Psychotherapy with homeless people: some learnings from the literature  by Paul Daly

• Poor naked wretches, wheresoe’er you are,
• That bide the pelting of this pitiless storm,
• How shall your houseless heads and unfed sides,
• Your looped and windowed raggedness, defend you
• From seasons such as these? O, I have ta’en
• Too little care of this. Take physic, pomp,

Expose thyself to feel what wretches feel, That thou mayst shake the superflux to them And show the heavens more just. (Shakespeare, 1608/1997, 3.4.28-36).

Much of Shakespeare’s language is hugely resonant and often anticipates the later insights of psychotherapy. King Lear’s empathic feelings for the homeless of his time are spoken in the middle of an imaginative world in which many aspects are simultaneously internal and external. The storm that rages is in Lear’s mind as much as on the heath, and the window-like holes in the clothes, the “houseless heads” and the nakedness of the destitute, which Lear is seeing for the first time, speak of psychic vulnerability as much as exposure to the elements. King Lear is a play about the gradual stripping away of a human being’s accommodations. Shortly after the words spoken above Lear says to Poor Tom, “Unaccommodated man is no more but such a poor, bare, forked animal as thou art” (Shakespeare, 1608/1997, 3.4.105-106). Lear’s own head is “houseless” and the shelter he seeks - as with many homeless people today - is not just a physical dwelling but the shelter of love and understanding (Seager, 2011). Although the words “wretch” and “thy” are from a different era, the idea behind Lear’s invitation to himself to “expose thyself to feel what wretches feel…and show the heavens more just” (Shakespeare, 1608/1997, 3.4.34-36) could be seen in the self-talk of someone today working with vulnerable homeless people on the street.

The insight that some homeless people experience psychic vulnerabilities and psychological distress is not new. We see this in literature and in personal observation. In the largely autobiographical Down and Out in Paris and London, George Orwell (1933: 204) describes “tramps” as “the most docile, brokenspirited creatures imaginable”. More recently John Healy’s (1988/2008: 1) visceral autobiography of alcohol addiction and homelessness begins ominously, “My father didn’t look like he would harm anyone.” Within a few sentences the six-year-old is being violently assaulted by his father (Healy, 1988/2008). There is a sense in this book that if people are not traumatised before they are homeless, they become so because of it:

Skippering is illegal; also rough. Some skippers are fair; most are bad. One feature common to both - they are all lousy. It is hard to describe to a clean and healthy person just how uncomfortable and degrading it is to share your clothes with a load of parasites: apart from the terrible irritation there is the nasty feeling of self-contempt. Fights break out in the night; the police come in, nick you or throw you out, depending on their mood; any nutcase can walk in, burn the place down while you’re in a drunken stupor. You try to sleep in the attic with the birds but end up in the basement with the rats. (Healy, 1988/2008: 161-162)

Structural narratives are outside the scope of this article which is about psychotherapy with homeless people, but it is worthwhile to note Declerk’s (2006: 162) observation that the unfortunate situation of the homeless

is compounded by the insidious sadism of a society - our society - that needs to punish those who live on its fringes, and which to this end, ensures that the health and welfare provisions made for the homeless are structurally inadequate.

How homelessness is thought of shapes how we respond to it. Homelessness is a multidimensional reality with socio-economic, familial, psychological, and health aspects. There is a limited but rich body of psychotherapy literature on psychotherapy with homeless people which I discovered when doing research for my Masters thesis in 2017, and in this article I would like to outline it and reflect on what may be missing.

It has long been recognised that some homeless people, in addition to requiring housing, have needs also for psychotherapy or psychiatric services. The Programme for the Homeless Mental Health Service in Dublin, which was set up in 1979, may have been the first consultant psychiatrist-led service of its kind in the world (The College of Psychiatry of Ireland, 2011) and it currently engages homeless people with “severe and enduring mental health difficulties” (Case Management Guidebook, n.d.). A 2012 study of a Dublin homeless hostel found a very high prevalence of mental disorders: 81.6% (Prinsloo, Parr & Fenton, 2012). Voluntary agencies such as the Dublin Simon Community provide counselling services for homeless people and their most recent annual report (2020: 15) states that in 2019 clients received 2,850 hours of one-to-one counselling and mental health support from the Sure Steps counselling service.

