The Mindfulness Response notes are taken from an outpatient group therapy setting.
The Mindfulness Response demonstrates how important our home is for helping us heal. This area of life affects many other areas on the wheel. Without a secure base, it is difficult to be successful with treatment. Homelessness is a day-to-day struggle to survive. Numerous barriers arise for those who don’t have a secure place to live.
Homelessness and Treatment
An outpatient therapy program is for people who have a stable and supportive family, relatives, friends, and providers. Participants who were homeless or were “couch surfing,” did not do as well as those with a stable home.
Participants who experienced the Distressing Reaction Response in this area had problems with a home environment or shelter. They don’t feel safe in their home, or they are homeless, and this makes mental health symptoms worse. Group therapy was difficult or not possible for participants with these experiences.
Awareness of Maslow’s Hierarchy of Needs and Homelessness
Maslow’s Hierarchy of Needs was developed in 1938 in the USA and is a commonly cited developmental model. The base addresses the physiological needs of food, drink, and activity, but it doesn’t address housing. The physiological needs assume that everyone has a home or shelter, but this isn’t the case today.
Homelessness is not usually considered in Maslow’s Hierarchy of Needs, but participants reported problems being homeless. When homeless, they needed assistance to get food, shelter, a place to receive mail, qualify for insurance, and get medical care. Most people assume that others have a home, food, running water, a place to sleep, and can stay warm, dry, and healthy. Things that most people take for granted are a top concern for the homeless.
Mental health treatment is best managed when a person has a safe place to live and has support. The diagram of Maslow’s Hierarchy of Needs shows how a person must achieve one level before advancing. A person can only move up to the top if the previous level was acquired (Feeney & Thrush 2010).
The US culture emphasizes independence and self-starting individuals. Participants talked about being homeless not by their choice, and how it was a nightmare situation. Other countries care for people with disabilities and don’t have problems with homelessness. (Garza, McGregor, Nguyen 2018; Hofstede, 1980, 2001).
Homelessness has a connection to one in five people with mental illness (NAMI 2023). Without a permanent address to call home, necessities are difficult to obtain. Health care, bank accounts, credit or debit cards, library cards, mail delivery, food stamps, financial assistance, Social Security checks, General Assistance, or a paycheck. Half of the people who have a mental illness reported that it began around age 14 years, and 75% of people who have a mental illness said it began when they were 24 years old.
For those who have experienced homelessness, physiological needs are a daily struggle. Many people don’t understand who these people are or why they become homeless. Participants talked about feeling stigmatized, and that others shunned them and ignored them.
Cultural Awareness Race and Sexual Orientation
Participants talked about couch surfing and being homeless for long periods. They were from many different racial backgrounds. The group discussed how homelessness was higher for those under 30 years old. Increased education decreased the risk of becoming homeless in comparison with those without a high school diploma or equivalent, those who had a diploma, and those who had college degrees. (Fusaro, Levy, Shaefer, 2018).
More homeless people identified as Black Americans, Africans, or Whites than Indigenous peoples (Native American or Pacific Islanders) or Hispanics. Most of the homeless were single males. Efforts and organizations working to reduce homelessness among youth and veterans have decreased their risks of homelessness (The U.S. Department of Housing and Urban Development Office of Community Planning and Development, 2022).
Those who were LGBTQ+ were more likely than the general heterosexual population to be homeless. LGBTQ+ populations were estimated to be 20-40% of the homeless populations, while other heterosexuals were 5-10% of this group. This raises issues from the intersectionality theory where people’s experiences differ and can become oppressed in response to their identities. This can create negative health and social outcomes (Fraser, Pierse, Chisholm, Cook 2019).
Understanding Mental Illness & Homelessness
Participants who experienced homelessness talked about a downward spiral, feeling overwhelmed, an increase in symptoms, and not finding support. Unless a family or supportive person intervenes, the participants talked about being vulnerable, being evicted, being placed in a hospital, being brought to jail, and not all of them could recall psychotic episodes.
