Understanding the Psychodynamics

of Chronic Homelessness from a Self

Psychological Perspective

Daniel Farrell

Clinical Social Work Journal

ISSN 0091-1674

Clin Soc Work J

DOI 10.1007/s10615-012-0382-5

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 Author's personal copy
Clin Soc Work J
DOI 10.1007/s10615-012-0382-5
ORIGINAL PAPER
Understanding the Psychodynamics of Chronic Homelessness
from a Self Psychological Perspective
Daniel Farrell
Ó Springer Science+Business Media, LLC 2012
Abstract Self psychology can help explain multiple
meanings and experiences of being chronically homeless.
While it is clear that homelessness is primarily caused by
structural deficits and not individual characteristics, for people
who are chronically homeless, this way of existence may have
developed to serve a variety of coping, cohesive, and self-
preserving functions as they have learned to survive and adapt
to hostile environments. Through the use of self psychologi-
cally informed clinical practice, this paper explores the sub-
ject’s multiple meanings and experiences as well as the
nuanced processes that led her to successfully attain perma-
nent housing. The paper begins by discussing macro etiologies
of homelessness, constructs in self psychology and strives to
link the two in theory and practice by exploring one person’s
life of chronic homelessness. The paper also explores ethical
challenges as coercive elements factor into the case.
Keywords Chronic homelessness
Self psychology

Selfobject transference
Therapeutic relationship

Permanent housing
Introduction
Homelessness continues to be a major social problem. One
of the most important independent conditions that affect
rates of homelessness is the rate of poverty (O’Flaherty and
Wu 2006). Other economic risk factors include job market,
the availability of income-based rent subsidies, and local
housing market conditions. When the conditions of high
D. Farrell (&)
New York University School of Social Work, 1 Washington
Square North, New York, NY 10003-6654, USA
e-mail: dcf253@nyu.edu; danielcfarrell@gmail.com
rent, diminished housing subsidies, and poor economic
indicators exist at a specific place and time (e.g., New York
City in 2009), rates of homelessness will increase (O’Flah-
erty 2004). Individual risk factors associated with home-
lessness include a history of foster care, social isolation,
forensic history, poor familial relationships, mental illness,
and substance abuse (Allgood and Warren 2003; Bradford
et al. 2005). When individual risk factors are combined with
economic risk factors, the chances of homelessness are
much greater for single adults. Most homeless families
experience homelessness related to economic conditions,
and their time in homelessness is not strongly correlated to
individual characteristics except for substance abuse
(Weinreb et al. 2010). However, a strong antecedent of
family homelessness is a history of birth parents’ having
been in foster care as children (Zlotnick et al. 1998). It is
clear that homelessness is most often the result of larger
socioeconomic forces, and the combination of these forces
with multiple risk factors, both macro and micro, tends to
push families and single adults into homelessness.
The deleterious effects of homelessness are well docu-
mented. Incidence of sexual abuse and violence is much
higher among homeless than nonhomeless youth (Rew
et al. 2002; Swick 2008). Additionally, homeless adoles-
cents are at higher risk than their nonhomeless peers for
substance abuse, delinquency, victimization, and physical
and mental health problems (Milburn et al. 2006; Zerger
et al. 2008). Single homeless adults also experience the
harmful effects of homelessness, which include greater
incidence of substance abuse and mental health issues
(Caton et al. 2007; Milby et al. 2010). Upon one’s descent
into homelessness, rights once enjoyed become nonexistent
because being homeless strips one of basic liberties and
equalities (Wright 2007–2008). These include losing one’s
right to property, personhood, and protection against illegal
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search and seizure, as these legal protections are contingent
on having a private, personal space (Stec 2006). In essence,
people who are homeless live in a legal status that Baron
(2004) describes as having ‘‘no property’’ (p. 280).
Chronic Homelessness
The US Department of Housing and Urban Development
(US HUD 2003) defines chronic homelessness as ‘‘an
unaccompanied homeless individual with a disabling con-
dition who has either been continuously homeless a year or
more or has had at least four episodes of homelessness in the
past 3 years’’ (p. 4019). Of the total homeless population that
lives on the street or in a place not meant for human habi-
tation, two-thirds are chronically homeless (US HUD 2010).
Approximately 111,000 people remain chronically homeless
nationwide, according to a recent report submitted to the US
Congress (US HUD 2010). The chronically homeless popu-
lation accounts for only 11% of total sheltered residents, yet
cluster analysis studies of two major urban centers indicate
that people who are chronically homeless and living in a
shelter account for 50% of total system days and bed use
compared to people who experience transitional and episodic
homelessness (Kuhn and Culhane 1998). People who are
chronically homeless frequently interact with, but are inef-
ficiently served by various services and systems. These sys-
tems include emergency medical and psychiatric services,
detoxification services, shelter beds, and public corrections
(National Alliance to End Homelessness 2007). The chron-
ically homeless population is much more of a financial drain
than their transient or episodic counterparts, as costs asso-
ciated with them are extremely high. In one study in New
York City, costs associated with their use of various systems,
including emergency shelter; medical and mental health
services; and public corrections averaged more than $40,000
per person in 1999 dollars (Culhane et al. 2002). Most people
who are chronically homeless and living in shelter are single,
over age 50, and have high rates of behavioral health treat-
ment and disabilities (Culhane and Metraux 2008).
