This case study illustrates how important it is to be consistent and patient when building trust with someone who is experiencing homelessness and mental illness. Positive engagement experiences and the development of a therapeutic relationship can help someone to move on from homelessness.

Daniel is the Director of Park Avenue Women’s Shelter, and also an Adjunct Professor at the Hunter College School of Social Work. He is a graduate of psychoanalytic training at the New York Institute for Psychoanalytic Self Psychology and a doctoral student of Social Work at New York University. Daniel is a contributing writer for the HRC website, as a member of the HRC Provider Content Network. Interested in submitting a story? Click here.

As a homeless service provider, you probably know that outreach and engagement works. Although the process of engagement can take a lot of time and patience, it is always worth it to try to help someone move on from homelessness.

Sometimes a person’s history or characteristics may seem overwhelming. You may find yourself wondering how you will ever get through to someone and build trust. Yet the therapeutic alliance is critical to help clients obtain and retain permanent housing. Studies have shown that the therapeutic alliance between client and social worker decreases symptom severity and length of homelessness.

Ms. Z’s story underscores the importance of building this relationship, as well as the benefits of low-demand, supportive housing to help end homelessness.  

The Case of Ms. Z

Ms. Z, a 57 year-old single woman experiencing homelessness for close to 20 years, has mostly lived in the same homeless shelter. She is diagnosed as schizophrenic. As part of this disease, Ms. Z has delusions that cause her to believe that she was once married to two famous men and that she once owned multiple businesses and properties, including the shelter building.

Ms. Z never left the shelter, which she had come to know as home, with the exception of a hospitalization. Ms. Z could not leave the shelter because she was afraid she would be kidnapped. Staying behind the shelter’s doors gave her a strong sense of safety and attachment. She claimed to have been kidnapped as a teenager and feared this could happen once again if she were to leave.

During a brief hospitalization, Ms. Z benefitted from a successful trial of an anti-psychotic medication. She was also re-introduced to basic socialization skills. Ms. Z started to see that staff could be helpful. She became more attentive to her hygiene and concerned about her appearance, showering more frequently and allowing staff to purchase clothes for her. At the shelter, social workers and psychiatric staff grew hopeful that she might allow a deeper therapeutic relationship to develop.

As Ms. Z settled back into the shelter, her social worker began engaging with her on a daily basis. They sat in the hallway and on the stairs leading up to the sleeping area. Staff would accompany Ms. Z to the basement of the building during fire drills. They would discuss the beauty of the ornate building. Initially, staff sought only to listen to Ms. Z and validate her experiences.

Through these constant and consistent engagement attempts, Ms. Z began to trust her social worker. The therapeutic relationship deepened more quickly than anyone expected. Within a few weeks, Ms. Z was eager to see her social worker, both informally in the hallway and formally during their scheduled sessions.  

Ms. Z began making slow yet steady strides toward housing. She began attending groups and eating meals with other residents. Still, Ms. Z made it clear that she would not leave the shelter because she “owned the building” and knew, “my children are coming for me.” However, staff believed that under the right circumstances, she might actually be willing to leave.

As the therapeutic relationship continued, the shelter managers along with local homeless service officials located a supportive housing provider who would readily accept Ms. Z without being “housing ready.” Staff from the housing provider visited Ms. Z on many occasions. She continually protested, stating that there were no reasons for the meetings.         

Over time, Ms. Z agreed to move out of shelter. Together, the staff and Ms. Z set a date for her to move out. That day, Ms. Z agreed to leave and simply stated, “If my social worker thinks it is a good idea, maybe I’ll go.” She said many times that the only reason she agreed to move out was because of the trust she felt for her social worker. Ms. Z successfully moved into permanent housing, leaving behind her life of homelessness.