Clinical Social Work with Homeless People
Julie Lorenzo, LCSW, Senior Associate Director for Programs and Adina Barbosa, LCSW, Associate Director for Programs, Center for Urban Community Services (CUCS)
Establishing Therapeutic Relationships in a Variety of Non-Traditional Settings
Homelessness means not having permanent housing. Frequently, however, this condition is combined with a mix of psychiatric and interrelated problems, particularly among people who have been chronically homeless for years on end. Returning to housing and assuming the associated responsibilities usually require clinical interventions to guide an adaptive change process that leads to long-term recovery and success.
Homeless people typically do not seek treatment and clinical support. They pursue survival. The day-to-day work with homeless people takes place at non-traditional settings: shelters, emergency rooms, soup kitchens, the street, parks and transit terminals. Social workers use clinical skills to establish a therapeutic relationship, creating opportunities in public settings to interview and evaluate underlying interests and problems.
Experience and current practice literature indicate that making a genuine offer to locate suitable, permanent housing early in the relationship is a preferred intervention. From the clinician’s perspective, “suitable” means it is combined with adequate clinical and case management supports to address the individual’s or family’s level of need. From the client’s perspective, it is housing s/he wants, which requires an assessment of the client’s interests, expectations and goals.
Using Every Encounter to Clinically Assess Client Functioning
The social work clinician must use every encounter to assess functioning. While some symptoms may be readily apparent, others are more subtle and require a clinician’s keen abilities to draw out and manage sensitive material. Common problems include mental illness, domestic violence, excessive substance use, illiteracy, interpersonal difficulties and medical issues. The diagnostic formulation is the foundation for using psychotherapy and other interventions to help people identify, work on and move past barriers. Homelessness can sap an individual’s confidence. Helping clients to reclaim hope and an interest in taking on the challenge of a new life is often the key to success, as the following vignette illustrates.
Multiple Opportunities to Utilize Clinical Skills in Homeless Services
“Veronica” came to our shelter with over ten years of homelessness on the streets and in shelters. She had a history of childhood trauma and psychiatric illness, and was disconnected from family and friends. She was angry and only engaged staff via confrontation and criticism. Social work staff met with her daily to listen, offer support, and help her to recognize that the collection of negative experiences was getting in the way of her ability to work with people who could help her.
An important element of the staff’s work involved Veronica’s mental health. She believed that she did not have the correct diagnosis despite many years of “being in the mental health system.” Social work staff responded by working with her psychiatrist to have her receive psychological testing. As a result, her diagnosis was changed and new medications and treatment helped her better manage interpersonal interactions.
In addition to helping Veronica identify and obtain suitable housing, social work staff worked with her to understand how experiences of trauma reverberate in the present. She recognized that physical safety and emotional safety were paramount concerns for her. She expressed wanting to live in a small building but not a “group home” environment. Since she resided in a shelter, there was institutional pressure for her to take whatever came first, but she nonetheless rejected the first three offers. Staff did not push her, believing she had insight into her needs. She eventually selected an apartment that was offered and is making an excellent adjustment.
Application of Evidence-Based Practice
At CUCS, social workers are also using evidence-based practices with homeless people. The social work staff receives extensive training in Motivational Interviewing to help clients move along the adaptive change process. Wellness Self-Management, another evidence-based practice, helps people with mental illness to focus on achieving personal goals. Behavioral Treatment for Substance Abuse in People with Serious and Persistent Mental Illness enlists drug refusal skills training and short-term goal setting.
The Clinical Social Worker’s Role in Ongoing Treatment
CUCS social workers provide quality clinical social work services. LCSW staff members conduct psychosocial assessments, diagnose people using the DSM-IV-TR, and provide both long-term and short-term crisis-oriented psychotherapy. They oversee assessments, formulate treatment plans, and prioritize mental health, physical health, financial and case management objectives. The psychotherapy they provide is designed to assist clients to address the psychiatric, social and behavioral issues that pose barriers to their social, emotional and financial well-being, which are all required to help people out of homelessness.
In instances of mental illness, substance abuse, domestic violence and other problems, clinical support needs to continue even after homeless individuals and families obtain housing. Most often, social workers are the dominant professionals in supportive housing and other community-based settings.
As members of multiple-disciplinary teams with psychiatrists, nurse practitioners, LMSWs and paraprofessional case managers, clinicians at CUCS work to ensure the most comprehensive approach to working with clients. It is a clinical social worker's capacity to exercise clinical judgment across a variety of settings—taking advantage of any encounter, no matter how brief or long—that can play a critical role in the continuity of ongoing services for homeless and recently-homeless people.