People who are chronically homeless are often the most
challenging to provide cohesive services to and to house
successfully and sustainably (Kuhlman 1994; Pollio 1990).
They present with multiple service needs, including sub-
stance abuse, psychiatric disabilities, and medical comor-
bidities (Barrow et al. 2004; Caton et al. 2007; Milby et al.
2010). People who are chronically homeless, unlike those
who are transient or episodically homeless, may become
embedded in a life of homelessness as a coping mechanism.
For example, they may organize their experiences by creat-
ing normalcy in the seemingly chaotic world of homeless-
ness. They may work and earn money in the underground
economy in an urban industrial section. And they may have
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carved out a niche by panhandling in a location that is tol-
erant of their presence. These experiences can serve a few
functions. These people may make enough money to sustain
their existence. Even more importantly, they may feel deeply
attached to the location and the people who give them
money, thus further cementing their ties to the experiences of
homelessness. At this point, they have learned how to survive
and, in a sense, to master aspects of their life, whether on the
street or in a shelter. This level of mastery can be considered a
strength, and for people who are chronically homeless, these
experiences may not be easily left behind.
Constructs in Self Psychology
Heinz Kohut, the founder of self psychology, believed that
psychopathology is characterized by a weakened or
defective self structure that results in a fragmented sense of
self. Kohut introduced the concept of the selfobject, which
is central to understanding the human experience. Healthy
selfobject experiences are facilitated by the consistent
presence of another, which will evoke the emergence and
maintenance of the self. Cohesion of the self is understood
to be the hallmark of mental health. The self is defined as
the psychological structure/system built on interactions
with environment and various selfobjects and selfobject
experiences (Wolf 1988). As Kohut and Wolf (1978) state,
‘‘selfobjects are objects which we experience as part of our
self’’ (p. 414). Rowe (1994) elaborated by stating, ‘‘Wolf’s
definition follows Kohut’s conceptualization of selfobject
relationship by focusing on the experience of functions
provided rather than on the person as provider’’ (p. 11).
The philosophical base of self psychology is grounded in
theoretical assumptions about human nature. From an onto-
logical perspective self psychology espouses the view that
humans have the inborn tendency to organize experience
based on the emergence of the self that ultimately leads to
consciousness (Wolf 1988). Self psychology believes in both
innate qualities and environmental influences that shape
experience (Lichtenberg and Kindler 1994). The human
organism is born with certain potentials that are actualized by
a loving, supportive, thriving, and interactive environment.
Innate qualities exist, and prewired capabilities will be
enhanced or thwarted by experience (Fosshage 2003). Self
psychology considers the argument as to whether tempera-
ment is innate or environmental to be irrelevant. One’s
temperamental style is greatly affected by the ability of one’s
caretakers to enhance the strengths of a particular style.
Conversely, caretakers may thwart certain aspects of a
child’s developmental possibilities based on the inability to
tolerate the child’s inborn temperament style.
Contemporary self psychology espouses a postpositivist
understanding of knowledge development for each person.
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It believes that knowledge and truth are based on a concept
of a decentered self, as the mind is continuously shifting
into nonlinear states of consciousness (Bromberg 1996). A
vital component of clinical work is to allow for thorough
and full understanding of the person through sustained
empathic immersion into that person’s own experiences
(Martin 2008). Epistemological truth is gathered by the
sustained establishment of a solid therapeutic relationship
in the clinical situation. This establishment is achieved
through sustained empathic attunement, understanding, and
respectful explanation and interpretation, as well as an
appreciation of the person’s situation within the environ-
ment, all of which enhance healthy selfobject experiences
(Baker and Baker 1987). These attributes are consistent
with basic social work values (Simpson et al. 2007). Self
psychology postulates that in order to live healthy, pro-
ductive lives, all individuals must meet certain develop-
mental needs and milestones early in life. It is the
disruption and thwarting of these developmental needs that
cause fragmentation of one’s self or disintegration anxiety
in the form of symptom formation.
An underlying value of self psychology is that humans
have capacity for individual achievement and for leading
healthy, productive lives that include the development of
empathic capabilities needed to form meaningful relation-
ships (Shane et al. 1997). These individual capacities are
innate imperatives that are enhanced or thwarted by rela-
tionships and experiences with others as children within the
developmental framework or as adults (Kohut 1977). There
are gradations along a continuum of mental health; it is not
simply that a person has a healthy or an unhealthy self
structure. People seek out others in meaningful relationships
to serve in developmentally appropriate functions in the
building and sustaining of healthy life experiences (Tolpin
1986). Healthy selfobject experiences favor structural
cohesion and vigor of the self, while faulty selfobject expe-
riences result in fragmentation and emptiness of the self.
