How do you help homeless people who refuse your support?

A group of women who sleep rough in London refuse help, seeing homelessness as their choice. They do not take drugs or abuse alcohol but may have undiagnosed mental health issues. We asked three College of Social Work representatives what they would do in response to two such cases

Case study: Andrea

Andrea has been homeless for the past 32 of her 66 years. She is known in her part of London for the plastic shopping bags that are tied over her feet with string and the many layers of clothing she wears underneath one of her capes.

She spends her days organising her correspondence, writing regularly to “people”, though she will not discuss who. Local hospital security staff recognise Andrea as she enters the building to wash and change the dressings on her lower legs.

Most mornings she sits in the post office near the social services office and most afternoons she can be seen in a car park where she also prepares her lunch. She refers to the green area as her garden. Police are regularly in contact with her – she informs them of people breaking the law, “obstructing the pavement, parking offences”.

She has been sectioned once but staff ultimately decided there was no reason to maintain the section.

Andrea likes living independently and according to her own values.

She resents being patronised by “charity” and is aware of how to seek help should she need to. She has a range of casual jobs and is aware of her pension though chooses not to draw it.

Andrea has often been verbally aggressive and offensive to passers-by and to people who approach her, but she insists these outbursts are provoked by people insistent on giving her charity when she has already refused and are not related to any psychotic beliefs.

Andrea has not had any convictions or cautions relating to this behaviour which suggests that she does not pose a risk to others, but there is a concern that it does put her at risk from others.

However, she is aware of her personal safety and does not engage in reckless behaviour.

She has not seen her GP since 1965 and has always eschewed orthodox treatments, but homelessness charity Thames Reach says she is aware of the consequences of disease and life-threatening conditions.

She has told people that she does not wish to be reviewed or followed up by mental health or other outreach services (including a social services homeless team). Although she understands their purposes, she prefers her network of friends in the neighbourhood who offer her “support on her terms” and do not “impose upon her”.

Andrea has also refused housing options from the council and meals-on-wheels.

Victoria Hart, social worker, approved mental health professional and spokesperson for The College of Social Work

It seems we need to be mindful of a number of things in relation to Andrea. What exactly is the “problem” that is caused by her behaviour? Is it more about concerns of society rather than concerns that she has for herself?

According to the Mental Capacity Act 2005, we make an assumption of capacity, and just because she is 66 this does not encumber her with any specific remit to be “vulnerable” under safeguarding guidelines. There has to be a specific need or “vulnerability”, and age alone is not enough for us to make assumptions about what is in her best interests.

Services cannot be forced on her against her will, unless she does present a risk to herself or others to a degree that would warrant compulsory action being taken such as a detention under the Mental Health Act 1983.

She has built up informal networks with the police so my advice would be to continue with a befriending/outreach service and to be mindful of any particular changes in her presentation.

Claire Barcham, professional practice development adviser, The College of Social Work

Whatever the temptations to intervene robustly for the sake of someone’s welfare, we have to respect people’s liberty to lead the lives they rationally choose.

In this case, the worker has clearly identified that, although Andrea has views that are different from those of other people in her community, she is conscious of the possible outcomes of her decisions. 

Respecting her right to make these decisions while ensuring that Andrea knows how to get help in the future is key. It may also make it more likely that Andrea will seek help from the outreach team in the future should she need it, whereas a more interventionist approach would seem likely to alienate her further.

It might be useful to see whether Andrea can identify situations where she might want help, and who she would plan to ask for that help. The worker might also then be able to work with a worst case scenario should any of these situations arise.

Chris Russell, social worker working with older people and spokesperson for The College of Social Work

Andrea is well known in her community and I would make the best use of this. Although she has consistently refused help, people’s circumstances change, especially in relation to physical health as they get older.

I would gather colleagues from health services, the police and others who, it is clear, Andrea knows well and has regular contact with, and ask them to construct plans to engage with Andrea at the point she requests help, or becomes in need of assistance, as a victim of crime for example.

