Therapeutic interventions

Outline of section

Background reading | Maslow's Hierarchy of Need | Therapy and Homelessness - an introduction | Counselling | Cognitive Behavioural Therapy (CBT) | Dialectical Behaviour Therapy (DBT) | `Dual Diagnosis`_ | Therapeutic communities | Brief Solution Focussed Therapy | News | Useful Links

Social and emotional aspirations of homeless and vulnerable people

Gerard Lemos has written Steadying the Ladder - the social and emotional aspirations of homeless and vulnerable people.

"The book makes you think deeply about identity, love, freedom and what makes the 'good and virtuous life' - the stuff that's at the heart of the aspirations of our service users if only we cared to ask them. Read on - and log in to the SupportActionNet website"

• Gary Lashko, Chief Executive, Carr Gomm

For further resources join up to the SupportActionNet website

Maslow's Hierarchy of Need

A useful concept in thinking about the needs of homeless people, and of us all, is Maslow's Hierarchy of Need. Abraham Maslow, (1908-1970) put forward the psychological theory that human needs can be represented as a pyramid, with the basis that the most primary needs are at the bottom and the more complex needs are met only once the lower 'rungs' of need are satisfied. As such, once an individual's physical and immediate needs have been met (food, water, shelter, safety), they may become interested in fulfilling more complex needs such as emotional support needs, the need for friends and relationships. It is very useful in understanding the motivations to change in those who use substances.

Therapy and Homelessness - an introduction

Homeless Link, in conjunction with the University of Southampton and Communities and Local Government produced a briefing on Cognitive and behavioural therapeutic interventions to tackle homelessness Nick Maguire, Helen Keats & Suzanne Sambrook write that there is evidence that unless the underlying causes of homelessness, such as drug or alcohol misuse, anti social or violent behaviour or mental health problems are tackled, some people will continue to be at risk of rough sleeping or of repeatedly losing their accommodation. There is also evidence of a link between mental health problems and substance misuse, with some people using drugs and alcohol to ‘self medicate’. The co-existence of mental health problems and substance use is commonly referred to as `dual diagnosis`_. See also our resources page on this subject.

For homeless people, and many of those using day centres, a range of traumatic experiences and difficulties is affecting their ability to cope independently and they are not occupied during the day at work or study, or with family or friends. The ‘therapeutic’ in therapeutic techniques or interventions is the common factor in the range of interventions and techniques listed here, that is that they all aim to provide therapeutic respite and the opportunity for positive change, focussing on the mental health and happiness of individuals.

Helen Keats, a Policy Advisor on homelessness at CLG, gave a presentation at Homeless Link's A Therapeutic Exchange conference on Therapeutic Interventions and Homelessness Prevention

Counselling

Westminster Primary Care Trust runs an award-winning counselling service for homeless clients. Diane Goodkind, the lead counselor of the project won the British Association of Counselors and Psychotherapist's 2005 award for Advancement of Counseling and Psychotherapy. The service was the highest scoring entry in its category on the basis of:

• being the first in-house counseling service for the homeless in the locality, allowing 'critical' clients to be slotted in for a holding assessment without delay, and maintaining counseling whilst clients are going through the housing process from no fixed abode.
• It identified the user group well, whose needs are widely recognised as being particularly difficult to meet.
• The service was very versatile in its approach in coping with supplementary issues, and the acceptance it got from the NHS represents a major achievement.
• Evidence provided was particularly strong, and the audit of how people have fared after using the service demonstrated that the service has used innovation to create positive change in a number of lives.

Diane Goodkind writes about the service in Connect and gives a case study of one of her clients.

As Diane mentions, one of the major barriers to providing counselling services to your service users is one of funding. While it would not be appropriate to describe it as such, staff may make good use of the skills involved in counselling, such as active listening, empathy, unconditional positive regard, congruence and paraphrase. Many educational centres provide short courses of introduction to counselling skills that can be studied part time and are not too expensive.

Alternatively, those training to become counselors or therapists are required to undertake a minimum number of hours of practice. The Charity Choice website contains listings of a number of counselling and psychotherapy students who are offering their time across the country. You can also enquire and make links with your local college or education centre.

Cognitive Behavioural Therapy (CBT)

CBT is a well-researched psychotherapy that has been developed over the last 30 years to deal with a variety of mental health issues. Although initially developed to treat anxiety and depression, the techniques have been expanded and refined to treat the more complex and severe mental health problems such as psychosis and personality disorders. CBT is practised mainly by clinical psychologists and specialist nurses, who sometimes work in primary care but more often in tertiary health services. It is of course extremely difficult and therefore rare for homeless people to be able to access these specialist services, so they remain a psychotherapeutically under-served population.