Understanding Chronic Homelessness from a Self
Psychological Perspective
Kuhlman (1994) describes a process he calls shelterization,
which ‘‘refers to an institutionalization syndrome of passiv-
ity, dependence, apathy, and neglect of personal hygiene
which befalls even nonpsychotic people if they languish in
shelter life for months and years’’ (p. 15). This description is
consistent with a recent qualitative study, in which more than
500 interviews were transcribed, which found people living
in a homeless shelter highly critical of the services available
to them (Hoffman and Coffey 2008). Consistent responses
included feeling ‘‘objectified’’ and ‘‘infantilized’’ (p. 209).
The study does not differentiate among people who were
transitional, episodic, or chronically homeless, but it is
assumed that the latter were interspersed throughout the in-
terviewees. The notion of respect, dignity, and holding onto
one’s humanity were common, important themes beyond the
concrete work of moving toward obtaining housing. From a
self psychological perspective, living in a homeless shelter
and repeatedly experiencing objectification and infantiliza-
tion contribute to extreme self-loss and breakdown of one’s
sense of self, which can result in psychopathology (Atwood
et al. 2002). Living in a homeless shelter for a long period
may produce its own psychopathology.
People living in homeless shelters are subjected to a
complex system that may not always work in their best
interests. People who are chronically homeless are often
subordinated in the homeless shelter hierarchy, and shelter
workers may not be able to view this population from a
client-centered perspective (Hartnett and Postmus 2010). The
role of social disadvantage is an important component since
living in a homeless shelter inherently produces a social
disadvantage for the individual (Draine et al. 2002). Home-
less shelters are generally constructed to ensure that basic
physical needs are met, but are not concerned with providing
a nurturing environment. As the emergence of a healthy self
structure is evoked by consistent, growth-enhancing experi-
ences, including collaborative interpersonal interactions
(Siegal 2001), a homeless shelter will more often than not
contribute to faulty, fragmenting experiences.
The issue of housing people who are chronically homeless
is often fraught with challenges. A chronically homeless
person’s rejection of an offer of permanent housing may
seem counterintuitive to service providers. Yet, if one views
the situation from a client-centered and self psychologically
informed experience-near perspective, it makes sense for the
person. Only a few studies on housing rejection exist, but
they highlight the way some people who are experiencing
homelessness prefer more freedom and autonomy related to
housing options and may reject housing options that limit
their choice and that they perceive as coercive (Tsembaris
and Asmussen 1999). As there are developmental potentials
that are actualized in the growth of a healthy self structure
(Fosshage 1995), housing rejection may be based on pro-
jections of future perceived faulty selfobject experiences.
Another factor may be that life on the streets or in shelters is
so precarious that the focus of a homeless person’s intentions
must be on day-to-day survival activities (Snow and
Anderson 1993). People who make a conscious decision to
refuse housing-based services may be doing so after having
calculated all sides of their decision.
Living in homelessness for long periods may produce
adaptive and coping strategies that have fostered survival
within hostile environments. There is no research supporting
a statement that the dynamic of rejecting housing is well
established for people experiencing chronic homelessness.
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However, one observational study surmises that there may
be some among the chronically homeless who become
acclimated to a life of homelessness as their life on the street
or in shelter becomes routine (Wong 2002). Some may have
actually adapted successfully to a life of homelessness and
may feel that life on the street (or in shelter) is one of the few
things within their control. The familiar experience may lie
in their actual state of homelessness, and they may organize
experiences by creating normalcy in that seemingly chaotic
world. There may exist an adaptive and coping state of
homelessness. In other words, because the experience of
homelessness is a constant state of being, adaptive states
may occur continually within the lives of those who are
homeless (Farrell 2010). There may be an ability to adapt,
survive, and even master aspects of a homeless lifestyle.
Programs and homeless service works, viewing this state of
being from an empathic and client-centered perspective,
should appreciate and value it as a strength. Homelessness is
not a unifying concept for those who experience it. For
many, homelessness is living a chaotic existence on the
streets or in a drop-in center or shelter which provides only
the basic essentials for survival. Others may experience
homelessness in a setting that provides an array of services
that surpasses the norm in homeless shelters of the lowest
common denominator of service provision.