Such services are perhaps a recognition that homelessness can come about for reasons other than structural factors such as a lack of affordable housing, poverty, unemployment or high rents (Focus Ireland, n.d.) and it may originate through “an inability to be at home, to feel some connectivity through house, neighbourhood and wider community” (Robinson, 2001: 5). Writing about homeless services in England, Martin Seager (2011: 183) states:

When it comes to tackling homelessness we act as if ‘getting a roof over a person’s head’ was more important than what is going on inside their head and as if the physical shelter provided by the roof was more important than any psychological shelter that might be provided under that roof from the relationships formed between that person and the others who live there.

Seager (2011: 184) goes on to state that the approach to homelessness is too often “mind blind”, focusing on the necessary aspects of bricks and mortar, food, medicine, skills and finance but not helping people meet their “universal psychological and spiritual needs” to be loved, listened to, belong, achieve, have meaning and hope.

Researchers have conceptualised aspects of homelessness in a number of different ways. One of the ways human beings make sense of experience is through narratives which are like threads which weave together certain privileged events and experiences (Morgan, 2000). The dominant narratives we tell ourselves shape our lives and relationships with other people and many of these narratives occur at the same time and are influenced by the cultures we live in (Morgan, 2000). While poverty, unemployment, social welfare and health provisions and lack of available and affordable accommodation are major factors in homelessness, there is a lot of research which links homelessness to psychological factors (Seager, 2011; Campbell, 2006; Finfgeld-Connett, 2010; Fischer and Breakey, 1991; Goodman, Saxe and Harvey, 1991). I would like to outline the narratives of homelessness in the psychotherapy literature in the hope that looking at the various related and often overlapping therapeutic themes will add to a greater understanding and prompt us to ask what else needs to be included.

Homelessness as lack of containment

O’Connor (2003: 115) outlines the concept of containment as described by Klein and Bion: the child’s anxieties are projected into mother who detoxifies them and gives them back to the child in a more palatable form. Each person’s first home is not a house but “the mind of one’s mother” (O’Connor, 2003: 121). This experience of a containing object is eventually internalised so that the child is able to go through a process of self-reflection which helps him or her to tolerate experiences of absence - though containment from others is always needed to some extent (O’Connor, 2003: 116). When containment does not happen or happens to a lesser extent the result is an uncertainty about the world; the child may avoid interactions where anxiety arises, reject the very act of containment or turn to external sources of comfort (O’Connor, 2003: 119). In addition, it may happen that the child is used as a container for the unwanted feelings of his or her parents and O’Connor draws the analogy that homeless people “become the victims of a collective projection of all that is unpleasant and unsavoury” and they may come to enact this role (O’Connor, 2003: 118). For O’Connor (2003: 120) the experience of containment and the experience of being at home are parallel and therefore to be without a home is also to be without a sense of belonging and safety: home is defined by one’s relationships and one’s emotional connectedness. Some people put up with chronic homelessness because it is a reflection of their internal experience of rejection and disconnection; others seek more intense containments such as prison or drugs (O’Connor, 2003: 122-123).

Campbell (2006) describes Rey’s concept of the claustro-agoraphobia dilemma, which Campbell states is intrinsic to both homelessness and to borderline disorders. This is where the person feels shut in when in an enclosed space and afraid and abandoned when in the open spaces of the streets. Campbell (2006) cites Rey’s insight that the characteristic occupation of doorways by homeless people stands for an inability to make choices. The doorways become an intermediary space between the ‘inner’ sense of persecution and the hostile ‘external’ world where their restricted ability for selfreflection is expressed in their wish to make sense of themselves through other people’s responses, drawing passers-by and support workers into fleeting encounters (Campbell, 2006, para 21).

