An area of diversity often overlooked is socioeconomic status. Homeless clients are at an extreme end of the socioeconomic status continuum and present with concerns and stressors related to poverty. People often start psychotherapy due to a major stressor in their lives. Finally, after some apprehension, they make the initial leap to get help and enter your clinic or office, scared, yet a bit relieved as they embark on the journey of healing through psychotherapy.
But, what if the client’s original stressor prevents them from being able to access the very care from which they could likely benefit? Homelessness poses such a dilemma. Homelessness prevents many from obtaining the help they need to overcome or manage psychosocial stressors and/or mental health diagnoses.
The classic and stereotypical image of a homeless individual is the unkempt, weathered man walking through city streets, shouting and yelling to himself. Meanwhile, a common stereotype of someone receiving psychotherapy is the upper middle class woman going to a private practice in the Upper West Side, sitting in a large office with attractive decor. These are outdated ideas. Organizations and clinics providing services for people with low-income and/or who are homeless are incorporating behavioral health into their services. Veterans Affairs medical centers are increasingly focused on homeless veterans and ensuring there are programs available to house and treat them. However, do not be fooled: Access to care is still a significant problem for most (Krausz et al., 2013) and studies examining access to psychotherapy often overlook the homeless population.
Psychotherapy with the homeless population is not “treatment as usual.” Clinics providing services to the homeless may need to accept Medicare, Medicaid, or no insurance at all. There may not even be a physical clinic or office, and instead psychotherapy is provided outside on a park bench or in a homeless shelter. Psychotherapists may find themselves working on assertive community treatment teams or visiting clients in transitional housing sites. Outreach work is often used with this population and is necessary (Krausz et al., 2013).
Currently, about half a million people are experiencing homelessness in the United States (U.S. Department of Housing and Urban Development, 2015). Between 79% and 92% of the homeless population have a mental health and/or substance use disorder (Bharel et al., 2013; Krausz et al., 2013). Substance use disorders are common in my work and, in Boston, my clients are frequently entrenched in the opioid epidemic. Additionally, opioid use disorders are a common means by which my clients have become homeless. In addition to drug use, the use of alcohol is also prevalent with this population (Bharel et al., 2013; Krausz et al., 2013). Another common presenting concern is trauma. A recent study reveals that up to 60% of homeless women have experienced a trauma, whether emotional, physical, or sexual, while homeless (Riley et al., 2014); and, of course, homelessness itself can be traumatizing.
When first working with this population, I found myself regretting my word choices in giving homework and discussing the nature of an assignment. Clients would say: “Well, I can do this but I don’t have a home for homework…”
Often, clients would present with difficulties that seemed, from my perspective, simple and easy to fix. Yet to them, these tasks seemed insurmountable. For example, a client with a college degree and decades of experience working in accounting presented with difficulty filling out paperwork to request personal records. This population has helped me to never forget the impact that stress, anxiety, and depression can have on our ability to concentrate, plan, and focus. Psychologists working with behavioral economists have produced powerful work looking at how having no money affects our cognitive processes (Shah, Mullainathan, & Shafir, 2012).
Similar to my work with clients with serious mental illness and psychosis, part of my work with homeless clients must initially focus on lengthy and high quality rapport building. Engagement with primary care and behavioral health services is difficult for this population (Krausz et al., 2013) and there is a major lack of trust in organized systems and authority among my clients. As a result, being engaged in the therapeutic process is not a given. I spend much time on building relationships and I feel honored when I am let in. The physicians, nurses, and case managers I work with often have a supply of socks and toiletries to give to clients, not just to help clients with their foot complications or hygiene, but as a means of building rapport.
Homelessness is a social issue, largely due to the lack of affordable housing (American Psychological Association, 2010). In Massachusetts, the primary reason for families becoming homeless can be attributed to unstable housing. The second most reason is rooted in intimate partner violence (Massachusetts Department of Housing and Community Development, 2016). Yes, once in a great while I will come across a malingerer whom is trying to use various supports and social services intended for persons experiencing financial hardship—but someone’s willingness to do that is also meaningful. Sometimes I become jaded, but then I remind myself of these statistics regarding the causes of homelessness.
While working with the homeless population, I’ve met tremendously brave and strong people. People who have endured significant traumas and repeated loss in destitute conditions, and yet who still have a will to keep going. I have clients who have not had the luxury of a shower and clean clothing in weeks, or the comfort of a peaceful night’s sleep in days. I constantly find myself feeling grateful for “the little things” in my work, as it is a reminder these things are not always so little.