Physiological Needs: A Safe Shelter
Having a safe place to live is necessary for treatment to be successful. This includes feeling safe at home. A participant can have a warm house and live in a huge mansion and be abused by family or friends. The home is supposed to be safe, but it isn’t always secure. Participants with serious mental illness need support from someone, and sometimes their family is not a support. A team approach ensures that basic human needs are met. Social services may need to be alerted when an adult or a child becomes vulnerable to abuse in their home.
Participants talked about their home if they felt safe, and times when they ran away and had to “couch surf,” or were homeless. This presents more safety issues for the person with serious mental illness, as it becomes more difficult to find the person who needs treatment.
Physiological Needs: Why do they leave a home?
Problems with severe symptoms can cause the family to lose control of the situation and contact with the individual. Family members may be estranged from the person, avoid them, ignore their calls, or feel so overwhelmed by the situation that they don’t know what to do. Mental health workers try to intervene on the part of the client, but there are times when the family is so worn down that they can’t return calls or communicate with the severely ill individual. Participants talked about their unsupportive family that had a mental illness, dysfunctional communications, and had been abusive, so contact was stopped.
Participants talked about leaving home to escape the chaos, violence, substance abuse, and neglect. Participants talked about being taken out of the home as a child and placed into Foster Care. This is traumatic and as adults, participants feared abandonment and distrusted new relationships.
One participant talked about being emancipated as a minor, going to court, testifying about the situation at home, and then receiving legal status. This person said that leaving home at the age of 16 years was the best thing to do. One participant talked about being an older sibling who tried to protect younger siblings and be their substitute parent.
The participant was tearful when recalling family life, explaining that bio-dad was non-existent, mom had a drug problem, and maternal aunts had depression. The participant decided to leave home, get a job, and try to help the younger siblings get out of the home, too.
Common problems for family who lose contact with a loved one:
Untreated mental illness: PTSD, Bipolar Disorder, Mania, Depression, Schizophrenia
Substance Abuse
Suicide attempts
Emotional, verbal Abuse
Physical Abuse
Sexual Abuse
Different values, morals & religious views
Sexual Identity issues
Cultural issues
Stigma
Arrests
Violence, arguments
Stopping all medications
Identify Problems That Can Lead to Homelessness
The process of entering an intensive outpatient therapy program takes many steps and there must be some factors in place before the referral is made, or therapy is not possible.
Homelessness can be a major barrier to receiving adequate help. Participants talked about homelessness and how important it was to have a safe place to live and be stable on medications, so they could focus on therapy.
Substance abuse or drug addictions interfere with their ability to learn and apply skills and interfere with functions of the brain. Longer-term use of different substances causes changes in moods over time, with alcohol and marijuana acting as depressants. Participants were encouraged to get sober and stay sober. Psychosis can be triggered by the abuse of substances. Longer-term use of marijuana leads to more depression, poor concentration, apathy, low motivation, inhibition, and suicidal thoughts. (National Institute of Health 2022)
Long-term use of alcohol is a depressant and will cause more trouble with poor concentration, interrupted sleep, mood swings, and suicidal thoughts. Participants are asked to cut down on their use of substances and take only their prescribed medications. Any substance interacts with other prescribed medications and has an altering effect on the mood and psychosis symptoms. Participants who maintained sobriety were congratulated for their courage to abstain.
Cultural issues can get in the way of treatment. Participants talked about family members who had religious beliefs that did not believe in mental illness or psychiatry. One participant said relatives believed that prayer would cure the psychosis and that medications were not needed. The group discussed NAMI.org for support with family education.
One participant talked about religions and culture and how mental illness was treated differently and may not accepted. The participant talked about different views of mental illness and how there were arguments about medications and treatment. The group discussed the importance of understanding cultural and religious beliefs and how they relate to each participant.
