By Stephen Edwards MAPS
Clinical Psychologist, Inner West Area Mental Health Service, Melbourne

Homelessness is a longstanding and complex social issue receiving some welcome political attention in Australia. The literature confirms the social and psychological disadvantage of homeless adults, who frequently report isolation from family, impoverished friendship and support networks, traumatic events, and a history of family difficulties during developmental years. They receive less health care, show lower clinical improvement and are at high risk of re-presentation at hospital emergency services than other adults.

Public attitudes toward homeless men vary between sympathy and scorn but mental illness is a common component of stereotypes. A link between housing and psychopathology probably seems obvious to psychologists, but the nature of this link and the implications for service provision are not simple. This article describes a unique psychological service that provides a public mental health service response co-located at an urban men's crisis shelter. The service provides men who have high prevalence (distress, anxiety and depression) and enduring (personality and developmental) disorders with access to primary consultation, and their case workers to secondary consultation.

Background to the development of the service

Non-government welfare agencies have been dealing with homelessness since their inception but not always with today's resources. Men's crisis shelters are longstanding fixtures of our biggest cities but are more than a bed and a meal when funded by the Commonwealth as Crisis Supported Accommodation Services. Each resident is required to work with a crisis case manager on more stable exit housing as a condition of their three-month stay. Outreach teams help men who maintain this commitment on leaving the shelter and priority access to public housing is a key intervention, especially for those with a long history of homelessness. Men who are substance dependent and commit to change can also progress toward this goal with case work and material aid support through the Drug and Alcohol Team, also located onsite. Research in the establishment phase of this program identified the presence of common mental health problems (anxiety, depression and general distress) as a major barrier to change with many clients.

In Victoria, urban Area Mental Health Services (AMHSs) had developed assertive outreach teams during the 1990s in response to the high rates of psychotic illness amongst the homeless population. These aimed to engage adults in treatment whilst respecting autonomy, and strong working relationships were built with the crisis shelters. However, the clinical scope of these teams was limited to the low prevalence disorders (psychotic and severe mood disorders; Holmes et al., 2005). Psychologically focused mental health care had been available through Community Health Centres, but clients required patience with waiting lists and the organisational capacity to attend appointments outside of the shelter. Case workers found few clients able to engage with these services and, furthermore, they needed access to focused secondary consultation to assist their own management of men with mental health problems. When the welfare agencies lobbied successfully for funding, a co-located model was agreed on with a clinical psychologist based at the shelter but employed by the local AMHS. The psychological service operates alongside onsite nursing, allied health, recreation and legal services.

Service description

A potent clinical impression in this setting is of men who lack constructive personal or professional relationships in their lives. This alienation means just ‘engaging' or participating in a helping relationship is a significant challenge. For a small group of men this is a temporary state. These men have known stability in their lives before and this is their first and possibly only stay in a crisis shelter. Stress relating to work, relationships, finances and health have accumulated and after exhausting their support resources the onset of mental health problems triggers homelessness. These men can engage constructively with professionals and are able to articulate their feelings of shame and thoughts of failure. Once social factors such as shelter and food are stabilised they are able to make good use of psychological assistance to generate meaningful change. A first step is to identify and acknowledge stressors and modified cognitive interventions can be facilitated with whiteboard illustrations and modifications for literacy level. Behavioural interventions can be easily monitored and onsite massage or acupuncture used for relaxation.

Most other men who seek primary consultation have long histories of damaged relationships and can only partially engage with the service. Typically, early learning and behavioural problems were met with inadequate parenting and unsympathetic school responses. Rebellion in early adolescence gave admission to marginalised groups but exclusion from institutions such as work and education. Risk taking led to substance use and contact with the justice system, so by early adulthood they have little stability, severe substance problems and a number of convictions. Some have already been given a personality disorder diagnosis in the health or forensic systems. Relationships tend to be short term and these men seek primary consultation for pragmatic reasons. Whilst they can identify reasons for their distress they are inclined to quick solutions that relieve them of responsibility. Usually they are not ready or able to consider a process of personal change. Just engaging in a constructive, honest but non-blaming conversation is a primary goal of work with this group. Sometimes they return with insight once substance use has stabilised or forensic issues have resolved.

