Hostel Visit 2nd March, 2007
Energised by a multi-agency visit from our town to the UK’s flag-ship Dawn Centre in Leicester yesterday, I feel affirmed that a greater CPN presence in homelessness as well as better GP access are the two things I must prioritise as recommendations in the HNA report. Seeing health services functioning as a multi-disciplinary homelessness team (MDT) highlighted my clinical isolation - picking up health problems that fall through the net, as well as the strategy required for service development.153
Today, my feelings plummet from vision to reality framing (Johns, 2009). There is an urgent message about Dean on my answer-phone. On the streets from the age of 14, he previously refused contact with health services, triggered by his dislike of child psychiatric services. Having opened the therapeutic space with him, he remarked, 'I can't believe I'm here talking to you like this'. His health issues related to substance misuse, aggression, nutrition, BMI and strong body odour. Today, Christine his key worker sounds anxious,
“He's hearing voices. He told me he had schizophrenia when he was 12…... Two days ago he talked about his plan to murder John, followed by his own suicide. He'll talk to you. I don’t think we should use a sledgehammer to crack a nut! "
Adrenaline pirouettes through me - murder and suicide - two days ago! I distinguish my healthy fear from unhealthy fear (Rutledge, 2005), I acknowledge the professional training required for mental health assessments of people experiencing auditory hallucinations, and I am aware of the resource tension within my clinical and strategic role. Ethical mapping (Johns, 2009) inwardly charted, I feel that hostel staff must enable Dean to access crisis intervention, empowering themselves to use mainstream services. I can't do it all. I must prevent 'burn-out' in this multi-faceted role.
I overhear Christine,
“No, Dean, she won’t section you. It’s just that she has more knowledge than us."
Fear of section - familiar scenarios in homelessness with people who have experienced mental
health services (Texts:1,5). Fear making engagement precarious. A CPN as a regular feature at hostels would address this.
153
E.g. Public Health HNA report, the homeless section in the annual Public Health report (2007), Admission and Discharge of Homeless people policy, homelessness strategic meetings, family homelessness notifications, homeless professional pack, health and homeless leaflets
173
“Christine, I'm not an emergency service. Your responsibility is to phone mental health services or the police. I'll visit when crisis issues are dealt with.”
Whilst I seek to enable Christine in health service access, she illuminates her worry: high level mental health needs means eviction for Dean; this hostel is low to medium support without 24-hour cover. There is no automatic transfer into a higher support hostel,
“There isn’t a bed available – we won't keep him here because he could be a danger to other residents.”
This is more than a health crisis - it is a homelessness crisis. Increased mental health needs triggering rough sleeping!154 In this awareness, I contact the mental health team manager to engage them with me in a joint visit. Her procedural voice is evident; he must go to A&E or contact the mental health crisis team if he gets worse! I reflect, is this the best response? What other choices are there? The ethical nature of homelessness practice is apparent. Aware of my developing 'moral' voice to connect her to homelessness, I draw on the Leicester model where a CPN is part of the homelessness team, and assert,
"But he refuses to go to A&E - he is frightened. Fear is an issue that causes people to fall through the net. A familiar CPN clinic in the day centre would help people engage with services.”
I seek to inspire her, to open-up local rigid health systems in homelessness, reaching across silo rules through joint multiagency working. It requires a strong voice as I chip away to uncover practice, push parameters, and become political. I negotiate the tensions, recognising that if services do not engage my ultimate power lies in HNA recommendations, and in lecturing and writing academic research to transform health cultures in homelessness.
She pauses. Instead of a joint visit, she offers phone support to hostel staff. I am still relieved. At intervals, I map how the crisis is progressing. Staff say, “We are walking on egg shells, waiting for
the police to arrive. We are trying to get him to register with a GP.”
In his pride of 'needing no-one', Dean had resisted GP registration.
As the working day ends, I phone the hostel again. The hostel worker says, “You have been
wonderful, Maria”. I am surprised. I negotiated guilt about fearing the unknown in an area of
practice I am inexperienced in which resulted in my own rigid rules on the SPHN role in crisis
154
Later, the Government's intention to end rough sleeping by 2012 (CLG, 2008) and concern about evictions (CLG, 2008) were published.