Indian Journal of Health Social Work
(UGC Care List Journal)
EMPOWERING THE HOMELESS: A CASE REPORT ON PSYCHOSOCIAL
INTERVENTION FOR A WOMAN WITH BIPOLAR AFFECTIVE
DISORDER AND ASSOCIATED CHALLENGES
Jatwinder Kaur Gaga1, Fayaz Ahmad Paul2, Arif Ali3, Wakar Amin Zargar4
1Psychiatric Social Worker, Institute of Mental Health, Amritsar, Punjab, 2Ph.D Scholar, Department
of Psychiatric Social Work, LGB Regional Institute of Mental Health, Tezpur, Assam, 3Associate
Professor, Department of Psychiatric Social Work, Institute of Human Behaviour and Allied Sciences
(IHBAS), New Delhi, 4Assistant Professor, Department of Social Work, University of Kashmir,
Srinagar, Jammu and Kashmir, India
Correspondence: Fayaz Ahmad Paul, e-mail : paulfayazpaul@gmail.com
ABSTRACT
Keywords: Homelessness, Psychosocial intervention, Rehabilitation & BPAD
Bipolar affective disorder (BPAD) stands out as a prevalent mental health condition among the homeless population, carrying an elevated risk of disability and mortality attributed to suicide, medical issues such as HIV/AIDS, hypertension, and substance use disorders Yale University reports classify an estimated 150 million individuals, or approximately 2% of the global population, as homeless, while an additional 1.6 billion lack adequate housing (Ayano et al., 2020). The multifaceted causes of homelessness encompass mental illness, sexual assault, poverty, domestic violence, unemployment, addictions, social isolation, family breakdown, and financial difficulties, identified as common factors in various studies (Habanik, 2018). Homelessness is considered an extreme form of social exclusion, placing individuals in conditions that exclude them from mainstream society (Hwang, 2001). This underprivileged group faces significant service needs, and their living conditions contribute to increased risks of premature death and a spectrum of health issues, i ncluding seizures, chronic obstructive pulmonary disease, and tuberculosis (Blid & Gerdner, 2006). Numerous studies have consistently reported a higher prevalence of psychiatric disorders among homeless individuals, with diagnosis rates ranging from 25% to 50% (Craig & Hodson, 1998). Among those who are street homeless, prevalence rates can soar to as high as 92%. The study estimates that bipolar affective disorder affects 2.41% to 42.42% of the homeless population. The consequences of BPAD among the homeless extend beyond the individual, affecting their families and communities (Ayano et al., 2017; Landefeld et al., 2017).
A single-subject case study design was employed to explore and implement effective rehabilitation strategies for the identified homeless woman with BPAD, contributing to the broader understanding and improvement of interventions for this vulnerable population. We intricately designed the psychiatric social work intervention to address the pressing rehabilitation needs of a 37-year-old homeless woman with BPAD, acknowledging the significant burden this population bears. The evidence points towards a higher incidence of BPAD among the homeless, exacerbating the risks of mortality, medical morbidity, substance use, risky behaviors, disability, and diminished quality of life.
Ms. R, a 37-year-old female with a 7th-grade education, finds herself in a complex web of l i fe experiences, marked by multiple relationships, separation, unemployment, and destitution. Her turbulent journey began in 1986, when the police, an institution under t he Department of Women and Child Development, brought her to Nirmal Chaya Ashram in Delhi at the age of 3. The ashram raised her until the age of 16, after which she left, married Mukesh, a rickshaw puller, and gave birth to a daughter named Sneha. Marital discord arose due to Mukesh’s smoking habit, leading to Ms. R leaving with Sneha after three years of marriage. A complex life history presents a challenging case, necessitating a comprehensive psychosocial formulation to understand the interplay of various factors influencing her mental health and well-being: 1. Early Childhood Trauma and Institutionalization 2. Unstable Relationships and multiple traumas 3.Unemployment and economic struggles Homelessness and social isolation 4.The impact of lockdown and restricted access is significant. 5.Treatment adherence and relapse
Rapport building Establishing rapport with patients was a crucial step in fostering cooperation and engagement. During sessions, we employed active listening, expressed empathy, and engaged in open conversations. The trainee addressed her concerns, particularly focusing on the reasons for her previous run from the residential home, contributing to successful sessions.
The patient was psycho-educated about the nature of the illness, its causes, and the various treatment options. The patient’s limited awareness of her illness prompted psycho-education sessions covering her diagnosis, treatment options (both pharmacological and non-pharmacological), medication side effects, and dispelling misconceptions. The goal was to provide her with knowledge to better manage herself.
Encouraging the patient to discuss her concerns, validate her emotions, and explore interpersonal relationships formed the core of supportive psychotherapy. We emphasized active and empathetic listening, fostering trust, and facilitating her engagement in both indoor and outdoor activities.