Brown et al. (2011) write about a pilot project which made up to 25 psychodynamic psychotherapy sessions available to chronically excluded people in 12 different locations across London. The clients at times put up a fierce resistance to psychotherapy: they engaged with psychotherapeutic thinking but they would not enter the therapist’s room, lingering in the doorway, the park, the garden, the corridor, the ward instead (Brown et al., 2011). Behind this resistance appeared to be an anxiety for some about being taken over and obliterated, recalling histories of neglect and abuse, and the doorway was the only place they felt safe (Brown et al., 2011). There were challenges in these border spaces for both therapist and client: lack of privacy, interruptions, poor weather, frequent uninvited spectators, difficulties hearing and focusing (Brown et al., 2011: 315).

Homelessness as psychological ‘unhousedness’ and psycho-social dis-memberment

Scanlon & Adlam (2006: 10) posit that some homeless people - in a similar way to those with personality disorders - are “psychologically ‘unhoused’ and psycho-socially ‘dis-membered’”. Homeless people with a personality disorder may have a deep sense of not being at home in their body or mind and experience painful unbearable feelings, and Scanlon and Adlam (2006) ask how someone who feels continually empty in their internal space would feel secure in the external space of a house. The authors cite Bateman and Fonagy who link this emptiness to lack of success in establishing a secure attachment, and they state that “in ordinary development the experience of ‘home’ is linked to the experience of one’s self being housed in others’, usually parents’, minds” (Scanlon & Adlam, 2006: 11). The personality-disordered homeless client seeks to refrain from “‘being inside’ anything” while at the same time wishing to be known and “inside the mind of others” (Scanlon & Adlam, 2006: 11).

Homelessness as broken attachment

Seager (2011) claims that broken attachments are one of the contributing factors to chronic homelessness and that long term rough sleepers may well be still searching for their first secure attachment in their lives. Smolen (2001) writes that when working with homeless children and parents there must be a clear focus on the early attachment relationships of both the child and the parents.

Homelessness as failure of self-care

While socially oriented theories see homelessness in structural terms, chronic homelessness can also be seen as involving a profound failure of self-care. Brown’s (2015) experience as a psychotherapist working with the homeless is that failure to care for one’s body may repeat scenarios of early neglect or abuse and this is often communicated through disturbances in relation to dirt and smell. Failure of self-care comes from a traumatised relationship between the person and his or her body in the first instance (Brown, 2015). Brown (2015: 37) cites Lemma’s observation that “the body never ceases to signal the relationship with the mother”. Odours, which are unconfined and which unavoidably cross boundaries, prevent us from ignoring the homeless person’s distressed mind and neglected body (Brown, 2015).

Seager (2011) sees long term rough sleeping as indicating an almost complete disregard of the value of the self. Sleeping rough and refusing shelter, particularly in the winter months, comprises serious self-neglect but it is often naively seen as a “lifestyle choice” (Seager, 2011: 185).

Homelessness as trauma

There is a lot of research on homeless people and trauma. Early developmental trauma including abuse, neglect, and attachment disruption are part of the narrative for many homeless people (Hopper, Bassuk & Olivet, 2009). For some people, adult domestic violence is the catalyst to homelessness and because homeless people are traumatised, they find it difficult to cope with the many obstacles they encounter or to escape homelessness (Hopper, Bassuk & Olivet, 2009).  Goodman et al. (1991) claim that homelessness itself is a risk factor for psychological trauma because the loss of one’s home can be a severe stressor, the conditions of shelter may result in trauma and many homeless people, in particular women, become homeless after experiencing sexual and physical abuse. Felix (2004) states that homeless people have experienced a high incidence of trauma and violence during childhood.