The life of a person who is chronically homeless may
serve a variety of organizing and cohesive functions in the
service of self-preservation. People who are chronically
homeless have been able to carve out an existence and, at
times, feel empowered by their life on the street or in a
homeless shelter, thus successfully adapting to a homeless
state. The protective and cohesive functions of this state may
preserve a fragile core self and protect a person against dis-
integration anxiety. This becomes apparent when housing
opportunities are rejected (Luhrmann 2008). The dynamic of
the powerful pull back into homelessness or, as Rowe (2005)
calls it, the homeless way of life, is the feeling that there is
something more in the unknown of life on the streets. One
may believe that he/she could master life on the streets and
expect to find and have something more than could be found
in an experience out of homelessness. Rowe describes this
experience, fittingly, as the undifferentiated selfobject
experience: ‘‘Mr. L’s longing for his homeless way of life
was a prominent theme in the treatment. He elaborated easily
on the undifferentiated selfobject experience of anticipating
discovering an unknown new find which ‘filled’ him with a
sense of happiness and well being’’ (p. 56).
The Case of Ms. Z
The case of Ms. Z illuminates the challenge of providing
client-centered services in a homeless shelter setting. Ms. Z
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was at a distinct disadvantage living in a system that was not
always working in her perceived best interest. The case
demanded an appreciation and understanding of the selfob-
ject functions the shelter and building that housed the shelter
provided her. A 76-year-old single Hispanic woman, Ms. Z
had been homeless for more than 20 years, consistently liv-
ing in a single homeless shelter. Diagnosed with schizo-
phrenia, Ms. Z harbored a number of delusional beliefs: that
she was once married to two famous men, John F. Kennedy
and Martin Luther King; and that she once owned multiple
properties and businesses in Manhattan, including the
building that housed her homeless shelter. During her time in
shelter residency, except for a 1-year hospitalization before
she moved into permanent housing, Ms. Z never left the
building, which she had known as home. Staying behind
closed doors seemed to give her a strong sense of safety and
attachment. Ms. Z was able to carve out an existence in the
shelter as an expectable and realistic response to the fear
invoked when the possibility of leaving the shelter for her
was real. In her words, she could not leave the shelter ‘‘for
fear of being kidnapped.’’ She claimed to have been kid-
napped as a teenager and feared this could happen again if
she were to leave the shelter. Her country of origin experi-
enced a revolution at the approximate time when Ms. Z was a
teenager and it is plausible that kidnapping occurred and that
she was either at risk for, or actually kidnapped. The trauma
imbued in Ms. Z undoubtedly left an indelible mark upon her
(Robben and Suárez-Orozco 2000).
Also, Ms. Z would frequently state that everyone around
her was ‘‘dead’’ and that she could not understand how or
why others could even speak to her. The belief that
everyone around her was dead can possibly be understood
as an experience of personal annihilation, self-loss, and a
disintegration of reality itself (Atwood et al. 2002), again
possibly based in actual events in her country of origin
stemming from her adolescence. It was certain that any exit
from homelessness would be a challenge for her as her
multilayered belief systems were firmly established.
Ms. Z’s history is difficult to fully know, given the
severity of her delusional beliefs. However, what is known
is that she was born and raised in an upper-class family in a
Central American country and that she immigrated to the
United States as an adult. Her migration to her United States
was probably forced given the political climate at the time.
She experienced status loss which would add severe
stressors to the normative, yet challenging psychosocial
process of arrival and settlement to a new country (Akhtar
1995; Halperin 2004). Not surprisingly, she states that her
life grew increasingly difficult after immigration. She
worked as an unskilled laborer at a laundromat and then as a
live-in nanny for families in New York City. These jobs
helped her sustain a meager financial existence until she
became homeless in the mid-1980s, after not being able to
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pay her rent. Ms. Z indisputably met with racism in New
York City in the 1960’s and 70’s as a woman of color
seeking decent and sustainable employment.
Ms. Z claims that she has three living children and other
family members, though many diligent social workers have
been unable to locate any relatives. She also states that her
children hold prominent employment positions, and she
talks about them in the present tense, saying that the birth
of each child was the result of her marriage to either
Kennedy or King. Ms. Z’s fantasy of marriage to these two
powerful men seemed to reflect her sense of importance
and moral values, that people and societies have a
responsibility to uphold standards of fairness. This belief
system may have possibly reflected the dramatic fall from
her status and the failure of her country to protect her. It is
clear to the social work professionals who know her well
that these ideas are products of her rich fantasy life, and
may originate to her high economic and class status in her
country of origin. If Ms. Z has family, she has not had any
contact with them since she became homeless more than
20 years ago.
History of Homelessness and Life in Shelters
Throughout Ms. Z’s homeless experience, she has lived in
only two shelters. The majority of her homelessness was
spent in her last shelter, a residency that lasted close to
13 years. Given her length of time in shelter, her experi-
ences of shelter may have emulated with long-term hos-
pitalization. The shelter, with which Ms. Z was most
familiar, is housed in a beautiful historic building, distin-
guished from other buildings in the neighborhood by its
grand size and red brick facade with carved granite trim.