The ward made arrangements for the patient’s physical examination after recognizing her living conditions prior to admission. The trainee utilized destitute funds to provide a pregnancy kit and HHH test kit, ensuring comprehensive health assessments before her transfer to a residential home.
The patient initially struggled with maintaining activities of daily living (ADLs). We motivated her and provided the necessary items to improve her self-care. Subsequently, her ADL scores improved from 6/12 to 12/12. We introduced activity scheduling, which included drawing, singing, dancing, evening walks, and football. The patient actively participated without persuasion.
We initiated the education of patients on healthy communication, self-management, and peer relationship abilities. Given her history of broken connections, we placed emphasis on rebuilding relationships, understanding emotions, and fostering friendships. She emphasized the importance of effective communication, which includes expressing apologies and gratitude.
Given the patient’s recent incidents of self harm during non-compliance, we introduced anger management strategies. We taught her techniques like deep breathing exercises, diversions through various activities, and backward counting to help her manage anger and prevent impulsive actions.
Behavior therapy sessions targeted patients’ inappropriate behaviors, including short temper, self-injury, and physical aggression. We established contingencies that tied her access to conversations with her son to the successful completion of scheduled activities.
Shifting We contacted the social welfare department to facilitate her transfer to Nari Niketan as the patient demonstrated improvement. On August 23, 2020, Nari Niketan successfully admitted her after assessments and follow ups.
Prior to discharge, comprehensive counseling covered medication adherence, regular follow-ups, recognition of signs and symptoms of relapse, self-care practices, and maintaining a balanced diet. The patient agreed to adhere to these guidelines.
The intervention helped the patient improve in maintaining self-care, including adherence to daily activities without external persuasion. We found a positive change in her communication style. The patient is gaining a better understanding of her illness, recognizing signs of relapse, and consistently adhering to treatment. The patient expressed gratitude appropriately, indicating improved social skills. Her progress in controlling her anger and actively engaging in assisting other patients in the ward has fostered a more supportive environment. We found the patient to be experiencing relief and in a stable emotional state.
The presented case of Ms. R, a homeless woman with bipolar affective disorder (BPAD) and associated psychosocial challenges, underscores the significance of comprehensive and multidimensional interventions in the mental health care of vulnerable populations. The success of the intervention strategies aligns with existing literature emphasizing the importance of tailored approaches for individuals facing homelessness and mental health disorders. Research highlighting the impact of homelessness on individuals’ overall well being aligns with the immediate attention to patients’ basic needs, including personal hygiene items. Studies emphasize that interventions targeting basic needs, such as clothing and hygiene, can enhance individuals’ self-esteem and contribute to their sense of dignity (Hopper, Bassuk, & Olivet, 2010). The challenges faced in securing funds for patients’ needs resonate with the broader issue of financial constraints in mental health care for homeless individuals. Research suggests that financial limitations often hinder access to essential resources, highlighting the need for innovative solutions and resource utilization, as demonstrated by the use of destitute funds in this case (Kushel, Vittinghoff, & Haas, 2001). The emphasis on establishing rapport with patients and providing psychoeducation aligns with evidence supporting the role of therapeutic alliances and patient education in mental health interventions (Hudson et al., 2016). Building trust and enhancing awareness about mental health conditions contribute to treatment adherence and positive outcomes. The incorporation of activity scheduling and social skills training reflects a person-centered approach to mental health care. Studies have shown that engaging individuals in activities they enjoy enhances overall well-being and contributes to the rehabilitation process (Glynn, 2003). Social skills training is crucial for individuals with a history of broken relationships, helping them rebuild connections and foster a supportive social environment (Bellack et al., 2013). Addressing anger management through behavioral therapy aligns with established interventions for individuals with mental health disorders prone to impulsive behaviors (Linehan, 2014). Contingency management, as applied in behaviour therapy, has shown efficacy in modifying behaviors and improving outcomes (Petry, 2013). The use of telephonic contact during the COVID-19 pandemic aligns with the growing reliance on telehealth services in mental health care (Aminoff et al., 2021). The challenges of contacting social welfare departments during the pandemic highlight the importance of flexibility and adaptation in service delivery. Successful residential shifting and pre-discharge counseling align with the literature, emphasizing the importance of planned transitions and ongoing support in preventing relapse among individuals with mental health disorders. The positive outcomes, including improved communication, enhanced self-care, and commitment to residential living, are consistent with literature highlighting the effectiveness of comprehensive interventions in promoting recovery among homeless individuals with mental health disorders.
In conclusion, the case of Ms. R demonstrates the potential for positive outcomes when applying a holistic and individualized approach to mental health care for homeless individuals with bipolar affective disorder. The psychosocial intervention’s outcomes were positive, highlighting the role of such interventions in addressing the multifaceted challenges faced by homeless individuals with mental illnesses. This case study underscores the necessity of a holistic approach that integrates psychosocial interventions with pharmacological treatments for the effective rehabilitation of individuals grappling with mental illness and homelessness.
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Conflict of interest: None
Role of funding source: None
