1. David case study Michael Hendon MH, Alexander Beer OT, Nicola Martin OT, Lynsey Virgo OT and Diane Ivory OT What underlying causes or factors could account for the psychological manifestations and behaviours identified. Fear – of authority; of persecution from society; threats from gangs to keep quiet. Become psychotic as a result of past experiences e.g. physical/sexual/verbal/psychological abuse in childhood or whilst living rough. What underlying causes or factors could account for the physical manifestation identified. Bleeding – could have been attacked; self harm; could be alcohol related; falls; painful feet. Undernourished – lack of food/money; malnutrition; alcoholism. Cold – hypothermia; lack of warm clothing/blankets; no home; malnutrition. Unkempt – lack of personal hygiene/place to wash/reason to wash; safety. Feet – alcohol related neuropathy, gangrene/necrosis; trench foot; risk of falls; muscle atrophy/weakness in legs.

2. What physical health issues could be associated with homelessness. Malnutrition; poor feet; hypothermia; poor teeth, skin hair condition; respiratory problems; muscular skeletal conditions; trench foot; wounds; alcohol ketoacidosis; food poisoning; poor eyesight; dehydration; infections. What mental health issues could be associated with homelessness. Paranoia; low self esteem; alienation from society; depression; anxiety; schizophrenia; drug/alcohol dependence; alcoholic hallucinations. What social and societal issues could be associated with homelessness. Poverty; abuse; loss – personal/employment; victim/cause of crime; run away; isolation from family and friends; history of being in care; bankruptcy; catch 22 no job no home; GP registration. How do you communicate with someone who is displaying difficult and challenging behaviour? Do not directly challenge with eyes; appear relaxed, without passive demeanour. Be genuine and warm; take your time and do not attempt to rush; listen; speak slowly and clearly; maintain large personal space; encourage patient to talk. What strategies could you adopt to win David’s confidence? Use of above to gain his confidence, so that he will trust you and proceed from there. Don’t offer more than you can actually deliver. Start with small things like offering a hot drink.

3. How could you obtain consent when someone is reluctant to cooperate with what you are trying to do? provide them with information to persuade them that what you are doing is for the best. They may be sectioned under the mental health act. What information is needed about David? How might this be obtained, and by whom. Past medical history; past mental history; family history; presenting conditions; medical history. Try to ascertain if there is any chance of contacting family or carers. Find out where David came from original to try and trace GP. Maybe known to police, have a criminal record – police may have information about David. What are the advantages and disadvantages of using self reporting when gathering information. Disadvantages – people’s memories of events can cloud through time or be exaggerated. In Hilda Peplau’s insightful words ‘people make themselves up as they talk’. Storytelling acts as an indirect view of their experiences and as such may not be accurate or a true account of events. Advantages – straight from the horses mouth! Therefore an element of heartfelt truth. Although this may not be a true account of what has actually happened to him it will give an insight into his mental state.

4. How do you gain information about a potentially sensitive aspect of someone’s life of lifestyle? Gain the patients trust and make them feel secure and confident about talking to you. What other factors and issues could be associated with David’s circumstances. Problems with authority – doctor’s/white coats. May not trust medical staff due to past experiences. Could be in trouble with the police. Drug taking. How could David have accessed health and other public services without getting arrested or admitted to A and E as the only way of getting into the system? Street outreach teams make contact with the homeless in areas that they are known to sleep as a part of the government policy of targeting the homeless to offer services. What might now happen to David? Prioritise your perceptions of his need into short, medium and long term strategies. Short – medical treatment for head injury and feet; assessment of mental health needs; stabilise abusive and threatening behaviour; health referrals; dietary needs and accommodation. Medium – reintegration into society, living independently, personal hygiene and day to day tasks, alcohol detox. Long – job skill training, social services and community support, alcohol independence.

5. Which health and social care professions have the potential to be involved in David’s journey, and what might be their contribution? GP – continuing care with medication and health issues. Nurse practitioners – treatment of feet and other illnesses. Dentist – for dental hygiene. Podiatrists – for feet care. Mental health team – for the mental health needs that David requires. OT – for rehabilitation. Social workers – for benefits and housing issues. Drug and alcohol counsellors – to treat problems. What other agencies and resources could also be utilise to help meet David’s needs. Housing officers. Home liaison people to get David back in touch with his family and help him to be reintegrating David to society to meet new friends. What could be the potential advantages and disadvantages of multi- professional and inter-agency working in this situation? Advantages – multi tasking services should in theory be able to provide David with everything he needs in one go in one package. Disadvantages – is the infrastructure there for them to liase between each other, or is David going to be let down and therefore risk relapsing. Need to encourage staff to accept responsibility for David’s care and not expect other parts of the team to pick up the pieces.

6. What challenges might David encounter on his journey, and how could these be overcome. Alcohol – David will have money when he gets a job and will therefore have access to pubs/alcohol in supermarket, money combined with stress from day to life could cause a relapse – AA counselling. May feel alienated on integrating back into society/day to day living – day centres, OT, life skill training. Stressful life occurrences e.g. redundancy, bad day at work, may lead back to alcohol/mental health problems – need for counselling. Difficulty in getting a job – no work history, job centre.