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We investigated the feasibility of recruiting patients unemployed for more than 3 months with chronic pain using a range of methods in primary care in order to conduct a pilot trial of Individual Placement and Support (IPS) to improve quality of life outcomes for people with chronic pain.
This research was informed by people with chronic pain. We assessed the feasibility of identification and recruitment of unemployed patients; the training and support needs of employment support workers to integrate with pain services; acceptability of randomisation, retention through follow-up and appropriate outcome measures for a definitive trial. Participants randomised to IPS received integrated support from an employment support worker and a pain occupational therapist to prepare for, and take up, a work placement. Those randomised to Treatment as Usual (TAU) received a bespoke workbook, delivered at an appointment with a research nurse not trained in vocational rehabilitation.
Using a range of approaches, recruitment through primary care was difficult and resource-intensive (1028 approached to recruit 37 eligible participants). Supplementing recruitment through pain services, another 13 people were recruited (total n = 50). Randomisation to both arms was acceptable: 22 were allocated to IPS and 28 to TAU. Recruited participants were generally not ‘work ready’, particularly if recruited through pain services.
A definitive randomised controlled trial is not currently feasible for recruiting through primary care in the UK. Although a trial recruiting through pain services might be possible, participants could be unrepresentative in levels of disability and associated health complexities. Retention of participants over 12 months proved challenging, and methods for reducing attrition are required. The intervention has been manualised.
The reasons why people become and remain homeless are complex; this is perhaps why, in the 21st century in a highly developed industrial society, we still have people living and dying on the streets. A single solution has not yet been found; nor is it likely to be, given the wide range of factors implicated in rough sleeping specifically and homelessness generally, as well as the multiple populations who are considered to make up the ‘homeless’.
Referring to ‘homelessness’ itself is an issue. There is a danger of oversimplifying the understanding of the issue in terms of a single population of people and therefore a single set of causes and effects. There are, of course, many issues that lead people to become homeless, the differences being idiosyncratic depending on the people and circumstances involved. For many, deprivation, poverty and financial issues may conspire to make sustaining housing all but impossible. For others, it may be that the housing situation was untenable because of domestic violence. For others, it may be that an inability to sustain rent payments due to funding drug addiction results in eviction. The term ‘homeless’ is therefore applied to a highly diverse group of people who are defined only by where they are, or are not, found.
This chapter will briefly cover a number of the main psychological factors theorised to be implicated in the causation and maintenance of homelessness. It is not possible to cover all factors in depth, but the point is to highlight them in enough detail that a model may be developed, which is presented near the end of this chapter. First, however, we need to consider what a good theory or model may do.
A useful theory
Any useful theory or model in this area needs to be useful enough to have predictive as well as explanatory power, but also needs to be loose enough to encompass the diversity of experience leading to homelessness, including different levels of factors, from genetic to societal influences. This chapter develops such a theory, which may then be useful in unpacking the psychological factors and concomitant interventions that may be useful in enabling people to break out of behavioural patterns that maintain a cycle of rough sleeping and homelessness.
This paper describes a project set up to treat four homeless men using cognitive behavioural therapy (CBT). The referral criteria were that individuals had alcohol and/or substance misuse problems, were roofless (i.e. sleeping rough) immediately before the intervention began and found it difficult or impossible to access hostel places in Southampton. Excessive alcohol use, violence (against self, others and property) and prison sentences were all features of their presentation. The project involved three levels of CBT intervention provided by the clinical psychologist: 1) training for the staff to enable them to work within this model; 2) continued supervision within model to ensure consistency and sustainability; 3) individual formulation (description of the problem within the CBT framework) and psychotherapy. The house itself was also run on a collaborative basis. A number of measures including mental health and social functioning constructs were used to evaluate the project, in addition to some qualitative data. All residents reduced incidents of theft, violence and alcohol consumption. Risk to self and others was also reduced for all residents. Perceived self-efficacy increased slightly for all residents, and staff perceived that they could be more effective, less hopeless, and therefore possibly less stressed as a result of training. More data will be gathered over time.
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