who apply for housing to local authorities are entitled to the same standards of professionalism, courtesy and respect as everyone else.
Some people with mental health difficulties will be no different from other applicants. In other cases, a person’s mental health condition may affect how they deal with officials through the various stages of an application and assessment process.
Some people may be very anxious or withdrawn. They may find it difficult to remember relevant information or absorb new information or answer questions. For other people, it may be difficult for them to organise or express their thoughts in a rational way. In more extreme cases, some people may have delusions or extreme mood swings. Sometimes, these behaviours may emerge over time, or may come and go depending on the person’s condition.
Use this section to find the the best ways to deal with people with a mental health difficulty.
Effective communication is an important part of any public service. Using clear and simple language in publications, leaflets, letters and websites will help everybody to understand the services available. People with mental health disabilities, people with intellectual disabilities, people with dyslexia and non-Irish nationals will benefit from clear and simple language.
The ‘Making your information more accessible’ section of the Accessibility Toolkit for public sector staff (http://accessibility.ie) provides practical tips on how to communicate directly with people with disabilities.
Important information should always be provided in printed form, so that people can take it away and absorb it at their own pace in their own environment.
HELP – Hear, Empathise, Limit, Progress
The HELP model is a four-stage model for customer service staff when dealing with people affected by mental health difficulties. This model is based on the Australian SANE Guide for Customer Service (2011). The four stages are:
- – Hear
- – Empathise
- – Limit
- – Progress
H – Hear
Listen carefully to the person, and take their concerns seriously, just as with other people. If they have a carer or family member with them, deal directly with the person concerned, and not the carer or family member. Listen to what they are saying, rather than being distracted by any of their symptoms. Sometimes, it is best to move to a private space to deal with sensitive matters, particularly if the person talks about their mental health difficulty.
Use active listening to keep attention on the person. Repeat your understanding of what the customer has said, such as “So since your sister and her partner moved back into the family home, you’re finding it very difficult to move around and use the bathroom – is that right?”. Don’t interrupt, and do let the person ‘off-load’ their concerns, as this will reduce her anxiety.
E – Empathise
Reassure the person, by confirming understanding of their feelings and concerns. Find some common ground to agree on, such as “I can understand it must be frustrating for you when your parking space keeps getting blocked in by neighbours”.
L – Limit
There may be times when people will repeat the same point unnecessarily, or they may be aggressive or confrontational. Their behaviour might appear to be selfish or self-absorbed. In such cases, limiting techniques as outlined below can help to calm and control the situation.
Confirm that their statements have been understood, and repeat their words back, so they can be confident that they have been heard fully. Get their agreement to take turns in speaking, something like “Thanks for explaining the problems with your bathroom. Now if you can give me a couple of minutes to speak, I’ll explain how we can get this sorted. Is that OK for you?”. Speak calmly and clearly, using short sentences. If any safety concerns arise, follow the standard procedures for such situations.
P – Progress
People may be unclear about what organisational responsibilities. If it becomes necessary to pass on the person to another department or agency, make sure they understand why this is being done. Check to see if the person has understood the explanation of what happens next.
Try to pass on as much relevant information as possible with the referral, so the person does not need to explain their situation again from the start.
Housing Application and Assessment
Where a mental health difficulty impacts a person’s need for housing, it is important that their housing application and medical information reflects this. Someone who is applying for housing consideration on any medical grounds will generally be expected to supply evidence from their doctor or other professional as to their particular condition.
For some people with mental health difficulties, an advocate may be able to support them through the process. The National Advocacy Service may be able to provide an advocate, or a peer or colleague can act as an advocate. It might be helpful to inform some applicants about the National Advocacy Service.
Because of the stigma around mental health, some people may not disclose a mental health difficulty or seek special consideration on that ground. It is important to be professional and non-judgemental with any person who discloses a mental health difficulty, and to understand that making this disclosure can be difficult. Housing staff should highlight the importance and value of disclosing any mental health difficulty, in terms of priority on the housing list and getting the right housing allocation.
There will be a certain level of stress associated with any housing need. This stress may be related to their current housing situation, or to other aspects of their life. It is important to distinguish between a routine applicant who is feeling somewhat stressed and those people who have been medically certified to have a long-term mental health difficulty that may be affected by their housing circumstances. Part 7 of the Social Housing Application Form can be used to provide details of the relevant people, their mental health difficulty, and the type of accommodation required to suit their illnesses.
Part 7 must be accompanied by supporting documentation, signed by a doctor or other qualified practitioner. The rules for what kind of practitioner is required vary across different councils. Check out the requirements about who can certify these needs, e.g. General Practitioner, Consultant Psychiatrist, or Psychologist for the local authority in question. Make sure the person understands clearly who must sign off on their medical needs.