The physical dimension of the shelter—within its huge
building—is quite expansive. The main living area is
unique and separate from residents’ eating and sleeping
areas. This living area is a very wide and high, with a long
hallway extending lengthwise throughout the building.
Almost the length of a city block, this promenade-like
hallway gives shelter residents and staff the space for
groups, multiple seating areas, and in recent times, a library
at one end. It is within this large and ornately decorated
hallway that Ms. Z has spent most of her time.
In many ways, Ms. Z’s time in shelter has been spent
much like other residents’. She was attuned to the rhythms
and functions of life in the building. She ate when everyone
else ate, she showered when others showered, and she spent
much of her time sitting in the majestic hallway much as
other residents did. If there were a group near the hallway
area that Ms. Z occupied, she seemed to listen to what it was
discussing. The constancy of Ms. Z’s silent presence in
shelter gatherings was unmistakable. Unlike other residents,
however, Ms. Z never left and returned to the shelter. She
did not have visitors. She did not interact with other resi-
dents. Ms. Z was essentially a wallflower, seemingly sat-
isfied to be a part of the larger landscape, but she never
interacted with others or joined in any activities. When she
entered the shelter, she was wearing clothing that she had
sewn herself. Although her sewing skills were excellent,
there was a slight bizarre aspect to Ms. Z’s appearance since
the fabrics used for her clothes were like materials used to
line garments. As the years passed, Ms. Z stopped sewing
her own clothing. Instead, she wore hospital gowns and
plastic bags, refusing to accept clothing from well-meaning
shelter staff.
Ms. Z believed herself to be an important part of the
world beyond the shelter landscape. She seemed to
experience her life in the shelter as just a segment of time
and to think that something better, something grander
would eventually happen. She was steadfast in her belief
that her world would change. She would often say that she
was ‘‘waiting for (her) children to come get (her)’’ and that
she did not ‘‘need assistance from staff (as her) family
would come and take care of (her).’’ Ms. Z would often
state that when her children came for her, they will take
(her) ‘‘to visit the great African city Nairobi.’’ Ms. Z, in
her grandiose ideation, was absolutely convinced that this
day of deliverance would come, but, as she repeatedly
stated, ‘‘only when the time is right.’’ Ms. Z seemed to be
describing an undifferentiated selfobject experience (Rowe
2005), which is defined as ‘‘the fundamental experience of
knowing that there will be unknown, nonspecific hap-
penings that will occur throughout life that will be sur-
prising, challenging, uplifting, and self-enhancing no
matter the positive or negative nature of our current cir-
cumstances’’ (p. 21). Ms. Z absolutely believed this fun-
damental experience would happen to her. It was this
belief, which she expressed with absolute joy and happi-
ness that took her away from her experiences of loneliness
and isolation. This belief system can be understood to be
an important self-preserving function, maintaining and
providing cohesion for Ms. Z’s fragile self structure.
Essentially, it functioned as a survival mechanism. To the
many staff members who tried to work with Ms. Z over
her years in the homeless shelter, it was clear that her
psychotic belief system would make their attempts to
place her in permanent supportive housing a challenge, if
not an impossibility. Throughout Ms. Z’s years in shelter,
the staff were unable to form what they defined as
meaningful relationships with her. It seemed to everyone
that Ms. Z’s elaborate internal world was sufficient for
her. Because Ms. Z’s fantasies seemed to be all she nee-
ded throughout her 20 years of homelessness, she resisted
all attempts made to connect with her in a relationship in
any shape or form.
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Hospitalization
In my 5-year tenure at the shelter, there were often differing
opinions on a course of action for a resident who presented
as a risk for harm to self or others, but did not reach the legal
threshold for harm. Often, I would have to navigate com-
peting forces and decide on a course of action that some-
times dismayed interested parties. These included our
funders, who wanted permanent housing placements as
quickly as possible, social work and psychiatric staff, who
often argued for more time to engage in treatment, and line
staff, who often wanted ‘‘troublemakers’’ transferred out of
shelter as it made their work of managing daily shelter life
more of a challenge. This was one of the few cases on which
most, if not all staff were in agreement on a course of action.
Staff members who had worked at the shelter for years were
frustrated and saddened as they watched Ms. Z’s condition
deteriorate as she descended over a psychotic cliff.
As I was recently hired as the director of the shelter,
initially I worked with Ms. Z. After a depth review of her
case it was decided that Ms. Z would be hospitalized.
