Transcript Homelessness and Mental Health: Chicken or Egg

A Psychotherapy Service in a
Homeless Setting
Dr. Adam Burley
Consultant Clinical Psychologist
City of Edinburgh Council Housing Department
Edinburgh Psychotherapy Department
A Definition
“Homelessness – It’s not about not having a home. It’s
about something being seriously f**king wrong.”
“Stuart: A Life Backwards”
by Alexander Masters, HarperPerennial, 2006
Background: RSI 2002
• To identify the prevalence of Personality Disorder
within a homeless population
• To investigate care received, and pathways to that
care for identified individuals
• To make recommendations regarding future service
design for identified individuals
Background: RSI 2002
• 70% with at least one diagnosable personality
disorder, 40% with two or more
• 50% with an ongoing diagnosed mental illness
• 75% with previous forensic history
• 55% with ongoing drug and/or alcohol abuse
n = 115
Background: RSI 2002
• 40% report history of sexual abuse
• 60% report history of physical abuse
• Relationship or family break up cited as the most
common cause of becoming homeless
• 60% reported having had experience of being ‘in
care’ at one time during their life
Background: RSI 2002
• High levels of ‘care activity’, an average of seven
contacts per month (sd=2.5, range 0-64)
• Seen in a variety of different settings by a variety of
different people
• No identifiable clear care pathway or care provision
Another Definition
“……deeply ingrained and enduring behaviour
patterns, manifesting themselves as inflexible
responses to a broad range of social and personal
situations. They are by nature developmental
conditions which appear in childhood or adolescence
and continue to adulthood.”
ICD-10
`Such people set up relations with carers that are
characteristic; they are characterized by the
defeat of help.`
R.D.Hinshelwood 2002
The Impact of the Interpersonal World
• Relatedness as central to the human experience and
mental health
• Difficulties in forming and maintaining functional
relationships has a potentially global impact
• Endpoint in extreme cases being isolation and
severely limited attachments to any object
An Emerging Theme
For some individuals, homelessness might best be
understood as an understandable developmental
endpoint, symptomatic of a longstanding incapacity
to form and/or maintain functional human
relationships. Fundamentally a disturbance in
relatedness
Symptomatic as well as being problematic
Psychodynamic Thought and Homelessness
• An interest in relatedness
• A framework from which to understand the ways in
which people don’t seem to make use of, or defeat the
intended care and provision
• Focus on development rather than symptom reduction
Establishing a Frame
• High level of interest amongst non-health agencies
• Based in, but not employed by, Edinburgh Homeless
Practice and The Access Point
• Availability, Accessibility, and Flexibility felt to be
very important
• Supervision in Psychotherapy Department
Establishing a Frame
• Evolution of service based upon reflection of
demands from agencies in supervision leading to;
• Strategic Levels – Homeless Planning Group
• Local System Level – EHP, TAP, Housing Team
• Individual Level – Direct client work
`The alternative approach is that the specific
reactions that institutions (in the form of their
staff's emotions) have to patients is itself a subject
for investigation as part of the process of caring.`
R.D.Hinshelwood 2002
Practice Example
• Exclusion group (Inclusion group)
• A pause for thought at the time when we have been
moved into ending the relationship
• Development of contracts (for staff) to attempt the
maintenance of a (potentially) therapeutic relationship
Implications
• A shift into a focus on the parts that we as staff play
in 'caring' relationships
• A reflection on what our agendas, our desires, and our
needs may be
• Thought about how our actions and interventions might
understood and experienced by others
Support Structures
• Teaching and training - development of interest rather
than 'definitive action and knowledge'
• Supervision - regular and protected, as an essential
part of practice
• Ongoing evaluation of our goals, aims and agendas.
In part, a shift from doing to, to trying to understand
about
Themes….
• Importance of transference dynamics between
providers and users in bringing an understanding
to difficulties
• Overwhelming material, can promote action over
thought
• Agoraphobic / Claustrophobic dilemma
• Limitations of understanding
• Maintenance of relationship in context of severe
attacks on linkage
The Experience
• High levels of defeat and disappointment
• Feast / famine experience
• Large amounts of hostility, anger and attack
• Resistance to thinking about parts that we play in the
‘caring’ relationship
Any thoughts or questions?