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Leticia Funston presentation

  1. 1. Responding to the<br />Trauma & Mental Health <br />Needs of Young<br />People Experiencing Homelessness<br />The early intervention outreach <br />mental health clinic evaluation findings<br /> <br />Caitlin Dixona , Leticia Funstonb , Catherine Ryana, Professor Kay Wilhelmb,c<br />aSt Vincent’s Mental Health Services, bFaces in the Street, Urban Mental Health Research Institute,cConsultation Liaison Psychiatry , St Vincent’s Hospital, Sydney, Australia<br />
  2. 2.
  3. 3. Youth Homelessness in NSW <br />4987 young people aged between 12 - 18 years; <br />2685 aged between 19 - 24 (Chamberlain & MacKenzie, 2009). <br />The NSW Homelessness Action Plan 2009 - 2014 identifies young people aged 12 – 24 years living in inner city areas as a priority group.<br />
  4. 4. Traumatic Pathways to homelessness<br />55% of the young people interviewed the immediate cause of homelessness for was, domestic violence, abuse perpetrated by parents or carers, and/or parents/carers who used substances (Collins, 2010); <br />
  5. 5. In Melbourne, 3/4 of young people in the sample <br />(N = 1677) had progressed to adult homelessness. <br />These findings reinforce the argument that the longer people are homeless, the more difficult it becomes to get out of homelessness; <br />Among those who remained homeless into adulthood, <br />65% had substance use issues<br />(Johnson & Chamberlain, 2008).<br />
  6. 6. Homelessness, trauma and mental illness <br />A study conducted in Melbourne found 26% of homeless young people surveyed reported a level of psychological distress indicative of a psychiatric disorder (Rossiter, Mallett, Myers, & Rosenthal, 2003).<br />Approximately 18% of homeless young people live with trauma-related symptoms meeting the diagnostic criteria for Post Traumatic Stress Disorder (Stelwart, Steiman, Cauce, Cochran, Whitbeck & Hoyt, 2004). <br />One study found that all adult women (N = 38) and over 90% of men (N = 119) experiencing homelessness in Sydney reported at least one event of trauma in their life;<br />50% of the women and 10% of men reported that they had been sexually assaulted whilst homeless, 58% suffered serious physical assault and 55% witnessed someone being badly injured or killed (Buhrich, Hodder, Teesson, 2000).<br />
  7. 7. Research also suggests that young people experiencing homelessness are less likely to approach and engage with Mental Health Services (Solorio, Milburn, Andersen, Trifskin, Rodriguez, 2006).<br />Many young people do not seek mental health support until experiencing crisis (Lloyd, Dixon, Hodges, Sanci & Bond,2004). <br />
  8. 8. Multiple barriers to accessing <br />mental health care<br />Lack of “youth friendly” services and dominance of adult mental health system (Marven, 2005)<br />Negative experiences with MHS and feeling dissatisfied with MHS service workers (Keys, Mallett, Edwards and Rosenthal, 2004)<br />Lack of outreach multidisciplinary mental health services <br />(Solorio, Milburn, Andersen, Trifskin, Rodriguez, 2006).<br />“Wrong door approach” or services not adequately resourced to manage complexity of client needs i.e. AOD use and mental illness <br />(Welch & Mooney, 2001) <br />
  9. 9. Program for Early Intervention and Prevention of Disease (PEIPOD):<br />Outreach mental health clinic<br />
  10. 10. Based on assertive outreach and early intervention principles the mental health clinic has operated on a weekly basis since January 2010 at theOasis Youth Support Network site in Surry Hills. The clinic aims: <br />To improve access to mental health services by providing a mental health assessment and brief interventions to young people experiencing homelessness. <br />To enhance the Oasis staff capacity to work with young people with complex needs. <br />
  11. 11. The Oasis <br />mental health clinic model<br />Youth friendly approach <br />Clinic staff work in close partnership with Oasis staff<br />Access to a Mental Health Assessment and Services<br />Consistency: Regular Clinic times based at the Oasis Surry Hills site<br />
  12. 12. Evaluationaims: <br />To describe the Clinic and to explore client and staff perspectives regarding the extent to which the Clinic interventions have:<br />1. Facilitated access to Mental Health Services;<br />2. Improved young peoples’ experience of Mental Health Services and; <br />3.Enhanced the capacity for Oasis to work with homeless young people with complex needs staying at Oasis. <br />