Other men don't seek mental health assistance but their patterns of behaviour cause concern for case workers. Usually this is because it makes them vulnerable, has a corrosive effect on others, or simply puts them at risk of eviction. Case workers are often the final safety net between shelter and the streets yet it can be frustrating when men can't or won't make use of their assistance. The challenges usually relate to long-term patterns of acting out personal distress by directing it at others or of withdrawing and avoiding contact with people. Personality and developmental disorder frameworks can help to inform management plans which can moderate rather than evaporate these patterns. Advice about management strategies, education about service systems and help with documenting plans can help workers to provide consistent and predictable responses. For these men change is minimal, if at all. Primary goals with this group are to build case worker confidence and empower them to relate in emotionally and physically safe ways whilst still demonstrating compassion. In the first two and a half years of the service, fifty five per cent of the referrals were for secondary consultation.

Evaluations

The benefits of integrating mental health care with drug and alcohol services as part of a pathway to stable housing have been advocated for some time, but there has been little evaluation of services that include high prevalence or enduring disorders within their scope. Those studies that were found used a primary consultation approach delivered by staff of a single agency, and there are no published service models with a strong secondary consultation component delivered by a clinician co-located in a shelter and employed by a mental health service. An outreach service which included psychological health goals in integrated care showed that clients who did engage with a counsellor improved significantly on measures of psychological distress, housing stability, substance use, relationships, violence and victimisation (Skeem et al., 2006). A drop-in centre provided integrated intervention through psychotherapy specifically designed for personality and substance disorders but found no difference in outcomes compared with standard care (Ball et al., 2005). Both evaluations highlight the challenges of engagement and retention, 62 per cent of clients discontinuing the first program by three months and 60 per cent dropped out of the second by one month. The latter is one of the first studies to highlight the prevalence of paranoid, schizoid, schizotypal (88 per cent with at least one) and avoidant, dependent and obsessive-compulsive (85 per cent with at least one) as well as the borderline, anti-social narcissistic and histrionic (74 per cent with at least one) personality disorders usually found in such samples.

Some preliminary evaluation has been conducted on our service. A survey completed by case workers showed that 90 per cent rated the secondary consultation they received as helpful and that 80 per cent thought their clients' primary consultation had helped. Similar themes were reflected in team leader feedback, with case worker confidence and knowledge as well as ease of access being major benefits of the service.

Therapeutic tool kit for psychological services in crisis shelters 

Fully engaged clients

  • Modified cognitive therapy
  • Behavioural methods
  • Interpersonal therapy
  • Assertiveness training
  • Relaxation techniques
  • Liaison with GP/psychiatrist
  • Court and referral letters

Partially engaged clients

  • Motivational interviewing
  • Single-session therapy
  • Therapeutic letters
  • Conversational encounter
  • Attendance prompting
  • Strategic information giving
  • Referral assistance

Case workers with non-engaged clients

  • Secondary consultation
  • Service system education
  • Skill education
  • Referral advice
  • Crisis plan development (for vulnerable or harmful clients)
  • Observation and feedback

  

Conclusion

As a clinical psychologist working for a public AMHS it is not unusual to provide secondary consultation but it is unique to be co-located within a welfare agency that operates a homeless men's shelter. The clinical issues are fairly clear but they must be viewed within the web of substance, legal and social difficulties which engulf men using a homeless shelter. Whilst high prevalence disorders are present, the enduring ones are pervasive and these dictate the clinical approach required, the prospects for clinical change and the challenging nature of the work. Significant service system issues also arise when delivering a service like this as a sole clinician. Working across a health and a welfare service means traversing two different professional cultures and accountability systems, accentuating the need for planning and coordination. Further evaluation of the service should consider not only the efficacy of clinical activities but the suitability of the service model.

The author can be contacted at stephen.edwards@med.monash.edu.au.

References

Ball, S.A., Cobb-Richardson, P., Connolly, A.J., Bujosa, C.T., & O' Neall, T.W. (2005). Substance abuse and personality disorders in homeless drop-in center clients: Symptom severity and psychotherapy retention in a randomised clinical trial. Comprehensive Psychiatry, 46, 371-379.

Holmes, A., Hodge, M., Newton, R., Bradley, G., Bluhm, A., Hodges, J., Didio, L., & Doidge, G. (2005). Development of an inner urban homeless mental health service. Australasian Psychiatry, 13(1), 64-67.

Skeem, J.L., Markos, P., Tiemann, J., Manchak, S. (2006). Project HOPE for Homeless Individuals with Co-Occurring Mental and Substance Abuse Disorders: Reducing Symptoms, Victimisation, and Violence. International Journal of Forensic Mental Health, 5(1), 1-11.

InPsych October 2009