16. Special needs of the homeless person with chronic mental illness

People who are without any type of basic shelter or housing and whc struggle to care for themselves in the face of significant physical and mental disabilities constitute the homeless population. Homeless people live on the street, stay in public shelters, or devise inadequate temporary living quarters. The homeless include men, women, adolescents, and women with children. Due to the nature of homeless-ness, it's difficult to estimate the number of people so affected. The Federal Task Force on Homelessness and Severe Mental Illness has indicated that between 1 million and 4 million people are homeless in the United States; of this group, one-third or more have a DSM-IV mental illness diagnosis. Since the Community Mental Health Act of 1963 was instituted, the number of mentally disabled homeless people who ve been discharged from state psychiatric facilities has increased. A major provision of the act was the mandate that delivery of mental health and mental illness services be community-based care rather than institutional care. The premise of the legislation was that deinstitutionalization would enable clients to receive humane psychiatric care within the community. However, the dearth of community resources for the chronically mentally ill contributed to their inability to seek out or follow through with treatment, especially medication management. For many of these clients with chronic mental illness, the transition from the hospital setting to the community was overwhelming. Consequently, they began to live on the streets, and the homeless population increased.

To further complicate the problem, additional people have become homeless due to financial circumstances or personal crises. These vulnerable populations include battered women, families. runaway adolescents, disabled people, illegal immigrants, elderly people, and former prisoners. Over time, from the combination of their overwhelming stressors and multiple losses, these people may either develop mental illness or experience an exacerbation of a previously existing mental illness.

The general categories of the mentally ill homeless are often defined as the deinstitutionalized, the never institutionalized, and the temporarily hospitalized. Often, these people receive only emergency care, or they can stay at crisis centers for up to 72 hours, after which they are released back into the community. This process of revolving-door care becomes the norm. Schizophrenia is the single most common psychiatric condition in the homeless population. Other types of mental illness repeatedly diagnosed in this group of people are affective disorders, personality disorders, organic mental disorders, substance abuse disorders and, less frequently, adjustment disorders. Dual diagnosis is a common problem. Many of the chronically mentally ill homeless use alcohol and street drugs, particularly cocaine and heroin, as self-medication for chronic pain or to distract themselves from the reality of their lives. Chronic physical health problems are rampant. (For further information, see Health Problems of the Homeless.)

COMMUNICATION STRATEGIES

• Work to establish a rapport with the client.
• Help the client identify and handle problems.
• Focus discussions on assessment of the client's needs and problems.
• Discuss stress, and help the client deal with daily stressors.
• Address methods to use for overcoming barriers to health care and meeting one's basic needs.
• Role-model ways of talking and relating to others.
• If the client demonstrates psychotic or paranoid behaviors, refer to “Communication Strategies" listed under Schizophrenia in chapter 6, Schizophrenia and Other Psychotic Disorders.
• If the client has a bipolar or affective disorder, refer to the two Communication Strategies" sections that appear in chapter 7 - Mood Disorders.
• Obtain information about living arrangements.

HEALTH PROBLEMS OF THE HOMELESS

Communicable diseases (hepatitis, acquired immunodeficiency syndrome, and tuberculosis) Cardiac and vascular diseases Respiratory diseases (pneumonia, chronic obstructive pulmonary disease) GI diseases (chronic diarrhea, intestinal parasites, alcohol-induced gastritis) Liver and pancreatic diseases (cirrhosis, diabetes) Skin diseases (Infections, frostbite, cellulitis, ulcerations, gangrene, lacerations, lesions, insect bites, lice) Musculoskeletal problems (fractures, foot problems, back pain, joint pain, arthritis) Neurologic problems (meningitis, head Injury, back injury, sensory deficits, especially auditory and visual problems) Malnutrition and nutritional deficiencies Dental problems Anxiety and depression (inability to make decisions or solve problems, disorganized or confused thought processes, difficulty retaining self-care information) Posttraumatic stress disorder (mental illness as a result of abuse, rape, or assault) Drug and alcohol abuse (self-medication for emotional distress, chronic low self-esteem, chronic pain, and frustrating struggles of daily survival)

NURSING DIAGNOSIS: INEFFECTIVE INDIVIDUAL COPING

Probable Causes	Defining Characteristics
Lack of personal, social, or community resources History of severe family dysfunction History of substance abuse or an organic mental disorder Repeated cycle of helpseeking-help-rejecting behaviors	Lack of social, interpersonal, and coping skills Disorganized, confused, or easily distracted thought processes Inability to problem solve Verbalization of feelings of vulnerability

Long-Term Goal The client will use health maintenance skills and demonstrate skill in daily life activities.

Short-Term Goal #1: The client will identify the coping skills needed to maintain health and self-care on a daily basis.