Homelessness as addiction

The most prevalent disorders found in a Dublin homeless hostel were “Alcohol Dependence (23.7%), Opioid Dependence and Major Depressive Disorder (both 18.4%), Opioid Abuse and Alcohol-Induced Depression (both 7.9%)” (Prinsloo, Parr, & Fenton, 2012: 22). The connection between homelessness and addiction has been made by Fisher and Breakey who as far back as 1991 stated that the research evidence consistently supports the high prevalence of alcohol, drug and mental disorders among homeless people.

Homelessness as unconscious familiarity with the street

Farrell (2010: 243-251) argues that there are three main dynamics which cause people to continue to be chronically homeless even when housing becomes available: an unconscious gravitation towards the familiar homeless environment; difficulty with situations which are structured; and an adjusting to being homeless. The unconscious tendency to gravitate towards the familiar is an example of Freud’s repetition compulsion (Farrell, 2010: 244). Some homeless people may gravitate to life on the familiar streets in the same way that people in abusive relationships keep returning to violent situations and there may be unconscious resistance to leaving this way of life (Farrell, 2010: 244-245).

Homelessness as breakdown

Volunteering first with an initially small homeless project (now called Project H.O.M.E.) in Philadelphia, Luepnitz (2015: 152) was struck by the situation of those who appeared psychically unable to live indoors and with the agreement of the project leader recruited psychoanalysts - now 14 in number - for the “deep work” that was needed. Luepnitz (2020) conceptualises three psychological categories of homelessness which reflect “increasing levels of trauma and dysfunction”:  First, homelessness can be an “expression of breakdown” where “one’s resources have been exhausted”. Second, following Brown (2019), it can be “a defense against breakdown”. Third, following Winnicott (1963), homelessness can be “an expression of the breakdown that occurred in infancy, but was not experienced”. In her earlier work Luepnitz (2015) highlights the idea that the breakdown one fears most has, in Winnicott’s words “already happened, near the beginning of the individual’s life”, and the patient needs “to experience this past thing for the first time in the present—that is to say, in the transference” (Luepnitz, 2015: 157). Luepnitz (2015: 159) writes of her way of doing psychoanalysis with homeless people: “We show up. We bear witness and make ourselves vulnerable to the dread, the aggression, the deadness of the patient’s inner world—without abandonment or retaliation.”

Homelessness as nameless feeling of dread

The Lacanian psychoanalyst Harper (1999: 84) states that for the homeless person on the street there is little difference between the public and private spheres and no sense of sanctuary or home. To describe this traumatic space Harper (1999: 84-85) invokes Bion’s “nameless feeling of dread”, Winnicott’s “state of endlessly falling” and Klein’s “pure presence without absence, a lack of lack”.

Homelessness and survival

Researchers coming from diverse disciplines focus on the narrative of survival. The resiliency and survival skills of homeless adolescents tend to decrease over time which may be due to the constant challenges faced (Lee, Liang, Rotheram-Borus, & Milburn, 2011). Roebuck & Roebuck (2016) found that young homeless people positively adapt in the light of the adversity they experience. Strategies for survival among homeless teenagers and young adults are diverse (Hein, 2011) and include socially approved and disapproved activities (Ferguson et al., 2011: 401).

Homelessness and resilience

Most research on homeless people has “focused on the problems faced by this vulnerable group” but a study of 87 homeless and ex-homeless people in London explored their resilience (Smith et al., 2008: 2).

Factors that enhanced resilience included being able to establish meaningful contact with their families and/or integrate in the wider community, opportunities for engaging in the creative arts and learning, and welfare workers who listened patiently, empathetically and non-judgementally (Smith et al, 2007: 20).