Although she did not present as an immediate threat to
herself, it was clear to the new multidisciplinary team that
her symptoms would not subside and that further attempts
at engagement would be futile. As the years progressed,
Ms. Z’s belief systems had been growing stronger and cer-
tain bizarre behaviors manifested in these beliefs had
deepened. Given her advanced age and unabated, slowly
increasing symptom formation, it was decided that
attempting to hospitalize her against her will would be a
worthwhile risk even though we did not have a solid legal
case for a forced hospitalization. We were acutely aware of
the coercive factor in this intervention for Ms. Z and strived
to persuade her to go willingly. On a carefully chosen day
and time, when most residents were out of the shelter,
emergency services and the police were called. After a case
discussion of the case, the police and emergency services
team agreed that Ms. Z should be transported to a psychiatric
unit for an evaluation. We approached her and expressed our
concerns for her well-being. Initially she did not respond but
slowly walked away from us, but we persisted. When that
message was conveyed to her, she began to listen, but she
protested, stating that she could not leave as she owned the
building and that we had no right or authority to demand her
removal. The police’s assistance was crucial in that they
reiterated to her that she had no choice but to go with us to the
hospital. She reluctantly relented, and much to everyone’s
relief, she did not have to be physically restrained.
I rode with her in the ambulance knowing full well that it
was the first time she had not left the shelter in many years. I
wondered what filled her thoughts during our 20-min drive
to the hospital. She presented as surprisingly and almost
unnervingly calm. I had taken over as director of the shelter
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only 2 weeks earlier, so I was a new presence in her life. Not
wanting to jeopardize our initial success in getting her into
the ambulance without restraints, I decided to leave my
curiosity about her experience in its rightful place; to myself.
Return to Shelter
I was in regular contact with the hospital social worker and
discussed Ms. Z’s history with the team at morning rounds
on multiple occasions. I received regular updates, and after
just a few weeks in the psychiatric unit, she was discharged
back to shelter. She had been prescribed a low-dose anti-
psychotic, and it seemed to allow her to recognize that staff
could be helpful. Upon her return to shelter, Ms. Z became
attentive to her hygiene and concerned about her appear-
ance. She showered more frequently and allowed staff to
buy clothing for her. Ms. Z was more responsive to staff
attempts to engage her in relationships. Upon her return to
the shelter, social work and psychiatric staff became
hopeful that she might allow a therapeutic relationship to
develop as her elaborate defensive structure seemed to
loosen slightly. However, much of Ms. Z’s core delusional
belief system did not recede. She no longer fully believed
that people around her were ‘‘dead,’’ but she continued to
believe that her children would come for her and that she
owned the building that housed the shelter.
At this time I decided to assign the case to one of the
staff of the social work team. I directly supervised the
social work team since the social service director position
was vacant. One member of the team, Lydia, had estab-
lished a reputation as an excellent social worker. Described
as hard working, kind, empathic, yet firm with an ability to
handle tough cases by navigating both administrative and
clinical challenges, Lydia was asked to take the case,
knowing the looming administrative pressures and clinical
challenges that it would bring. However, it was her option
to decline if she felt it would be too much to handle. She
agreed to accept it. The initial focus in supervision was the
development of a positive selfobject transference rela-
tionship (therapeutic relationship). We surmised that upon
development of the therapeutic relationship, Ms. Z would
be amenable to ideas and options outside her delusional
belief system. The development of this relationship was
critical to the success of the case. The most important
variable that can be controlled for in any treatment setting
is the subjectively experienced value of the therapeutic
relationship (Bordin 1979; Carr 2011; Elvins and Green
2008; Graybar and Leonard 2005; Martin et al. 2000;
Smerud and Rosenfarb 2005; Zeber et al. 2008).
Ms. Z settled back into the shelter, and Lydia began
engaging with her daily. They sat in the hallway or on the
stairs leading up to the sleeping area. Lydia would seek her
 Author's personal copy
Clin Soc Work J
out daily; on occasion, she would have the opportunity only
to say hello, but on other days, Ms. Z was open to discussing
innocuous topics such as the weather or food served at
previous meals. Although I was usually not involved with
Ms. Z directly other than to exchange superficial greetings, I
accompanied Ms. Z to the basement during fire drills and
had discussions with her about the building and its ornate
beauty. There were no specific agendas other than to
express curiosity about all aspects of Ms. Z’s inner life and
thoughts. Between Lydia and me, these engagements were
carefully planned, and the goal of these moments was to
validate and appreciate Ms. Z’s inner experiences. (This is
an example of an experience-near mode of understanding
and observing Ms. Z’s thoughts and feelings.) The expres-
sion of nonspecific and nonintrusive curiosity, allowed the
beginning of a therapeutic relationship to emerge. The
constant, consistent engagements between Ms. Z and Lydia
allowed the therapeutic relationship to deepen much more
quickly than expected. As Josephs (1991) states, ‘‘consis-
tent empathy allows the patient to use the therapist as a
selfobject; such a relationship provides the patient with an
increased sense of self-cohesion, enabling an advance from
regressive and pathological states to a more reality-oriented
and mature level of functioning’’ (p. 170).
After a short period of consistent daily engagement
attempts, the therapeutic relationship was fully established.