Interventions and Rationales

• Have the client recognize the skills that are necessary for daily living. Due to the client's chronic mental illness, sense of frustration, and less than adequate physical health, the client requires assistance to identify the skills needed to ensure that basic personal needs are met.
• Help the client formulate goals, such as the healing of a laceration and talking to people, and work with the client to achieve such goals.Having the client participate in working on goals provides motivation and self-confidence.
• Help the client identify sources of support or help.The client needs to know where and how to access social support and services.
• Look for signs that the client's mental or physical problems have become overwhelming in relation to current coping abilities.It's important to assess how the client Is coping or struggling with the management of illness and identify whether denial is present.

Short-Term Goal #2: The client will practice self-care, social, and community living skills.

Interventions and Rationales

• Work with the client to identify what the client is able to do physically, financially, and mentally, and explore what resources are available. Empowering the client promotes a feeling of self-worth and personal competency.
• Have the client select (or give the client guidance in selecting) a skill that can be mastered by practicing over a reasonable period. Acquiring a skill through practice enhances client self-concept and encourages development of additional coping skills.
• Teach needed skills in a setting that resembles the actual environment in which the skills will be used. For example, teach the client how to use a pay phone rather than an office phone. The more realistic the setting, the less difficulty the client will have transferring and using the skill in the real world.
• Have the client learn and practice decision-making skills. Due to factors such as the client's illness, lack of resources, and dependce on others, there may have been few occasions to make persona, decisions

NURSING DIAGNOSIS: POSTTRAUMA SYNDROME RELATED TO ASSAULT OR INJURY

Probable Causes	Defining Characteristics
History of personal or family trauma and abuse History of being assaulted Military experience during wartime	Reexperience of trauma through flashback, nightmares, or intrusive thoughts Sleep disturbances, including nightmares Self-medication to decrease emotional or physical pain

Long-Term Goal The client will gain control of personal response related to the traumatic situation and resume a socially acceptable level of functioning.

Short-Term Goal #1: The client will discuss the traumatic event with the nurse.

Interventions and Rationales

• Encourage the client to describe the trauma experience. Its im-perative to identify the trauma and associated injuries to provide crisis intervention.
• Support the client's efforts to express feelings about the trauma by encouraging expression of emotion, crying, or verbalization and pain.Expression of feelings helps to diminish anxiety and facilitates grieving, thus allowing the client to begin the healing process.
• Recognize the client's angry, demanding, or abusive behavior, and help the client appropriately express rage within limits.Allowing the client to ventilate while providing for safety needs are two priority nursing interventions.
• Encourage the client to talk about fears related to the trauma experienced.A realistic discussion about the client's fears can he.c the client determine ways to decrease the danger of injury or assault associated with the fears.

Short-Term Goal #2: The client will participate in follow-up care.

Interventions and Rationales

• Work with the client to assess the extent of injuries, and determine what care is needed. This action is necessary for prompt intervention and for the development of a plan of care.
• Arrange for transportation, and have someone accompany the client to an emergency center or clinic for follow-up care. The client may be frightened and unable to make decisions to follow through with obtaining health care.
• Teach the client how to be safe in the community, identifying where to go for shelter. This information helps the client gain some control over personal safety.
• Talk to the client about how to avoid situations that increase the risk for accidents or violence. Providing the client with knowledge about the environment can help decrease the clients feelings c' vulnerability.

NURSING DIAGNOSIS: SELF-CARE DEFICIT IN HYGIENE, GROOMING, FEEDING, OR TOILETING

Probable Causes	Defining Characteristics
Cognitive disability Lack of support system and necessary resources for care History of being institutionalized or frequently hospitalized History of schizophrenia or mood disorder History of organic impairment from substance use	Lack of concentration or decreased attention span Inability to accomplish basic hygiene skills Inability to manipulate articles for hygiene Physical problems, such as malnutrition, leg ulcers, tuberculosis, lice, frostbite and heatstroke Presence of injury, such as fractured ribs or lacerations as a result of being assaulted

Long-Term Goal The client will demonstrate adequate self-care practices.

Short-Term Goal #1: The client will develop a routine for meeting basic physical needs.

Interventions and Rationales

• Have the client identify and use a facility for obtaining food and shelter. The client must develop a consistent and comfortable routine for meeting basic needs.
• Provide the client with adequate clothing, and teach how to care for clothing. The client needs seasonal clothing, washing supplies, access to a washer and dryer, and directions for washing and caring for clothes.
• Teach, identify facilities for, and assist the client with meeting hygiene and health needs. The client needs resources and assistance to perform grooming and bathing activities.
• Inform the client about resources for housing, food, job training, and health services. Use of available resources and participation in services contribute to the client's ability to be as independent as possible and responsible for aspects of self-care.