It is generally helpful if the medical report specifies what aspects of the proposed housing would be essential to the person’s mental well-being, and what aspects are desirable. The practitioner could also be asked to specify the risks and likely outcomes if the person’s current housing situation is not changed, if the person is vulnerable to abuse in their current housing, and the likely outcomes if suitable social housing is provided.
The information provided by the certifying practitioner will normally be reviewed by the local authority’s medical referee and used to prioritise the application. It is important that the housing applicant is given every opportunity to get medical certification of their needs, and is clearly aware that the council requires medical certification to take these needs into account.
There is an agreed protocol that sets out how the HSE works with and communicates with local authorities on housing matters for people with mental health difficulty. This protocol can be found in the Department of Environment circular SIS 01/2011, and sets out arrangements for regular meetings and appointment of key support workers where required, and appropriate communications. The HSE social worker will have a key role in linking with local authority housing staff. Where the tenant is going into hospital, the HSE should inform the local authority about the expected absence, with the tenant’s consent.
An Occupational Therapist (OT) can provide a valuable and relevant service in detailing the housing requirements for a person with a mental health difficulty. While Occupational Therapists have traditionally reported to local authorities for people with physical or sensory disabilities, they can also play a significant role for people with mental health difficulties. The OT report can provide an assessment of independent living skills, along with useful guidance on the kind of neighbourhood that would best suit and the level of external support that will be required.
The HSE Community Mental Health team will normally include an Occupational Therapist with experience in these matters. Contact the HSE social worker or the Community Mental Health team for more details. The Association of Occupational Therapists in Ireland (http://www.aoti.ie) has a Mental Health Advisory Group of OTs who can provide more information on this.
As with any housing applicant, it is very important that people with mental health difficulties get an appropriate housing allocation in an appropriate environment from the outset. Allocation of housing normally involves balancing the needs of the applicant and the available housing units, to find the best allocation within the facilities available.
Many of the factors relevant to finding appropriate housing for people with mental health difficulties are the same factors that are relevant for anyone else. Some of these factors are particularly important to people with mental health difficulties, and should be given particular attention during the allocation process. The relevant factors include:
- – Location is important in all housing decisions, but is particularly important for people with mental health difficulties. They need to be able to access professional support services, including mental health units, therapists and counsellors. They may also have greater needs for informal and community support services from family and friends than others. The nature of the community will also be important. Some people may need a quiet, reserved environment where they are unlikely to be disturbed. Others may thrive in an active community with children and families. The size of the neighbourhood may be a factor for some people, in relation to how they will meet and engage with neighbours. Some people with mental health difficulties may be unable to drive due to effects of their medication, and will need to be close to public transport services.
- and security – These will be an important factor for most people, particularly for people with mental health difficulties. People with mental health disabilities can be vulnerable to abuse, bullying, prejudice and discrimination. They need a safe environment to support their recovery.
- and sharing – The size of any housing unit has a significant impact on how the property can be used and enjoyed. Similarly, the number of other people in the property and the relationship with those people will be very important for the well-being of a person with mental health difficulty. There are no fixed rules here. Each person’s needs should be reviewed individually. Some people may need to share with family or other supportive persons. Others will need a degree of distance from family to prosper.
- – Access to facilities such as a private garden space, or an open green area, or storage for tools or leisure equipment, or room for a particular pet or perhaps access to a full-size bath may be particularly important for some people with mental health difficulties. An Occupational Therapist can play an important role in defining needs for such facilities.
- needs – There may be particular issues arising from a person’s history or background that will impact their housing need. There could be a history of being abused, or threats to their safety from family or other people. There may be indications that the person does not generally engage well with, for example, teenagers. These needs should be given serious consideration during the housing allocation process.
The Housing Agency’s ‘Review of the Housing and Support Options for People with Mental Health Related Housing Needs’ (see http://www.housing.ie) reported negative features of housing for people with mental health difficulties that should generally be avoided:
- in estates with a young population
- corner site
- deep in an estate necessitating passage through it
- isolated from the community
- too close to sport and recreation areas (noise irritation)
- too close to main roads with heavy traffic (noise irritation)
The Housing Agency’s ‘Review of the Housing and Support Options for People with Mental Health Related Housing Needs’ reports on international research that found a strong, consistent pattern in evidence-based best practice for people with persistent mental health difficulties. The following attributes were found in best practice housing:
- living units
- not clustered in large projects
- should be of the occupant’s choosing
- accessible to community services and amenities
- should not be contingent upon meeting pre-conditions of ‘housing readiness’, sobriety, treatment compliance or use of mandatory services
There are a number of housing associations that specialise in providing services for people with mental health difficulties. Many other housing associations include people with mental health difficulties within their target audience. The Irish Council for Social Housing’s website at http://icsh.ie has details of housing associations. The Housing Agency’s ‘Review of the Housing and Support Options for People with Mental Health Related Housing Needs’ includes a set of case studies detailing services provided for people with mental health difficulties by a number of housing associations.
