In cities and towns across America, the problem of homelessness is on visual display: men and women in tattered clothing sleep in makeshift tents, ride buses carrying overfilled shopping bags, or stand in line in coffee shops counting change to buy a coffee and use the restrooms. According to the National Alliance to End Homelessness, in January of 2020—the last time homelessness data was collected thoroughly using the Point in Time count—nearly 600 thousand people experienced homelessness on the streets and in shelters across America. The homeless are everywhere, in every city and state. They include all gender, racial, ethnic, and age group. Luckily, awareness of the problem has grown, and access to publicly funded treatment has improved, allowing more clinicians to provide mental health counseling for the homeless and for those at risk of homelessness.
When I first joined the staff of a homeless services center after 26 years of working in publicly funded community mental health centers, I was interested in learning more about this growing population. I embraced the responsibilities and challenges of being the lone behavioral therapist on site. During my orientation, the Vice President of Operations described my new working environment as “organized chaos,” a phrase that hit home when I met my first client.
Janice was a 73-year-old widowed female. We met in one of the medical respite rooms the center provides. She was seated in a wheelchair and dressed in a nightgown. I thanked her for her willingness to talk with me, with the caveat that I’d be seeing her for two initial intake sessions. After that, we’d collaborate on a comprehensive psychosocial intake.
Janice invited me to make myself comfortable on a stool that was the only seating option available in the room. The floors were cluttered with boxes and stacks of papers. Jars of peanut butter, clothing, and plastic bottles lay strewn across an unmade bed. I’d been warned by the Nurse Practitioner that she was a hoarder and had “dependent traits,” both of which contributed to her eviction from her apartment in 2020. Even so, I found her pleasant and articulate.
“It’s nice to meet you,” she said.
“I’m so glad you invited me to visit,” I replied. “How are things going?”
“As well as can be expected,” she replied, gesturing toward her room.
After this brief exchange, I redirected the conversation back to what I saw as her problems. Although she allowed me to take the lead during our interview, and was polite and responsive, I had a nagging sense that I wasn’t connecting with her in the way I do with my office-based clients. Granted, I had an ambitious mental checklist for our first two sessions. After years of laboring in community mental health centers, I’d come to believe conducting comprehensive biopsychosocial assessments from the start of treatment was an essential and non-negotiable first step to therapy. I’d also bought into the importance of following these assessments with person-centered treatment plans and detailed SOAP notes. The list of things I’d been taught to do in the first session was formidable.
“What has it been like for you here?” I asked.
“I love it! The staff are like family to me,” she responded.
“Are you in touch with any actual family members?” I continued.
“Just my son,” she answered. “But I feel iffy about him right now.”
She responded to my questions to the best of her ability. I was focused on assessing her functioning, completing a risk assessment, evaluating her diagnostic history, screening for a substance use disorder and finding out if she was taking medications—and if so, getting a clear read on whether she was adhering to the recommendations of her psychiatrist. I wanted to identify her strengths, figure out where she fit into the stages of change model, and provide psychoeducation where it might be useful. I ambitiously hoped to determine, by the end of our 50 minutes together, an eclectic intervention strategy that might fit her needs.
But my problem-focused approach didn’t turn out the way I’d hoped. Janice canceled her next session. What had gone wrong? I wondered. I’d been meticulous and thorough. Then it dawned on me that clients in this population might not share my affinity for treatment planning. I hadn’t built a treatment alliance—earning her trust before focusing on my agenda—and that had undermined therapy. We hadn’t made it to a second session. In fact, Janice had responded logically and appropriately to my initial interventions by ending our therapeutic relationship. Why would a client like Janice share the details of her situation with a stranger who hadn’t earned her trust first, particularly when I was rigidly adhering to a clinical mindset that wasn’t in sync with her needs?
I began thinking about what might have worked better. From that point forward, I stopped viewing formal intakes as a non-negotiable first steps to treatment.
With this population, individual personal history emerges organically over time and through a variety of channels, including “small talk” and collateral reports from others. People experiencing chronic homelessness lack basic control over routine daily tasks, such as when to eat. This contributes to feelings of helplessness and loss of control, both of which are universal triggers for trauma. I was determined to mitigate this by empowering my clients to dictate the agenda of our sessions, engaging them as true collaborators in their own care.
I tried a different approach with my next client, George, a 37-year-old man who suffered from co-occurring schizoaffective disorder and opioid addiction. George had been in and out of the foster care system as an adolescent, ended up in a West Coast juvenile detention center after stealing a car, and then supported himself for over a decade working as a building contractor. Instead of beginning our work with an agenda anchored in paperwork, I was focused on the therapeutic alliance.
“How can I help you today?” I asked.
“Wait a minute,” he said, with a conspiratorial expression on his face. “Don’t I know you?”
“I don’t think so,” I responded as amicably as I could.
“I do know you,” he said. “I’m sure of it. I know you from California. Did you live in California?”