Another participant talked about being more than one ethnicity, and a minority. The participant talked about cultural events at a pow-wow and connections made there. All ethnicities are important for treatment and understanding what is important to that person. (National Institute of Mental Health 2023)
Participants who lived between friends’ homes and a shelter were deemed homeless. They focused on a daily routine of searching for food, warmth, companionship, and where to sleep. Without stable housing, scheduling a doctor’s appointment, getting medications, refilling medications, or mail was difficult without a permanent address.
Since the start of the Affordable Care Act (ACA), more people have been able to access health care and receive mental health care. This has been the spark that started a warm fire for those who were left out on the cold night. Participants talked about having help from community mental health workers to obtain insurance. This has helped participants get help for their severe symptoms, and they talked about how they can remain stable.
Serious Mental Illness
Maslow’s basic needs include shelter and safety. Participants with serious mental illness may need a supportive residence or sheltered accommodation where there are 24-hour staff available. The staff manages the residence, provides meals, manages chores for housekeeping, and helps residents stay active. Without the staff, there may be self-neglect and an inability to do self-care. People with serious mental illness may need prompting to do basic needs and that takes a paid staff, like a mental health project worker to initiate this (Ellerby, 2016).
Attachment Theory – A Support
Attachment theory speaks about the relationship as a key to emotional regulation. Establishing a secure base helps children grow into adults who can manage when they have skills to use in times of crisis. (Bowlby, 1988). A relationship with a supportive caregiver can provide a “secure base” in times of stress, helping the child to manage their emotions, develop resilience, and navigate the world as they become adults with confidence. (Biggart, Ward, Cook, & Schofield 2017).
A group therapy member talked with others about how they found supportive providers and people to substitute as a family, since the bio-dad was not present in the home, and the bio-mom had difficulties with serious mental illness and was absent at times or in the hospital. They spoke of being in foster care and how a supportive foster parent had recently died. They had a team of providers and social workers but sought out a parent figure to help them fill the void of not having a mother in their lives regularly.
I’m not homeless, I live in my car.
A referral to the program introduced a new problem with homelessness, with the person claiming residence in a car, and not a home address. After discussing and answering many questions about a home address, the person said the listed address wasn’t correct, it was the estranged family contact, and the person lived in a car.
The person reported that they lost a job and were too depressed to get another one. The person reported that many people lived in their cars, and they parked close to each other in out-of-the-way places for safety. The person said staff from a nearby store gave them donuts and everyone was grateful for that.
The person described a lifestyle centered around how to get food, what to do when the weather gets colder, and how to make safe contacts. The person talked about being estranged from family and friends.
The person acknowledged every depression symptom from hopelessness and helplessness to low motivation, low energy, appetite problems, poor sleep, poor concentration, and suicidal thoughts. When asked about suicidal ideation, and attempts, the person talked about three separate times and explained the details. It was quite evident from the description of the attempts that this person should have been dead. Sometimes at the last second, something happens, or someone walks in and interrupts a suicide attempt, even when they are planned down to every detail. The person reassured me that there would be no more intent or plan to do anything today. The person’s eyes looked tired and weary, and their demeanor was sad. The person appeared to carry a heavy burden on his shoulders. The person didn’t shed a tear, however.
It’s unusual to have a conversation with someone with three serious suicide attempts. The person said they didn’t believe there was a God and had no religion or church community. This is common for people who have recurrent depression. The depression creates a fog throughout their lives, and they lose hope for the future and of God. A discussion about spirituality followed. The person’s facial expression was questioning and contemplative when the issue arose that God wanted them on the planet, and when their time was to come, they would be taken, but not before this time.
Like a good soldier, the person appeared sincere. This was a gamble. It was a surprise that the person showed up for the intake. It is not expected that a person living in their car would make it to treatment, but all staff hoped that it would be true. The person had no supportive friends or family.
The homeless people have a routine that is filled with unimaginable things. Most people would have no idea how hard it is to obtain food and shelter. Expectations were low for this person to come to the program. After many phone calls some that include referrals or emergency contact, the program staff noted the attempts and had to move on to other referrals.
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