A Psychotherapy Service in a Homeless Setting

Dr. Adam BurleyConsultant Clinical Psychologist

City of Edinburgh Council Housing DepartmentEdinburgh 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?