Ms. Z began to look forward to seeing Lydia, both infor-
mally in the hallway and formally in frequent sessions sit-
ting beside an office desk. We agreed that frequent, yet short
sessions were best suited to Lydia’s ability to handle Ms. Z
by allowing her to manage and mitigate her own negative
countertransferencial impulses. She seemed comfortable
and related well to her worker. Their interactions were
framed by Ms. Z’s grandiose visions of her place in the
world. For example, she could not believe that she needed to
listen to Lydia, seeing their interactions as a platform to
expand on her magnificent past and future exploits. As well,
she frequently demeaned Lydia and her position at the
shelter. In our work together, Lydia and I discussed the
challenge of staying in the moment with Ms. Z by mirroring
her grandiose and narcissistic ideas. Lydia did not react to
the directness of her demeaning comments, but structured
them in the larger context for her—recognizing that this was
part of her coping strategy that had allowed her to survive
living in shelters for two decades. Her guiding principle was
to work with Ms. Z within an empathically attuned frame-
work, knowing quite well how utterly unbearable life had
become for her and how this had prompted the grandiose
and narcissistic frames of reference.
In the ensuing weeks, Ms. Z began making slow, yet
steady strides toward healthy selfobject experiences. She
agreed to continue the medication regimen that began in
the hospital which was administered daily by the shelter
nurse. She allowed staff to buy the clothing for her and to
change her bedsheets, and she slowly began to integrate
into some shelter functions by attending groups and eating
meals with other residents. Ms. Z essentially allowed us to
provide important environmental support that was vital to
achieve a permanent housing outcome (Kanter 1990). Ms.
Z made clear to Lydia that she was not leaving the shelter
as she ‘‘owned the building’’ and she knew for certain that
‘‘my children are coming for me.’’ Staff believed that there
might be a part of her that understood that under the right
circumstances, she might actually leave the shelter.
As the therapeutic relationship was established, Lydia
and I recalibrated our plan accordingly. We decided that the
time was right to begin discussion about housing options.
Working with local government officials and a nonprofit
organization that operates supportive housing programs, we
received an approval to move Ms. Z into their supportive
housing program without preconditions. Ms. Z’s case
became increasingly well known by city and state officials
interested in shifting the culture of the shelter system to
increase housing placements and decrease the average
length of stay. As Ms. Z was one of the longest-staying
shelter residents in the history of the system, the pressure to
move her into permanent housing mounted quickly. At one
point a number of high-level officials attended a case con-
ference and strongly suggested that we ‘‘just set a date and
inform her that she is moving, and move her quickly.’’ My
job was to allow Lydia to guide clinical decision making
without undue pressure from government officials and to
remind them that it was our decision to settle on an
appropriate time to move Ms. Z into permanent housing.
Transition to Permanent Housing
Lydia and I fostered an excellent working relationship with
social workers from the supportive housing program. We
agreed that one social worker and one nurse from the
housing program would visit Ms. Z in shelter weekly for at
least 2–3 months before she was moved out of shelter. We
hoped that Ms. Z would be able and willing to develop a
relationship with either staff member from the housing
program. She was always cordial and pleasant, but she made
clear that she was not interested in their housing as she was
living in her own ‘‘house.’’ These interactions highlighted
the challenging aspect of the case, which was to get Ms. Z to
agree to accept a housing option. We knew the inherent
challenge, given her rich fantasy life, that accepting such an
option would counter her belief systems, and we appreci-
ated the protective functions shelter life and the building
itself had provided her. We knew that she would fiercely
resist any threat to that stability and further traumatization,
and we feared that the communicative network that had
123
 Author's personal copy
been carefully established would break down. As Pao
(1983) states, ‘‘with schizophrenic patients the building-up
process is, as a rule, much more strenuous, and once the
breakdown in connectedness occurs, it may well be final’’
(p. 154). The delicate dance had begun between our con-
sistent validation of Ms. Z’s experiences and belief systems,
on the one hand, and our advocacy for her consideration of
permanent housing options, on the other. Lydia decided that
the belief system worth challenging was Ms. Z’s belief that
she owned the building that housed the shelter.
In the service of building the therapeutic relationship, we
had initially met with clinical neutrality Ms. Z’s belief that
she owned the shelter. However, the shift from neutrality
and curiosity to actively question its veracity began. The
function of this belief seemed to be provision of a sense of
safety and security (despite Ms. Z’s fear of being kid-
napped). A shift in her thought that she owned the building
was essential to moving her into permanent housing. We
knew that her belief that she owned the building was
completely in line with other grandiose beliefs that she held
and that it helped her maintain her sense of self-importance
in the world. The new plan was to gently challenge her
ownership of the building. We were aware that a challenge
to her sense of omnipotence could lead to a disruption in the
relationship and further fragmentation of the self. The
process of respectful, yet firm challenge to her belief system
resulted in resistance that, interestingly, seemed to primar-
ily manifest in her relationship with Lydia. Ms. Z was more
closely related to Lydia than with anyone else she had
encountered in at least 20 years.