Andrea’s community associates know her better than anyone and they are an essential resource in planning the best ways to engage her in the longer term. The group could be informal or be part of local arrangements for adult safeguarding.

I don’t believe this will be a swift route to success but a key part of good practice is planning ahead and having appropriate contingencies in place.  

Case study: Beatrice

Beatrice is a 42-year-old Irish woman who has slept rough in and around two outer London boroughs for two-and-a-half-years.

Preferring to get about at night, when it is quieter, Beatrice sleeps during the day in a highly visible part of a park, .

She has some circulatory and fluid retention problems that distend her ankles and age her. Her reluctance to engage with services was typified by her supplying an alias which made background checks difficult, and her refusal of all accommodation offers.

Little is known of her background though it is believed she may have worked as a PA in the City and she has said she wants to return to work at some point.

An initial meeting with a community psychiatric nurse was met with a large degree of disdain. Beatrice felt patronised and responded similarly. But the same nurse also went to the local library, where Beatrice was a member, and following enquiries could establish her true identity.

She was assessed under the Mental Health Act in June but was not considered sectionable, though she did agree to engage with a community mental health team manager.

Ultimately, Beatrice convinced the manager that this was a lifestyle choice, that she did not have a mental illness and was not depressed.

The outreach worker responsible for the locality followed up with a visit, but kept the engagement on a casual, chatty level with reassurances that there was no pressure.

THE OPTIONS FOR PROFESSIONALS

Claire Barcham

Beatrice’s story is not an unfamiliar one. As the outreach worker indicates, there is likely to be a long road ahead before she can be engaged by services.

I was impressed by the work of the CPN in going to the library – which emphasises the importance of getting to know her own world view and what is important to her. It may, for example, be feasible to engage with her about the possibility of returning to work and what might need to happen in order for that to happen.

It is possible that there is an underlying mental health problem which she is able to mask with her intellect. If so, it may be that Beatrice will only be able to manage if she is not faced with a stressful event.

As a consequence, while she may not be sectionable at present, I wouldn’t rule out this possibility in the future.

Given her Irish ancestry, it might be worth asking local Catholic churches whether they know her. If so, depending on the priest, they may provide a useful alliance either to encourage Beatrice to accept help or to alert professionals if her situation deteriorates.

Chris Russell

Some success has already been achieved here, for example through a contact and gathering greater knowledge of Beatrice.

The Steven Hoskin serious case review would be a useful resource to consider. Significant learning from this was that professionals must continue to try to engage with people they assess as vulnerable, even when they are discouraged from doing so.

Contemporary adult safeguarding practice would promote prevention in this situation, so I would make a safeguarding referral as a formal method of formulating an engagement and safety plan.

Beatrice’s work history is also significant. She has been employed in the past and has ambitions to be so again in the future. This could be a route to engaging her.

Library staff could play a part in reporting concerns for her, while it may also be possible to engage her through her interest in the services the library provides.

Beatrice has chronic health difficulties. Thus, I would establish links with health services locally where she might present in an emergency, and make plans to maximise opportunities for engagement should she do so.

Victoria Hart

There are issues regarding choice and capacity in Beatrice’s case, including the right of people to make “unwise” decisions. However, there is plainly a potential vulnerability due to her fluid retention, which may also mask other physical health problems.

It is important to say, though, that there has been no diagnosis of mental health needs and it may be that statutory services cannot provide the services that instinctively we might assume should be involved.

Eccentricity doesn’t necessarily mean you would lack the capacity to make a decision whether to engage, although there is clear evidence that she is amenable to building relationships as she did with the outreach worker.

In this situation, regular, reliable outreach work is the way forward, in the hope that Beatrice will build a relationship of trust with a key worker who will be able to encourage her to access more services.

The Mental Capacity Act 2005 sets clear guidelines about the limits of imposing services on people who do not wish to access them. Although it is important to offer assistance, we need to be mindful that people have autonomy and choice.

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