By Mili A. Thomas, MA, Debbie Browen, Polina Kitsis, Claire Lisco, and Nadine J. Kaslow, PhD
The Grady Nia Project helps abused, suicidal, low-income African American women, many of whom are homeless. They often times live on the streets, go from shelter to shelter, or end up homeless in an effort to escape an abusive partner. We have learned a lot from these women, particularly about their experiences being homeless and how we can most effectively engage them in therapy. We have also come to appreciate their remarkable strengths and resilience; working with them has enriched our lives.
Laquita came in for help after living under a bridge for weeks and being so cold and afraid that she felt her life was no longer worth living.
Dashanda loved her two children and didn’t want them taken by Child Protective Services. She knewthey would be if she couldn’t find a place for them to live.
Alexis left her abusive partner, who had raped her at gun point. But there was no bed available at a domestic violence shelter and the homeless shelters required that she check-out each morning and check back in each night space permitting. She had nowhere to leave her belongings or those of her children and she was scared her abuser would find them on the streets and kill her.
Overcoming Barriers
These women and women like them remind us that culturally sensitive care must take class into account. When our socio-economic status differs from the people we serve, we must learn about the challenges they face living in poverty and being homeless. It is essential that we integrate these contextual factors into treatment. Doing so builds safety and sets the tone for open dialogue.
Often, people who are homeless face multiple barriers to accessing behavioral health care and adhering to treatment recommendations, such as the following:
Poverty
Transportation issues
Limited social support
Limited education (low literacy)
Emotional factors
Fragmented systems
Therefore, our psychological interventions must address these challenges.
Poverty – We have an ethical duty to not only provide people with cost-free services, but also to help them access resources that may improve their financial situation and quality of life. People who are homeless have realistic concerns about meeting their own basic needs and those of other members of their family. As psychologists we need to be knowledgeable about the range of available resources and actively connect people with these services. Resources to consider include housing options, food, healthcare, medications, child care, legal services, etc. Addressing people’s basic needs is essential in therapy before higher-order psychological concerns can realistically be addressed.
Transportation – Transportation can affect consistent attendance and timely arrivals. We must define “being on time” in terms of what is realistic for the people we serve. If people cannot find the funds to come to us for care, we either need to provide services right in the community or offer financial resources so they can come to us. For example, we have been fortunate to secure donations to provide access to public transportation for the women in the Grady Nia Project. Many of them also are part of our Assertive Community Treatment (ACT) teams and more psychologists are needed on these ACT teams.
Limited social support – The presence of caring and supportive family, friends, and community members fosters resilience in people who are homeless. So, we use group interventions to help build a sense of community and these interventions prioritize connecting or reconnecting women with formal and informal social support systems.
Limited education and low literacy – If individuals cannot read and/or write connecting them with literacy programs should be a top priority. Being able to read improves people’s self-esteem, improves their access to employment and increases their access to helpful information affecting the therapeutic process. Also therapists working with individuals who struggle to read should take this into consideration when determining whether or not to assign homework and the nature of the homework.
Emotional factors – Depression, anxiety, suicidality, hopelessness, low self-esteem, and substance use are some of the most common problems seen in people who are homeless. Unfortunately, they often do not get the appropriate psychological help in a timely fashion. Also, individuals with serious and persistent mental illness are disproportionately represented in the homeless population. As psychologists, we play a critical role in working on interdisciplinary teams to bring strength-based services directly into the communities where children and adults who are homeless reside. The more accessible these services are, the more likely people are to avail themselves of these services and hopefully less stigma will be associated with participating in psychological assessments and interventions.
Fragmented systems – Typically, people who are homeless receive fragmented care. Electronic health records often do not cover people across different systems. Psychologists can be leaders in ensuring clear communication among providers within and across systems.
Capitalizing on Strengths
Unfortunately, we often focus on the challenges that people who are homeless face and the risk factors associated with homelessness. As a result, we often neglect or overlook the remarkable strengths people seeking services possess.
We found that a strength-based approach to providing behavioral health care to people who are homeless not only maximizes their outcomes but also enriches our lives as psychologists. Such an approach includes, but is not limited to, the following:
Engaging them as collaborators in their own care
Emphasizing empowerment and self-efficacy
Viewing the person who is homeless as an expert on her/his life
Amplifying their strengths and resources as tools to use in reducing the frequency/intensity of their emotional difficulties
Encouraging them to share their stories and highlighting the myriad ways in which they demonstrate resilience
Offering them choices in services and honoring those choices
Helping them explore solutions and mobilize their own resources to attain their goals
Being encouraging and communicating genuine hopefulness for the future
Providing them access to interventions that consider the whole person within the context of homelessness
Serving as a stable contact person who invests time to help them locate and secure necessary resources
Reconnecting them with supportive communities
Being an advocate on their behalf when appropriate
Resources for Clinicians
APA Past-President, Dr. James Bray, commissioned a Task Force report that highlights possible ways you can assist those who are homeless.
Here are some governmental guidelines to frame questions and formulate an action plan.
Here are some journal articles with practical guidelines and research on integrative, psychological assessment and intervention with people seeking treatment in this population:
Dadlani, M.B., Overtree, C., & Perry-Jenkins, M. (2012). Culture at the center: A reformulation of diagnostic assessment. Professional Psychology: Research and Practice, 43, 175-182.
Hayes, P. A. (2009). Integrating evidence-based practice, cognitive-behavioral therapy, and multicultural therapy: Ten steps for culturally competent practice. Professional Psychology Research and Practice, 40, 354-360.
Resources for People who are Homeless
The United Way provides a plethora of national resources. Visit www.211.org or call “2-1-1” to learn about regional resources for homeless individuals.
The Nia Project at Grady Health System has compiled a comprehensive list of local resources in Atlanta, GA. This may serve as a model as you gather relevant resources in your community.