The team delivering ‘guerilla’ mental health support to hard-to-reach homeless

“Many times, I’ve had an irrational vision at best: this is what I want, but I don’t have a clue how it’s going to happen,” says Liam*, reflecting on the impact a life that’s taken in long-term addiction, sheltered accommodation, rough sleeping and prison has had on his mental health.

“I’ve become deskilled through multiple rehabs and dependency on services. I’ve had a repetitive, habitual yearning since the age of 23 – I’ll get my head above water, then run back into the concentration camp.”

We’re chatting in the fag smoke-wreathed garden behind Bristol’s Compass Centre. It’s a one-stop homelessness drop-in – including a GP, methadone service, cafe and educational facilities – just off the city’s steadily gentrifying Stokes Croft.

Al fresco cafe culture is expanding in this neighbourhood. But its historical association with darker kinds of street drinking, and the complex issues that go with it, is reflected in the housing and support agencies clustered nearby.

Two of them, national homelessness charity St Mungo’s, which has its Bristol base in the Compass Centre, and local mental health organisation Second Step, have been jointly operating the Bristol Wellbeing Service for the past three years.

The project, which recently won an award for its psychological therapy services – offers a range of on-demand psychological interventions – 825 between April 2012 and March 2013 – to homeless people, a client group often beyond the reach of social services (few of the service’s clients are in touch with statutory adult mental health services).

Engaging a group beyond social services’ reach

“It’s lots of different things,” explains Gordon Wilkinson, one of two engagement workers, of his role within the project. “I go around places where people congregate. I drop into the Big Issue office; go where sellers are on the streets to see if they’re all right; work in hostels around the city centre.”

Within the Compass Centre, Wilkinson runs open-access recovery groups, including a mindfulness session for a recovery college (this offers courses and resources to help service users – and staff – understand self-care and the process of recovery). He also works on the wet provision, which seeks to reach out to alcoholics by allowing them to come in drunk, or with drinks.

Many clients visit regularly, or can be signposted to other services. But 40 per cent are ‘returners’ – people living chaotic lives who attend more erratically.

“When I first came it was for something to eat,” recalls Bond, who’s dipped in and out of the service for several years. “I had no interest in what was going on. Slowly I realised there was something else – the engagement process comes initially from the client, which is absolutely more sustainable.”

Learning to meet people on their own terms and encouraging them to make independent decisions is, Wilkinson asserts, what sets this service apart. Seventy-seven per cent of clients assessed there have experienced multiple traumatic events – including deaths, domestic violence and sexual abuse – which present ongoing barriers to forming relationships of trust.

“We don’t adhere to a programme – it’s no good doing a class on self-esteem if 10 people come in with relationship problems. What we do is like guerilla therapy: we’ll meet them where their needs are at that day,” he says.

“One class we do is about how to get the best out of support – these guys know services better than I do,” he adds. “What’s a good service; who’s a good person within it – it’s an exchange of information and ideas.”

Like Bond, Richard Almond has attended Wilkinson’s drop-in sessions. He’s been using the Compass Centre since being declared homeless in October, and has just volunteered for St Mungo’s Community Bridge Building programme to offer advice to others in similar situation.

“I functioned for most of my twenties – childhood trauma came back to bite me two decades later.” says Almond, who used to be a successful builder. “I’m a hell of a lot better than I was. I still have squiffy days; still got family issues. There’s difficulties but I’m getting back on the path.”

As well as group work, Almond has begun meeting regularly with one of the Wellbeing Service’s three part-time psychotherapists. On Tuesday afternoons, they also offer immediate support to people in distress, a facility unique in Bristol.

“We have people in their twenties, thirties, forties and fifties coming in saying, ‘My life is shit and I don’t want it any more’,” explains clinical lead Pennie Blackburn. “Our intention is being able to say, ‘What can we do to help?'”

The challenges of patchy engagement

Blackburn admits clients’ patchy engagement over long timespans presents administrative challenges, but says it’s part and parcel of working with individuals for whom things can go “horribly wrong” without warning. “It’s important people don’t feel like they can’t come back if they haven’t been ready to engage the first, second or third time.”

At an organisational level, however, the flexible policy can cause headaches. Manager Kevin Bache explains that Bristol Council, which with the NHS funds the Wellbeing Service, wanted to see progression-based outcomes.

“We were looking at a whole chunk of soft engagement [drop-ins] that wasn’t being measured – you don’t want it to be intrusive, so you’re not going to use [traditional assessment tools] CORE or HoNOS,” he says. “We came up with ‘magic questions’: one-liners where people say how they’re feeling on a scale of one to 10 in terms of their mental health.”

For more regular clients CORE and HoNOS are used, but Bache says that they’re still a poor fit for the chaotic circumstances many find themselves in. “There’s learning to be done about how you monitor a service like this – without anecdotal evidence and client testimonies, the tools we’re using don’t give off a [full] picture of what we do.” he adds.

Bache hopes the Wellbeing Service will continue to play a role in developing that process between now and October 2014. Beyond that date, changes to Bristol’s mental health pathways mean a new set-up will be commissioned, with the final specification still to be decided on.

“Hopefully not all the learning will go,” he concludes. “And hopefully the knowledge around flexibility and being adaptable will stay with the new service. Certainly [that’s] what we’d take into any recommissioning.”

*Some names have been changed