  13. 13. Method: <br />Case file audit of triage forms and assessment notes for clinic attendees between January 2010 and January 2011. 29 case files were included in this audit. <br />Client interviews and client survey: <br />Focus Groups with staff: One focus group with PEIPOD mental health staff and two focus groups with Oasis accommodation staff <br />
  14. 14. Results: Case file audit <br />Case file audit N = 29 young people assessed by the Oasis clinic between January and December 2010<br />11 female clients<br />18 male clients<br />Age range: 16 – 22 years<br /> Average age: 19 years<br />
  15. 15. 10 of the young people reported significant traumatic events in their past including domestic and family violence, child abuse and sexual assault<br />
  16. 16. 41.4 % of Oasis Clinic clients have recent forensic histories including: assault, affray, arson, break and enter, malicious damage. <br />Reported traumatic events included recent experience of being assaulted, witnessing an assault and receiving threats. <br />One client was asked to leave <br />Oasis for violent behaviour<br />
  17. 17. Risk Assessment <br />
  18. 18. Young People’s appointment attendance<br />
  19. 19. Reasons recorded for missed appointments<br />
  20. 20. Current supports<br />The following supports were mentioned however data was not recorded in all instances.<br />Centrelink<br /> Oasis<br /> Friends<br /> Family contact <br /> Case management<br /> Juvenile Justice support worker<br /> Community Services support<br />
  21. 21. Barriers to <br />engaging with <br />young people <br />staying at Oasis<br />
  22. 22. Young people are highly mobile<br />S2: But often they would be gone the next day. They have been asked to leave or there has been some sort of incident. Or even that day. And that’s constant. All the time.<br />S1: And we don’t know where they have gone. <br />S2: But they can bounce back in a few weeks or few months.<br />S1: They go out early in the morning. That’s one challenge. We go at nine in the morning, which I would think is quite early for a young person. But they’re up earlier and sometimes they’re out at eight. <br />S2: Or they are intoxicated by nine o’clock. <br />S1: And we miss that window because there is no point in seeing them in the afternoon because they have been out doing whatever all day. It’s pretty hard to get there any earlier.<br />S2: It’s pot luck.<br />S1: It’s their lifestyle. <br />Conversation from PEIPOD staff focus group held October 2010<br />
  23. 23. Case file audit findings<br />24.13% did not engage with services as they had moved out of area<br />1 client planning to move overseas following clinic appointment <br />4 clients planning to move out of Sydney following appointment<br />5 clients missed their initial Oasis clinic appointment <br />1 client planned to move but Oasis staff unsure where<br />
  24. 24. Life-time of housing mobility: <br />couch-surfing, shelters & sleeping rough<br />In the recent Niagara study, young people were highly mobile and had moved/changed accommodation an average of 3 times over the course of the 1 year study (Collins, 2010).<br />
  25. 25. High turn over of casual staff at Oasis<br />It can be difficult because it’s all casual staff. They might not be aware of what’s been happening for the person or why the person is being referred or even who the person is. <br /><ul><li>PEIPOD staff</li></ul>…we may lose information there about things that could have been followed through and implemented. <br />-PEIPOD staff<br />Staff turnover is relatively high in this sector – due to limited funding and resourcing <br />(National Youth Commission, 2008). <br />
  26. 26. Qualitative Themes <br />“Trauma robs the victim of a sense of power and control: the guiding principal of recovery is to restore <br />control to the survivor”<br />Judith Herman, 1992, p. 159<br />
  27. 27. Creating Safety and Consistency:<br />Meeting young people on their “turf”<br />