Limitations of narratives

The available narratives on any given subject, while often offering valuable insights, are also necessarily limited. In the case of the above narratives, they are conceptualisations of some aspects of people who are homeless and there is no space in this article to describe the unique human beings involved or the compassionate therapies that the therapist-researchers engage in. We know from other sources such as news media (e.g. Irish Times, 2015) and the annual reports of homeless charities (e.g. Dublin Simon Community, 2020) of the resilience, resourcefulness, creativity and solidarity of many homeless people. However, this is generally not reflected in the psychotherapy literature. Moreover, there is very little, if any, academic research on this work which comes from an explicitly humanistic perspective. Humanistic psychotherapies share a broad set of values and philosophical assumptions (McLeod, 2014) which incorporate relational, experiential, existential and phenomenological approaches (Cain, Keenan and Rubin, 2016). They emphasise the benefits of relational connection and support, emotional expression and processing, the movement towards authentic being, focus on the self and self-concept, discovering a sense of meaning and purpose and the cultivation of the capacity for freedom and choice (Cain, Keenan and Rubin, 2015). One such is existential psychotherapy.

The existential dimension of homelessness

In research for my Masters thesis in 2017, I interviewed three psychotherapists working with long-term homeless clients. I had expected that the findings would mirror the mainly psychodynamic narratives of the literature. Instead, I discovered that the themes that emerged were existential. The stark facts of existence are faced most clearly by homeless people: being isolated and estranged from society, experiencing meaninglessness and anxiety, having no place of one’s own or sense of place, facing danger and death. In Waiting for Godot (1956) Samuel Beckett’s “existential tramps” (Gold, 1988) have achieved iconic status, becoming an identifiable narrative of those without a place and anxiously waiting for meaning. Given the situation of the homeless, it is surprising that the existential dimension is almost completely absent from the literature on psychotherapy with homeless people. The only peer-reviewed research discovered was that by Sumerlin and Bundrick (1997: 1304, 1311) who write that “existential anxiety is poignant for homeless people as they struggle to find food, clothing, and shelter every day” and they note that insufficient attention has been paid to “the existential dilemma of the homeless”. Eustace (2014: 136, 159) interviewed six homeless people in Dublin for her doctoral thesis and her conclusion is that “homelessness can be viewed as a profoundly boring, deeply anxious existence characterised by the breakdown of caring relationships with self or others”. I have identified below some themes from existential psychotherapy which emerged out of my research. These themes reframe or expand some of the above narratives and I have outlined them below as they are expressed in general psychotherapy literature.

Existential anxiety

It has been said that the characteristic mood of human beings today is anxiety (Collonello, 1999). Existential psychotherapy goes further: from this perspective anxiety is a given of existence (Iacovou and Weixel-Dixon, 2015: 52). Anxiety is not just one feeling among others: it is an ontological characteristic of human beings, rooted in our existence (May, 1958: 50): “Anxiety is the experience of the threat of imminent non-being”, the “most painful and basic threat which any being can suffer, for it is the threat of loss of existence itself” (May, 1958: 50, 52).

For Spinelli this anxiety is about “the fragility of human existence” (Du Plock and Fisher, 2005: 73). Tillich views neurotic anxiety as a distraction from and an evasion of existential anxiety (van Deurzen and Kenward, 2005: 7). May (1958: 52) looks at both sides of existential anxiety which he characterises as a condition where “some potentiality is present, some new possibility of being, threatened by nonbeing”. Existential writers value such anxiety because “it marks the start of our openness to the human condition” and it is “the necessary counterpart of being truly alive” (van Deurzen and Kenward, 2005: 7). Existential therapy strives to help people to find the courage to face life and death resolutely (van Deurzen, 2012: 48). Cooper and Adams (2005: 84-85) strike a cautionary note in relation to translating existential philosophical insights into clinical practice, emphasising the importance of respecting clients’ defences about death, and that therapists need to be aware of their own death-related issues so as not to impose them on clients and, importantly too, appreciating the brightness of life, as well as anxiety about death.