“No, never,” I responded.
“Well, did you ever visit California?” he asked.
“And if you had seen me somewhere before, would it impact our work today?” I asked gently, wary of provoking him.
“I don’t know,” he countered with a menacing glare. “You tell me?”
It was clear that developing trust with George was going to be an uphill battle. Intuitively, I knew it would require my complete acceptance of him as the expert on his own life, and that I needed to respond genuinely, even in the moments he provoked me. This wasn’t easy. I feel demoralized after encounters with clients like George who don’t stick with you long enough to establish even a modicum of trust. Often, I got up in the morning and went to work feeling irrelevant at best and incapable at worst. Sometimes I’d daydream about quitting. Instead, I educated myself about homelessness and practiced putting myself in my client’s shoes and trying to see the world from their perspective. I came to realize that this population is not only challenging, but also misunderstood and ingeniously adaptive.
With George, I quickly learned it was futile to dispute his entrenched belief that we’d met before in California. Instead, I opened our sessions saying, “I’m so glad you’re here and we get to spend some time together.” As I got to know him, I was able to learn more about his needs and support him in receiving additional services.
“From what you’ve told me,” I said in our fifth or sixth session, “one way you cope with your fear of being watched is by isolating yourself. I see how this helps, but can we add other strategies to the mix? You mentioned a medication last week that’s been helpful in the past.”
“Yeah,” George said. “Seroquel. I felt a lot calmer when I took it.”
“Would you be open to meeting with a psychiatrist to see if it makes sense to get this reinstated?”
“Totally.” With his eyes fixed on mine, George unhesitatingly agreed.
I’d gone with my gut and gambled successfully. Soon afterward, I contacted George’s case manager and we transported him to the County Same Day Access office, a place where anyone requesting a mental health assessment gets seen on the spot.
With clients like George who struggle with entrenched mental illness and diminished insight, I was mindful of prematurely suggesting medications. Although I was tempted to bring up this subject early on with him, I knew that what people experiencing chronic homelessness want most is connection, and to be seen and heard. With George, I reminded myself that just because he’d trusted me enough to attend our sessions didn’t mean he was under any obligation to also surrender the last and most guarded elements of his autonomy.
People residing in adult shelters represent only a small fraction of the larger homeless population. At the center where I worked, my focus was on treating those identified as chronically homeless. These individuals are a subset of transient adults who cycle through human service systems over many years and sometimes decades due to inadequate resources and the lack of social support for marginalized people living with serious mental illness, co-occurring addictions, and other disabilities.
Chronically homeless people are individuals with a 100% probability of exposure to multiple traumatic events. This is because it’s generally some form of trauma—such as eviction, assault, or job loss—that leads to homelessness, which is then compounded by the trauma of homelessness itself. Being homeless means feeling—and being—dangerously vulnerable to hunger, the elements, and violence.
Furthermore, many homeless individuals actively use substances to cope, and many others are simultaneously managing two or more behavioral health diagnoses and untreated medical conditions, such as diabetes and hypertension. Their experiences with authorities, including doctors and therapists, haven’t always been positive. They’ve been coerced into shelters, forced onto medications, and treated with contempt or indifference. When clinicians like me enter their lives, telling them, in so many words, “Trust me,” it’s not so easy to oblige.
To further complicate the situation, most homeless individuals with mental health issues don’t believe they have an illness, thanks to the influence of neurologically based cognitive and perceptual distortions intrinsic to their illness, a condition called anosognosia. This affects approximately 60 percent of those experiencing schizophrenia and 50 percent of those with bipolar disorder.
When a first session is your one opportunity to engage a client in a way that increases the chances that they’ll be back for a follow-up appointment, there’s a lot at stake. In my experience, it means setting aside, at least for the moment, a lot of what I’ve learned about conducting effective treatment, much of which has been based on the assumption that the average number of sessions clients attend is eight. My standard interventions have receded into the background in my work with chronically homeless clients. For me, the immediate clinical goal is engagement.
Three Strikes and You’re In
People experiencing chronic homelessness are pursuing basic survival. They consider behavioral health a low priority at best, and at worst, a declaration of vulnerability. For them, the absence of relationships in their lives—a state known as disaffiliation—combined with a deep distrust of authorities and the transient nature of their existence, stacks the deck for the overly ambitious clinician. Most of us are accustomed to the captive audience of clients showing up for office-based services.
I formulated what I call the “three strikes and you’re in” approach to first sessions with homeless individuals as a way of adapting to their needs and ensuring, as much as I can, that a first session with these clients isn’t necessarily the last.
Strike 1. Your goal is engagement. Begin by thanking clients for coming in to meet with you and validate their perceptions and preferences as the conversation unfolds. Reflective listening is the tool of choice because it communicates unconditional acceptance and can deflate client anger, denial, and intransigence. It’s empowering for clients to feel listened to and respected, and this can provide a foundation for hope and trust early in the therapeutic relationship.