  28. 28. Outreach and Early Intervention <br />So, for instance, say we were to take (a young person) down to the Hospital now, they’re going to feel uncomfortable in that sort of space….going crazy, that sort of stuff, but in their comfort zone it makes them a little more...able to respond to the program. Oasis staff<br />We struggle often with getting our clients to go down to the Hospital so it’s quite good that PEIPOD are coming here and being able to chat to them and sort of have the early contact if they’re not quite sure if they should go or they’re a bit nervous. It gives them an option instead of going down to hospital. Oasis staff<br />It’s very good the Clinic’s on site. So clients don’t have to come up here to the health centre…it’s on their turf So it’s not out of reach for them, they don’t have to make a lot of effort . PEIPOD staff<br />This is a chance to go in and try to meet them at a location and engage them when they are not acutely unwell hopefully and give them a chance for them to talk through their mental health issues, picking it up a bit earlier.’ PEIPOD staff<br />
  29. 29. Building connections and <br />trust with young people <br />Itry make them feel comfortable… “we’re not wanting to put you on medication”, I think that’s the biggest fear that some of these kids have… they are fearful of the potential outcome’. PEIPOD staff<br />(The Clinic staff) builds relationships with the young people certainly. Mental health is, it’s not a big deal. Like if one person has to go through mental health away from here…it seems less scary. Oasis staff<br />There might be several attempts to see somebody. One day they are just not in a good mood, they don’t want to speak with you and the next time they will talk to you. But it’s definitely about gaining their trust and to try explain to them that we are not there just to take them away and make them do things, force them to do things they don’t want to do. PEIPOD staff<br /> From my personal experience with the Clinic, I know they do explore…a range of things, not just mental health; they explore all aspects of the clients life, so it’s a process and the young people generally respond to it . Oasis staff<br />
  30. 30. Consistency, flexibility and<br />ease of access<br />It’s easy access for young people to get mental health support. Oasis staff<br />It’s very opportunistic and I think that’s one of the beauties of the OASIS Clinic. They know we’re there every Wednesday. So they may not, on that day, want to engage but next week they might want to. So I think that fluctuates, but I think that every opportunity is given to the young person to engage with us and, you know, I guess there’s some choice on their behalf… PEIPOD staff<br />Sometimes you to see someone else, but they’re not there, but you end up seeing another person and they actually do need to be seen. PEIPOD staff<br />
  31. 31. Importance of a mental health assessment - Clarifying young people’s mental health needs <br />Some people have been on medication for years and it’s never been reviewed. You know anti-psychotic medications for two or three years and they may not need to be on them. PEIPOD staff<br />It’s surprising the number we see in the clinic that then don’t need a mental health service… We can work out some strategies for managing other needs that person might have. PEIPOD staff<br />Without the clinic, there would be young people that slipped through the net and they would have gone on another few months, years of being untreated got themselves into all sorts of problems maybe ended up in the prison system before that mental health problem is picked up… I mean this is an ideal time to get in there and stop that happening if possible. PEIPOD staff<br />I think previously they didn’t really get that unless they were acute or coming to ED in that they would get referred to us in a community health centre setting but they would never make it to an appointment. They were too chaotic.PEIPOD staff<br />
  32. 32. Regular time and place at Oasis<br />Young people can choose when they want to meet with PEIPOD <br />Explaining MHS system and service options<br />Oasis is a youth friendly environment<br />Normalising mental health <br />Early intervention<br />Maximise young person’s choice and control in their mental health care <br />Young people are more relaxed and able to discuss their concerns<br />Holistic mental health assessment<br />
  33. 33. Supporting <br />the <br />young person’s support network <br />
  34. 34. Mental Health and Youth Support Partnership <br />(The PEIPOD staff) are great…I don’t have a clinical background, so to just to say we have concerns about someone, with their behaviours, they help us with a decision in referring instead of us being completely on our own backs. Oasis staff<br />Oasis staff can see why we come to the conclusion that we do about our impression of a young person’s mental health needs because we are not doing any assessment in isolation we involve them’Peipod staff <br />
