1. A Psychotherapy Service in a Homeless Setting
Dr. Adam Burley
Consultant Clinical Psychologist
City of Edinburgh Council Housing Department
Edinburgh Psychotherapy Department

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. `Such people set up relations with carers that are
characteristic; they are characterized by the
defeat of help.`
R.D.Hinshelwood 2002

9. 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

10. 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

11. 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

12. 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

13. 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

14. `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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Any thoughts or questions?