Short-Term Goal #2: The client will learn and practice communication skills to obtain needed services.

Interventions and Rationales

• Teach the client how to ask for or talk about personal needs.Clients with cognitive impairments may not know how to ask for services; clients who feel guilty about their problems may also feel unworthy of receiving assistance.
• Have the client work on developing basic communication skills.The client's mental illness, along with impaired perception and cognitive difficulties, makes communication difficult; basic skills must be taught and reinforced.
• Help the client learn and use assertive behaviors. Improved, selfesteem occurs when a client can speak on his own behalf
• Encourage the client to utilize opportunities for interacting with peers and staff. Interaction with others can strengthen communication skills and decrease social isolation.

THERAPIES

Psychotherapy is not the focus of therapeutic intervention with the chronically mentally ill homeless. The priority of care is to assist the client with self-care activities, medication compliance and management, and basic social and survival skills. Nurses serve as case managers who coordinate and implement strategic: that enable clients to meet their basic needs for food, clothing shelter, health care, social services, and educational services. After the initial client contact, the nurse must closely supervise all other services and appointments made on the client's behalf events with chronic mental illness are usually unable to assume responsibility for making appointments or requesting services o-their own. In some shelters, nurses may hold informal group sessions for the purpose of decreasing social isolation, while psycho-educational sessions can be used to teach rudimentary knowledge about self-care. An additional consideration for the mentally ill homeless is that these clients are mobile and may of stay in one geographic area long enough to be diagnosed and placed in a treatment relationship.

Group Therapy

• Provide support, and reinforce each client's feeling of self-worth.
• Decrease social isolation and apathy about the current life situation.
• Teach self-care practices, ways to communicate needs, and how to relate to others.
• Inform the client about community resources and how to access them through the agency or shelter or on the client's own.
• Develop a plan to obtain crisis intervention services when needed. Teach basic first-aid skills if the client shows an appropriate level of cognitive ability.
• Discuss ways to change unhealthy or unsafe behaviors.
• Help the client obtain the basic necessities despite personal physical, financial, and mental limitations.
• Teach ways to cope with personal anxieties, crises, and environmental concerns. Focus on developing strategies to reduce stress.
• Discuss ways to promote personal safety while out in the community and teach how to seek assistance when in danger.

MEDICATION MANAGEMENT GUIDELINES FOR HOMELESS CLIENTS

Make medication doses and administration times as simple as possible. Give clients medications in simple, easy-to-use containers, preferably those that muffle noise, such as a soft plastic zipper bag. Rigid pill containers or small bottles that cause contents to rattle may place the client at risk for assault and robbery. Write essential instructions and medication information for the client to keep with the medication. Emphasize that the client Isn't to take the medication with other drugs or alcohol. Discuss with the client how to find a safe place to stay because some medications can cause drowsiness and place a person at risk for injury. Develop a plan for taking the medication. For example, make sure the client knows where to get food before taking a drug; make sure the client understands the purpose of ingesting adequate fluids when taking certain medications; give a small bottle of sunscreen to use for skin protection when photophobia is an adverse effect of the drug. Give the client a telephone number to use if there is a problem with obtaining or taking the medication or if adverse effects develop.

MEDICATIONS

For the chronically mentally ill homeless, medication therapy can be useful in stabilizing the client's condition. However, many of these clients are unable to take medication as prescribed due to cognitive impairment. Inadequate monitoring of medications, especially the adverse effects, may cause the client to discontinue the medication.(See Medication Management Guidelines for Homeless Clients.)

• Neuroleptic medications are used for clients with schizophrenia.
• Antiparkinsonian agents are used to treat the extrapyramidal adverse effects of the neuroleptics.
• Antidepressant drugs are used for clients with a ma)or depressive disorder. (See Appendix D for medication information.)

FAMILY CARE

Some clients need assistance with developing community support networks because they are often estranged from family and peers. The emotional problems that these clients experience are often accompanied by difficulties like suspiciousness, limited attention span, inability to concentrate, and impairments in thinking and perceiving. Such additional burdens make it difficult for the clients to have social contact with others.

Nurses and other health care providers can help the client in the following ways.

• Provide medication management and supervision after ensuring that the client understands the drugs, uses, and adverse effects.
• Teach the client self-care, and use success to motivate the client to perform more activities of daily living.
• Acknowledge that relationships with biological family members are conflictive and may be nonexistent.
• Assist clients in locating support people and developing casual. contact with merchants and members of the neighborhood for use as contingency resources.
• Help the client establish an address where social services can send information or benefits to the client.
• Explore the use of drugs and alcohol as coping mechanisms.
• Help the client pursue appropriate social, occupational, case management, and rehabilitative services.