  35. 35. PEIPOD Clinical team<br />Oasis staff<br />St Vincent’s MHS<br />Ongoing PEIPOD support <br />Young person<br />Other services: AOD, counselling, <br />GP referral<br />Youth Mental Health Service <br />
  36. 36. Service gaps identified and<br />possible strategies<br />Enhancing communication with casual staff members at Oasis<br />Determine if clients have taken up referrals to other services i.e. alcohol and other drug counselling, GP appointments<br />Improved Resources: need to Include a Registrar or Doctor within the assessment/clinic<br />Expand the youth mental health clinic to other youth service sites<br />
  37. 37. Questions <br />&<br /> Comments? <br />THANK YOU<br />
  38. 38. References:<br />A Way Home: Reducing Homelessness in NSW, NSW Homelessness Action Plan 2009 – 2014 <br />Chamberlain, C., & MacKenzie, D. (2009). Counting the homeless 2006: New South Wales. Cat. no. HOU 204. Canberra: AIHW<br />Bonin, J., Fournier, L. &Blais, R. (2007). Predictors of Mental health Service Utilization by People using Resources for Homeless People in Canada, Psychiatric Services: 58, 936-941.<br />Darbyshire P., Muir-Cochrane E., Fereday J., Jureidini J & Drummond, A. (2006). Engagement with health and social care services: perceptions of homeless young people with mental health problems, Health and Social Carein the Community<br />Collins, S. (2010). Sofas, Shelters and Strangers: A report on youth homelessness in Niagra, Niagra Community Services.<br />Farmer, Robinson, Elliot & Eyles (2006) Weighing up Triangulation and Contradictory Evidence in Mixed Methods Organisational Research, International Journal of Multiple Research Approaches, 1 (1), 27 - 39 <br />French, R., Reardon, M., & Smith, P (2003).  Engaging with a Mental Health Service: Perspectives of At-Risk Youth. The Child & Adolescent Social Work Journal, 20 (6), 529-548<br />Herman, J. (1992). Trauma and Recovery, New York: Basic Books. <br />Gallet, W. (2008). Finding My Place: The Salvation Army’s Response to Youth Homelessness, The Salvation Army Australia Eastern Territory, Communications and Public Relations Department.<br />Johnson, G. & Chamberlain, C. (2008). ‘From Youth to Adult Homelessness’, Australian Journal of Social Issues, 43(4), 563–582<br />Kamieniecki, G. (2001). ‘Prevalence of psychological distress and psychiatric disorders among homeless youth in Australia: a comparative review’, Australian and New Zealand Journal of Psychiatry, 35 (3), 352–358.<br />
  39. 39. Keys, D., Mallett, S., Edwards, J., & Rosenthal, D. (2004). Who can help me? Homeless Young Persons Perceptions of Services: A report of selected results from Project i: Homeless Young People in Melbourne and Los Angeles (2000 –2005) Department of Public Health, University of Melbourne.<br />Lloyd, S. Dixon, M. Hodges, C. Sanci, L. Bond, L. (2004), Attitudes Towards and<br />Pathways to and from the Young People’s Health Service Mental Health Services,Young People’s Health Service and beyondblue, Melbourne.<br />Martijn, C.& Sharpe, L. (2005). Pathways to Youth Homelessness, Social Science and Medicine. Social Science and Medicine, 62, 1-<br />12.<br />McManus, H. & Thompson, S. (2008). ‘Trauma Among Unaccompanied Homeless Youth: The Integration of Street Culture into a Model <br />of Intervention, Journal of Aggression, Maltreatment and Trauma, 16(1), 92-108.<br />Mildred, H. (2007). Eastern Health Child and Adolescent Mental Health Service, Supplementary Material, Melbourne Day 14. <br />Robinson, C. (2010). Rough Living: Surviving violence and homelessness, UTSePress in association with the Public Interest Advocacy Centre: Sydney. <br />Rossiter, B., Mallet, S., Myers, P. & Rosenthal D. (2003). Living Well? Homeless young people in Melbourne. Parity, 16(2), 13-14.<br />Solorio, R., Milburn, N., Andersen, R. Trifskin, S. & Rodriguez, M. (2006). Emotional Distress and Mental Health Service Use Among Urban Homeless Adolescents, Journal of Behavioural Health Services and Research 33, (4), 381-393<br />Stewart, Steinman, M., Cauce, A., Cochran, B., Whitbeck, L. & Hoyt, D. (2004). Victimization and posttraumatic stress disorder among homeless adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 43, 325–331<br />Welch, M., & Mooney, J. (2001). Managing services that manage people with a coexisting mental health and substance use disorder. Australasian Psychiatry, 9, 345–349.<br />