The basic premise of CBT is that the way that one makes sense of a given situation governs how one feels and what one does. It also acknowledges that humans are imperfect in terms of the way in which they perceive the world, and make many mistakes. For instance, we tend to be influenced by how we feel at the time when we look at the world, so we will perceive ambiguous events according to that mood. Many people who suffer mental health problems have learnt to think of themselves and their worlds in particular ways in childhood and adolescence (eg ‘I am a worthless person’, ‘I am always to blame’, ‘the world is a dangerous place’). The same may be true of those who are homeless, suffering undiagnosed mental health problems. A CBT intervention is designed to enable a client to understand their own personal rules for living, and how they impact on their lives. These beliefs can then be tested using individually designed ‘behavioural experiments’ to reveal that a particular belief has little or no foundation. This process, although simple to describe, takes a great deal of time to develop - possibly up to two years for a person suffering severe and enduring mental health problems.

Dr Nick Maguire, Deputy Director of the MSc in Cognitive Therapy at the University of Southampton, explains in this presentation where CBT can be used in the field of homelessness. Here he explains a pilot project that provided CBT to very hard to engage homeless men with mental health and substance use issues, with excellent results.

Nick's full article on CBT and the Southampton project is available in PDF. Nick is facilitating a 4 day CBT training course specifically for homelessness workers.

Dialectical Behaviour Therapy (DBT)

DBT is a therapeutic technique designed to help people who get trapped in repeated cycles of self-defeating behaviour. It has been adapted particularly effectively for women who have experienced domestic violence and for people who self harm.

DBT

• Focuses on enhancing capabilities
• Teaches skills to manage life effectively

What makes DBT different?

• Focus on dialectics
• Balancing opposites, finding the middle ground
• Combines traditional approaches with ideas from Zen traditions
• Mindfulness
• Acceptance

Mindfulness means paying attention in a particular way

• On purpose
• In the present moment
• Non-judgementally

Dr Suzanne Sambrook, Consultant Clinical Psychologist, explains a pilot project between Southampton Women’s Aid and Hampshire Partnership Trust .

Therapeutic communities

Therapeutic communities, or TCs, were first created to house ex-veterans (many of whom were suffering post traumatic stress disorder) in the 1950s, in a community of shared responsibility. The movement of therapeutic communities has evolved considerably and there may be many lessons that the homelessness sector can learn from TCs. Residents are highly involved in decision-making and the communities are based around collective responsibility and empowerment. Interestingly, there may also be lessons the mental health sector can learn from those working in the homelessness sector.

Community Housing and Therapy runs residential therapeutic communities for adults with severe mental health problems, and a dispersed housing scheme for homeless ex-service personnel. CHT's therapeutic programme is designed to create structure and learning opportunities that will lead to permanent change and eventual independence.

For more on working with ex-service personnel see our briefing

The Association of Therapeutic Communities describes their movement as an association of individuals who share the view that “the most effective kind of residential treatment or day care is where all members are involved in creating and maintaining the therapeutic environment. Change occurs through belonging to and involvement in the life of a group or community - in a culture of enquiry and openness. With a secure sense of attachment and containment, the distress behind symptoms of problematic behaviour can be articulated, understood and changed.” For more information on TCs see the Association of Therapeutic Communities website and this article by Penelope Campling in the Journal of Advances in Psychiatric Treatment.

Brief Solution Focussed Therapy

Three basic questions underpin solution focused brief therapy:

• What are your best hopes from this therapy?
• What would your day-to-day-life look like if these hopes were realised?
• What are you already doing and have done in the past that might contribute to these hopes being realised?

The task of the therapist is to trust that each client has the answer to these questions and to ask the questions in such a way that the client finds the answers.

The Brief Therapy Practice in London offers free therapy to half of its clients.

News

• Find out about the joint pilot project (Department of Health and Care Services Improvement Project) entitled Improving access to psychological therapies and read their recent guidance report into computerised CBT

• Coming Soon - a fantastic good practice and support website for services in Brighton and Hove, with information avaiable for practitioners everywhere, from the Brighton & Hove Single Homeless and Rough Sleepers Psychology Team, called mortar (More Than A Roof). Read the press release here

Useful Links

• David Brandon on compassion, the art of Zen and homelessness

• Talking Therapies - information from the Mental Health foundation

• In 2006, the Mental Health Foundation trialled an on-line CBT course for sufferers of depression. The trial has now closed, but the evaluation should be interesting. Watch this space!

• Discoveryquest is a walking therapy group set up by Julian Housing.

• Personality Problems as described by the NHS

• Support organisations for people who self-harm

• National Personality Disorder website

• Borderline-UK the national user-led forum for people with Borderline Personality Disorder.