Housing First, Cultural Competence and Ethno-Racial Communities

The Toronto Housing First (At Home/Chez Soi) Ethno-Racial Intensive Case Management (HF ER ICM) project[1] delivers Housing First ensuring culturally based options for ethno-racial groups experiencing homelessness. We relied on the lessons learned from the AH/CS HF teams so that we can be confident that the information presented here is based in clinical experience and the practices of HF programs that produced excellent outcomes for housing stability and improvements in quality of life for participants and this was documented in rigorous research evaluations.  Serving the diverse needs of different minority groups requires an Anti-Racism/Anti-Oppression (AR/AO) practice. Combining a Housing First model with an AR/AO practice allows for a comprehensive, culturally sensitive approach to the housing, health, and socio-cultural needs of various ethno-racial groups.  The many lessons learned from the successful Housing First Ethno-Racial program are summarized in this module.  [A complementary module based on the success of Winnipeg’s At Home/Chez Soi project describes lessons learned from operating Housing First for an Indigenous population.]

Key Messages

• Understand the range of factors that contribute to lower rates of access and service use experienced by marginalized groups.
• Work with Anti/Racism and Anti/Oppression principles making sure that there is high fidelity to these practices on all levels of management and in all varieties of services.
• Foster a sense of empowerment, alliance building, and advocacy with a commitment to social justice.

Challenges that Ethno-Racial Groups Face While Dealing with Health-Related and Social Services:

It is essential to recognize that immigrant and ethno-racial groups use mental health services less frequently compared to the majority population. Lack of culturally sensitive services, together with cultural stigma and discrimination lead to a lower rate of access and service use.

Factors contributing to these lower rates of access and service use:

• Systemic, institutional oppression and racism reinforcing barriers.
• Lack of service provider knowledge and inquiry about traditional beliefs and practices
• Traditional distinctive perceptions about how to manage health, mental health and addiction.
• Lack of translators and culturally competent providers.
• Lack of culturally appropriate alternative interventions and treatment.
• Lack of information about access and lack of knowledge about the usefulness of services.
• Cultural mistrust of “the system’s” services leading to a somewhat corrosive perception of mainstream treatment approaches.

Anti-Racism/Anti-Oppression Strategy and Definitions:

The AR/AO approach acknowledges that racism and oppression have negative effects on all aspects of health. The approach also recognizes that these types of discrimination occur both at an individual and systemic level. The philosophy of AR/AO takes into account all levels of discrimination and puts the service user in the forefront by allowing them to heal in ways that are meaningful.

Anti-Racism = recognizes and strives to confront all dimensions of power imbalances, as well as a transformation and restoration of unequal social relations.

Anti-Oppression = guiding practitioners to address the issues of dignity, human rights, and access to resources and power.

This approach serves the diverse needs of people from ethno-racial backgrounds by strengthening the service systems designed to support them. These adaptations apply to all levels of service with a strong commitment to social justice.  

AR/AO Guidelines Ensuring High Fidelity to the Program:

Combining a HF model with an AR/AO approach works best when the following guidelines are fully met. These guidelines are taken from the Anti-Racism/Anti-Oppression Fidelity Assessment Scale[2], which was used as the fidelity evaluation in the HF ER ICM. This assessment tool follows ten criteria to evaluate an organization’s adherence to AR/AO.  This model addresses the unique needs faced by homeless individuals from different ethno-racial groups through a process of inclusion and empowerment.

1. A Commitment to Anti-Racism/Anti-Oppression
   Dedication to the principles of AR/AO and an effective implementation can be made through:

• • AR/AO in the form of agency and program policy or mission, vision, value, or mandate statements.
  • Management’s accountability for and oversight of anti-racism activities.
  • Agency’s participation, evaluation of formal commitment to addressing intersecting grounds of oppression.
  • Implementing a dedicated budget for AR/AO activities.

2. Anti-Racism/Anti-Oppression Training and Professional Development

• • Providing staff with educational and training activities in which AR/AO principles are addressed as a requirement, and making sure that the process includes implementation support, supervision and is ongoing throughout the course of employment.

3. Recruitment, Hiring and Retention

• • Recruitment and hiring of staff that are representative of the community served. This leads to positive role models for service users and increases knowledge about the target population.
  • Tracking the ethno-racial composition of the groups served to target specific staff.
  • Staff retention and satisfaction is reviewed taking AR/AO into consideration.

4. Staff Engagement and Voice

• • All levels of staff should have the opportunity and be encouraged to make formal complaints and participate in decision making processes regarding AR/AO.
  • Power imbalances in the organizational hierarchy are addressed and acknowledged properly.
  • Open-door and whistle-blower protections as a standard part of management policy.