Housing associations can be an important support for people with mental health difficulties, by opening up access to additional sources of housing, and by providing specialised supports as required.
Most local authorities will carry out a background check on a housing application as part of the allocation process. This may involve checking vetting of any criminal record by An Garda Síochána and checking with anti-social behaviour experts within the Council.
In checking the background of a person with mental health difficulty, be sensitive to possible impacts of their illness on previous incidents. It is possible that people with some mental health difficulties could have come to the attention of the Gardaí in the past from incidents that relate to their illness.
Local authorities generally have limits on the number of times that a housing applicant can refuse offers of housing. Some particular consideration should be given to the needs of people with mental health difficulties when reviewing a refusal of an offer. If there is a valid reason for refusal that relates to the mental health difficulties, then the refusal should not be counted towards any limit in place. For example, a person with a history of being abused may have a valid reason for refusing housing at a location that would result in constant reminders of that abuse, or the probability of contact with the abuser. Other people may have valid reasons to avoid particularly noisy locations.
Ideally, these issues would have been reviewed during the housing allocation process. If they only come to light as a refusal, this should be treated sensitively.
Tenancy Support and Estate Management
Preparing the ground
A person with mental health difficulties has the same entitlement and expectation of confidentiality as any other housing applicant. There should be no discussion with neighbours or others about their mental health difficulty, beyond those staff who are directly involved with the tenant and need to know about their difficulties.
Anecdotal evidence suggests that the best outcomes in terms of community integration arise when a mixed group of tenants all start out in a particular development around the same time. The mixed group may include some people with mental health difficulties. As this group gets established and settles down, they will tend to develop meaningful relationships and can often be a source of mutual support.
People with a mental health difficulty will have varying levels of support needs, on a spectrum varying from full-time medical support to occasional social support. The support needs of people can be categorised as medical, social and personal needs. Multi-disciplinary teams including the HSE Community Mental Health teams, local authority housing welfare staff and housing association staff may need to work together to provide appropriate supports for tenants with mental health difficulties.
Many councils have a ‘tenancy sustainment’ service available to help tenants to address difficulties around their tenancy. While these services may initially be focused on homeless people, they are generally open to referrals for other reasons, such as mental health difficulties. Some housing associations have particular targeted supports available to people who are at risk of losing their homes due to mental health difficulties.
The Housing Agency’s ‘Review of the Housing and Support Options for People with Mental Health Related Housing Needs’ identified two elements found at the centre of successful support provision:
- provision of clear information to people with mental health difficulties, their advocates and associated support staff
Inter-agency co-operation is particularly important in ensuring that a tenancy is sustainable for the long term. Sharing of information across agencies should be done with permission of the tenant. For example, where a tenant is hospitalised, it is essential that the health and housing authorities are in regular contact to ensure that a tenant does not lose their property in the case of a short or medium term hospitalisation.
The Housing Agency’s ‘Review of the Housing and Support Options for People with Mental Health Related Housing Needs’ provides considerable detail on the supports that may be required, including:
- and household maintenance supports
- domestic and practical skills
- and advice
- safety and security support
- support and advice
- support services
Local authority welfare officers should liaise with relevant HSE staff to ensure that necessary supports are in place. These supports will greatly increase the chances of maintaining a successful tenancy. Housing Welfare Officers within the local authority will play an important role in ongoing engagement with the tenant. The protocol that sets out how the HSE works with and communicates with local authorities on housing matters for people with a mental health difficulty can be found in the Departmental circular SIS 01/2011.
As with other tenants, a pre-tenancy course can be a useful exercise in establishing expectations of services available and behaviours required. Be flexible in scheduling and presenting this course. Some people with a mental health difficulty may not be able to participate constructively at certain times of the day due to medication. Others may have a limit of perhaps one or two hours on their concentration time. Speak to those who will be attending the course beforehand, to make sure that it will meet their needs.
SANE Group (2011) SANE Guide for Customer Service. Melbourne: SANE Group.
SANE Group (2003) The Blueprint guide to supported accommodation. Melbourne: SANE Group.
Carroll, Sean & Cotter, Noëlle (2010) A Review of Housing and Support Options for People with Mental Health related Housing Needs. Dublin: Housing Agency.
National Disability Authority (2010) http://elearning.nda.ie - Disability Equality Training for Inclusive Customer Services. Dublin: National Disability Authority
Department of the Environment, Community and Local Government (2011) National Housing Strategy for People with a Disability, 2011 – 2016 Dublin: Department of the Environment, Community and Local Government
Health Services Executive