Not-at-home-ness

It is interesting that one of the key terms in the existential lexicon is Heidegger’s not-at-home-ness or Unheimlichkeit (van Deurzen and Kenward, 2005: 209). In this form of anxiety, the person feels homeless but this feeling of homelessness is “a fundamental state of Being, which corresponds to the intrinsic temporary nature of human existence” (van Deurzen and Kenward, 2005: 209). The sense of “homelessness, feeling lost and deprived of human relationships is the metaphysical condition of modern humanity” (Collonello, 1999: 41). The feeling of “not-at-homeness” may lead the person to engage in “metaphysical questioning” because it calls on each of us to consider “our actual state of Being rather than hide in the They” (van Deurzen and Kenward, 2005: 209).

Alienation and isolation

In existential psychotherapy there are four kinds of estrangement or alienation: “from oneself, from others, from the world and from God” (van Deurzen and Kenward, 2005: 2-3). Whereas hysteria was the “typical” kind of psychic problem in Freud’s day, the schizoid state is the problem of today where therapists see many persons who are “detached, unrelated, lacking in affect, tending towards depersonalisation, and covering up their problems by means of intellectualisation and technical formulations” (May, 1958: 56). For Yalom (1980: 355) existential isolation is the “unbridgeable gulf between oneself and any other being” but, paradoxically, he is still able to say of psychotherapy that “it is the relationship that heals” (401).

Freedom

Freedom is perhaps the quintessential existentialist theme. The Christian existentialist, Kierkegaard, said that “anxiety is the dizziness of freedom” (van Deurzen and Kenward, 2005: 6). Macquarrie (1972: 177) states that for Kierkegaard freedom and existence are indistinguishable: “One does not first exist and then become free: rather, to be human is already to be free.” If the human being did not have some freedom to fulfil a new potentiality, he or she would not experience anxiety (May, 1958: 52). People surrender freedom in order to escape this unbearable anxiety (Goldstein, as cited in May, 1958: 52). For Yalom and Josselson (2014: 274) freedom refers to the fact that the human being is responsible for and the author of his or her own world, own life design and own choices and actions.

Meaning and meaninglessness

For Frankl the person’s most basic motivation is to find meaning in life (Cooper, 2003: 53). Frankl (1946/2004: 131) sees the loss of meaning as an existential vacuum which is “the mass neurosis of the present time” which can impel people to turn to addictions and compulsions to fill their existential void (Cooper, 2003: 53-54). For du Plock and Fisher (2005: 75-76), a client’s dysfunctional behaviour is meaningful because it serves to defend against anxiety and cannot be left behind until that which is defended against is addressed. Baumeister (1991: 56) views the human being as having four basic needs for meaning: purpose, value, efficacy and self-worth; and when these are not satisfied people show distress.

Conclusion

I have presented here an outline of some therapy narratives of homelessness, noting the lack of research from a humanistic perspective and offering some existential themes as an extra perspective to view the situation of homeless clients. While existential psychotherapy is often most associated with the more challenging aspects of life such as anxiety (van Deurzen, 2012) and despair (Binswanger, 1958), it also focuses on joy (van Deurzen and Kenward, 2005), the deep relatedness of ‘I and Thou’ rather than ‘I-It’ (Buber, 1937), potentiality (May, 1958), meaning (Frankl, 1946/2004), authenticity (Cooper, 2003; Pollard, 2005; van Deurzen, 2012), embodiment (Dreyfus, 1996) and sex (Barker, 2011). These themes could be unpacked usefully in relation to homelessness but there is no space to do this here. Nowadays, therapists are all integrative to a greater or lesser extent and being pragmatic, combine elements from a number of different therapeutic orientations, depending on how useful they are for the client. Existential therapy is one of a number of therapeutic perspectives which a therapist can include in working with homeless or indeed any clients. By having an existential dimension, the big picture is included - values, meaning or lack of meaning, purpose, freedom, choice, responsibility, authenticity, the four worlds of physical, personal, social and spiritual (van Deurzen, 2012) - and these are brought into clear focus by considering both the fragility of existence and its possibilities. Because each of the existential themes apply equally to therapist and client, the approach is less likely to be othering and more likely to be truly humanistic.

Paul Daly is an IAHIP accredited psychotherapist working in private practice and community-based therapy in Dublin.

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