5. Service User Engagement and Voice

• • Service users are able to have access and voice any complaints and concerns about the program and have influence during decision making.
  • Striving to get rid of power imbalances in the consumer-service relationship, being mindful of issues of power and voice.

6. Advocacy and Community Capacity Building and Engagement

• • Recognizing that processes of empowerment and disempowerment are rooted in societal and community practices.
  • Creating collaborative planning and advocacy efforts, and acknowledging that systemic issues go beyond the agency’s and the program’s immediate control.
  • Finding potential partners and stakeholders; forming alliances and partnerships with other AR/AO organizations.
  • Influencing legislation or institutional policies.
  • Disseminating service information to racialized communities in the service areas, facilitating various community dialogues around health and broader issues in innovative ways that help counter stigmatization.

7. Anti-Racism/Anti-Oppression Front Line Praxis
   Through an AR/AO process, case managers will be able to:

• • Develop an intuitive grasp of how all aspects of AR/AO translate into their practice.
  • Minimize power inequities in their relationships with service users.
  • Reflect upon how their own background and social location can impact relationships with service users.
  • Help service users identify, analyze and understand how racism and oppression can find expression in health and social services.
  • Advise and instruct service users on how they can cope and challenge racism and oppression, and put these mechanisms into action.

8. Holistic Approaches to Health and Well-Being

• • Exploring participants’ cultural views of wellness and illness; extending beyond immediate physical/biological factors, including but not limited to cultural, social, emotional and spiritual determinants of health.
  • Engaging the families of the service users, if desired, acting as informal caregivers who can provide more emotional support.
  • Supporting participants in accessing alternative treatments (eg. Chinese medicine, Ayurveda, yoga) and making sure that various resources are made available (eg. houses of worship, community leaders, community-based organizations)

9. Need/Asset Identification and Assessment of Services

• • Service provision based on the needs and assets/resources of the individuals.
  • Working with a strengths-based, recovery-oriented perspective focusing on the resilience of the people facing life’s adversities.
  • Annual collection and reviews of satisfaction, service deliveries, and informing service planning and delivery.

10. Appropriate, Accessible and Welcoming Services

• • Ensuring that the programs are culturally appropriate and accessible as well as linguistically competent.
  • Creating a physically and emotionally welcoming environment.
  • Seeking to mitigate socio-economic barriers to participation in programs and services.
  • Commitment to addressing experiences of exclusion and enhancing notions of citizenship or belonging.

Challenges and Expected Model Outcomes

Challenge: Meeting the cultural and linguistic requirements of a highly diverse group of participants – hard to accommodate all backgrounds.

Strategy: Hiring peer workers, seeking out staff who better reflect the diverse make-up of the participants. Increase the number of translational or linguistic services and find help from other agencies.

The strength of the approach is that AR/AO can be applied broadly, to multiple ethno-racial groups. The guidelines, when met, allow for a range of meaningful outcomes notably empowerment and choice, education, and advocacy.

Empowerment and Choice:

• Choice of acceptance of treatment and choice of housing.
• Clients are allowed to work as a team with their case manager to select the course of action/intervention/services that best suits their own needs – influenced by personal history, knowledge and experiences.
• Giving a platform where service users can vocalize their experiences, and are involved in solving strategies in order to ensure a corrective experience of welcomeness and inclusion.
• Validation of service users’ various experiences and belief systems, regaining control that may have been lost due to the power struggles that exist in society.

Education:

• Teaching about the pervasive nature of racism, and how it can negatively affect all aspects of life.
• Through techniques of motivational interviewing and sharing of own past experiences, encouraging clients to speak explicitly about discrimination.
• Encouraging discussion and admitting that discrimination and racism can produce mental health problems via their ability to generate stressful circumstances and emotional distress. It can also empower through providing awareness and learning skills and coping strategies.  

Advocacy:

• Importance of agency involvement and collaborative advocacy efforts, making sure that communities are engaged and mobilized.
• Commitment to social justice on the individual and systemic level.

Overall, AR/AO and HF work well together because they both value and commit to harm reduction (in this case reducing risk and negative consequences of racism) and client-driven recovery. It is essential that AR/AO service provision be specifically tailored to meet the unique needs and interests of minority or racialized community members since mainstream services are often designed primarily with dominant groups in mind.

Recognizing that racism and oppression both disregard the resilience of ethno-racial and disadvantaged individuals and communities is a first step toward a more inclusive philosophy. The AR/AO approach fosters improvements in all realms of health through pathways including validation, corrective experiences of inclusion and empowerment which facilitate participation and support client recovery.

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[1] Stergiopoulos et al., “Moving from Rhetoric to Reality: Adapting Housing First for Homeless Individuals with Mental Illness from Ethno-Racial Groups”, 2012.

[2] At Home/Chez Soi & MHCC. Center for Research on Inner City Health. Assessment Guide.