Strike 2. Identify what clients are experiencing as their most pressing concern and normalize it. What worries you the most? What would you like to see happening right now that would help you feel better or safer? Understanding how people with diminished insight conceptualize themselves helps undo their sense of isolation and build a trusting relationship. Identify what isn’t working in a client’s life from their perspective and find common ground. If they keep complaining about being hospitalized against their will, you might say, “You’re right that avoiding another involuntary hospitalization is a good thing.”
Strike 3. Discuss only perceived problems and symptoms. Instead of using words such as “delusional” or “insomnia,” you might say, “You’re really frightened that the CIA wants to assassinate you and this worry is keeping you up at night.” Propose a specific goal that’s likely to be meaningful to clients along with a short-term timetable to accomplish it. For example, “I heard you say your stress level is as high as the ceiling. You can’t sleep, you’re on guard all the time, and you’re exhausted. Let’s see if we can come up with a way to lower your stress. Would you feel safer if we moved you to a bed with more privacy?”
Ultimately, it’s important to shoot for a brief, informal first session that can be longer if clients signal their desire to continue, and the work being done with them seems productive. Formal intakes and treatment plans are deferred during this engagement phase because they distract from what the client needs most of all: to feel like the therapist gets them.
Shh! On Being Seen, Heard, and Helped
The most reliable predictor of whether homeless clients return is how successfully the therapist attunes to them and their needs. Fundamentally, all clients want to be seen, heard, and helped, and these constitute the three most essential tools in your tool kit.
Clients feel seen when clinicians listen from the beginning with genuine empathy and respect. To illustrate this, you might say, “I’m so glad you came to meet with me. This is not such an easy choice for you to make when you have so much going on. What can I do to help you?” This can lead to a brief but critical discussion about expectations. Rapport is developed by providing simple reflective and empathetic responses throughout the session, always clarifying with clients if you heard them correctly. For example, “I can see your distress about feeling constantly watched by others. You’d like to worry less about this. Do I have that right?”
Clients feel heard when clinicians elicit and validate their concerns. One way to do this is by asking, “What worries you the most? What causes you to feel bad?” Statements from therapists such as, “If I was in your shoes, I’d feel exactly the same way,” or “I really see and admire how hard you work to retain your freedom,” are affirming and will help clients to feel understood and accepted. It’s important to keep your biases and personal views contained so you can concentrate your attention on what clients feel and perceive.
I knew my session with Ted was my one and only opportunity to engage him so he’d return for a follow-up appointment. He was a 47-year-old man who had come down with a disabling neuromuscular disorder while recovering from Covid, which had left him unable to work. In the first few minutes of our session, I pointed out the immense determination he’d demonstrated to survive 123 days in the bowels of historic Union Station, the transportation hub near the US Capitol building in Washington, DC. He immediately began weeping. Even though I didn’t actively take a psychosocial history, I learned a great deal about him in our first session. He shared that his wife hadn’t visited him during his two-month medical hospitalization. He was undocumented, and according to him, she’d exploited his immigration status by using her financial advantages to hire an attorney, change the locks of their house, and ultimately end their marriage in a way that was disadvantageous to him.
Toward the end of our first session, I let Ted know I’d understood what he’d shared. I also suggested a next step we might take in our work together.
“So, it sounds like you want to feel more hopeful about the future,” I said.
“I can’t remember what hope feels like,” he responded. “But that’s what I want.”
“And I also hear you want to know that someone here is working with you to find an affordable apartment. Is that right?” I asked.
“I do want that,” he affirmed, his eyes glistening with tears.
The third objective in a first (and possibly last) session with a homeless client comes about only if clients feel they’ve been seen and heard—which on a psychological level equates to being respected, accepted and validated. From there, you move into helping them in some real way, however small. Helping means you identify and skillfully define some practical way that a clients’ coping responses to current problems can be augmented.
It’s an odd paradox that a population with so many complex needs can be engaged with the most basic and noble of human responses: care. This doesn’t require advanced training or specialty skills and is usually thought of as a quality or capacity that all humans possess, particularly those of us in the helping professions. Because our basic care for another person can have such a powerful effect, I focus on it as my primary intervention when working with chronically homeless clients, particularly during the initial session.
By putting all my eggs in this one clinical basket, I increase my chances of enticing people in this client population to see me a second time, and often a third and fourth time after that. Taking in the impact their lived experiences have had on them and their fundamental value as human beings, particularly in a world that responds to them with fear and judgment, I’m able to treat homeless clients with more compassion. I try to deploy it generously, even if only for a single session. My hope is that it will communicate safety and care, allowing for a second opportunity to deepen a trusting connection.
Harry Ayling, LCSW, is a clinical social worker at PathForward, a non-profit homeless services center in Arlington Virginia. Prior to this he worked for 28 years as a therapist and clinical supervisor in multiple community mental health centers in Northern Virginia.
Photo by Mental Health America (MHA)