Tuesday, August 13, 2013

Exploring the Ambivalence with Chronically Homeless Veterans

My research interest is trauma, PTSD and resilience, particularly how attachment security moderates the relationship between these variables.

I'm funding my last year in the program with part-time work as a clinical supervisor, so I am supervising MSW clinical case managers working with chronically homeless veterans.  This is a new population for me but the issues of trauma, PTSD, resilience and attachment security resonate.

I had dinner with my clinical supervisor of many years, Reevah Simon.  Now semi-retired, I run to her regularly when I need her wisdom.  She was on fire.

One of the most important clinical concepts she taught me was the power of exploring the ambivalence clients have about change - even if the change is positive.

Implementing a program that attempts to fast-track housing for chronically homeless veterans seems like a no-brainer but the challenges are numerous and mostly invisible.  That's where clinical assessment and interventions come in handy.

Exploring the ambivalence

Reevah recommends that clinicians imagine that they are homeless - what are the advantages and disadvantages?

What's the best thing about being homeless?
  • Freedom from rules and regulations
  • The street is an unstructured setting
  • People that are homeless form networks - pairs look out for each other
  • Avoid feelings of paranoia and feeling trapped within four walls, feeling suffocated
  • Can move on when feel they feel like it
  • Can hide in plain sight - hard to locate
  • Form families and are willing to give up their life for each other
  • Taking care of their buddies motivates them - gives them a sense of belonging, community, and purpose
  • They have a place on the sidewalk
Having an apartment may mean that everyone knows where they are - like a sitting duck.

For chronically homeless veterans, traumatic experiences probably date back to childhood.  Insecure attachment to primary caregiver may have left them vulnerable to PTSD.

As a veteran, they may feel like
  • they don't belong anywhere - don't have a job
  • miss the structure of the military
  • miss the identification of their position/role/rank - someone always told them what to do
  • civilian life is individualistic vs. military life is group oriented
Any change, even for something seemingly better, provokes feelings of ambivalence.  We feel ambivalent about everything.  So when veterans don't show up to appointments or don't return phone calls, exploring their ambivalence about moving into stable housing is in order.  We all feel ambivalent about everything - so we either explore it using language and words or it goes underground and we act it out behaviorally (missed appointments and other forms of self-sabotage).

More questions for exploring the ambivalence:
Why wouldn't you want to move into stable housing?
Do you feel you would be giving something up?  What would you have to give up to move in?

Explore ambivalence with empathy - by putting yourself in the place of the other person and imagining what it would feel like to you.

What we, as clinicians, bring to the conversation is that we know the alternative.  We know the situation that veterans are in (assuming we have asked and listened well) and know what could be, that is, what is possible.

First, establish the way things are and then bring in the alternatives.

What do you do to prevent feeling claustrophobic?
What are the advantages to living in an apartment?
Are there difficulties living with another person?

Scheduling appointments

When scheduled to meet at a certain time and place, veterans may feel trapped.  "I'll catch you around" vs. commitment to time and place.

What are you comfortable with?  What do you think you could live with?

Keeping appointments carries with it symbolic baggage - feeling controlled.

Who's goal is it?

We've taken on the goal when the goal is more important to us than to the client.  The more we want it, the less likely they are to show up.  They take pleasure in screwing us especially if we act like we know better.

Understand who they are

What do they like about their current life?
What are the negatives about moving in?
Tell me what you like about living on the street?
If I was gonna live on the street, what would I need to know?
You are not trying to get them to do anything.
No matter what it looks like, they are immersed in a community.

When client may be acting like it's all our problem (as clinicians):
What are you planning to do about this?
How did you think I could help?
I notice this is the second time that this happens on the first of the month.  Do you run out of money?

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