This critical juncture resulted in Ms. Z’s openness to
considering an alternative to living in the only building she
had known for many years. She continued to protest Lydia’s
questioning her belief system, but the intensity and tena-
ciousness of her protest diminished. After nearly a year, it
seemed a good time to set in motion a date to move Ms. Z out
of perpetual homelessness into permanent and supportive
housing. A date was set for her move-out, and although she
protested every day leading up to the date, the team believed
that she would agree to leave shelter. When the day arrived,
Ms. Z continued to protest, but ultimately agreed to leave
shelter simply stating, ‘‘If my social worker thinks it is a good
idea, maybe I’ll go.’’ She made it clear that the only reason she
agreed to move out of shelter into permanent housing was her
trust in Lydia, highlighting the importance of the therapeutic
relationship (Walsh 2010). Ms. Z’s successful move into
permanent housing left behind her long life of homelessness.
Discussion
Coercion exists on a continuum and may range from
friendly persuasion to interpersonal pressure to control of
123
Clin Soc Work J
resources to use of force (Dennis and Monahan 1996).
There is the issue of beneficent coercion for people whose
experiences may be at the extreme end of psychosis and
who experience great suffering because of their untreated
symptoms. However, these experiences may render people
incapacitated and unable to comprehend and appreciate the
severity of their illness and to know that they have the right
to ethical and humane treatment (Bazelon 1975). On the
day she moved, Ms. Z pleaded with us to take her back to
the shelter. It was a sad, poignant moment in our work with
her as it was clear that she subjectively experienced our
‘‘success’’ as a coercive move out of the only place she
knew as home for many years. The moment was quite
challenging, but of course we left her in her new home. We
visited her the following day and approximately six more
times in the ensuing 2–3 months, tapering off as time
passed. We remained in contact with the social work team,
and 3 years following Ms. Z’s move out of homelessness,
she remains in permanent, supportive housing. Three years
following her move, Ms. Z continued to live in the sup-
portive housing program. Staff at the program describe her
very reserved and delusional, but continuing to take med-
ication and speak regularly with her social worker and
other staff members. She attends various groups, even if
she refuses to actively engage in any activity. In some
ways, Ms. Z experienced life in permanent supportive
housing similarly to her time in shelter; in the throes of
psychotic belief systems that preserves her grandiose sense
of self to protect against disintegration anxiety.
As a team, the struggle was to balance a number of
competing forces. These included Ms. Z’s legal right to
live in shelter as long as she remained homeless and her
right to refuse or engage in treatment. Upon my arrival at
the shelter, I made clear that housing was the new mandate
and that we would use resources to leverage housing for
shelter residents when appropriate. We struggled with
balancing the city officials’ pressure to move her quickly
and respecting a timeline that we thought would be more
suitable to Ms. Z. Ultimately we agreed that the coercive
elements in this case were appropriate even if, today, Ms. Z
would clearly disagree. There is an argument that since she
did not subjectively experience her life in shelter as being
homeless, our intervention only benefitted larger systems.
However, from an objective perspective, her life changed
for the better. She no longer lived with 100 other adults in a
dorm setting. She was no longer relegated to life as defined
by the shelter: when to eat, what time lights would be
turned on and off, which new resident slept a few feet from
her. Upon her move, she received a key to her room and
became, in the eyes of the law, a person with legal claim to
private property. Ms. Z could define her existence in any
manner she chose. Psychodynamically, it was clear that her
life would and probably could not change as dramatically
 Author's personal copy
Clin Soc Work J
as do the lives of many formerly homeless people, but the
potential for change in a permanent, supportive housing
environment exists for her for the first time in more than
20 years. How could we ethically let that opportunity pass?
For Ms. Z, attainment of permanent and supportive housing
became the most obvious structural intervention.
Conclusion
This vignette illustrates how self psychology is well posi-
tioned to help understand coping patterns into the experi-
ence of people who are chronically homeless. This is
achieved by a central tenet of self psychology; empathic
immersion. An empathic and experience-near perspective
is based on an understanding and appreciation of the per-
son’s thoughts and ideas, no matter how pathological they
may seem (Preston and de Waal 2002). An experience-near
perspective is one that views the world through a person’s
eyes to gain insight into the thoughts, actions, and behav-
iors from that person’s unique perspective (Rowe and Mac
Isaac 1989). It is through the slow buildup of consistent
interactions that trust between worker and client is estab-
lished and the client begins to believe that the worker may
have his or her best interests in mind. It is well documented
in the literature that establishment of the therapeutic alli-
ance is a critical component in the move of people who
either are or have been homeless into obtaining and
retaining permanent housing. Studies have shown that the
therapeutic alliance between the social worker/case man-
ager and the homeless person can help reduce symptom
severity and length of homelessness (Chinman et al. 1999,
2000; Klinkenberg et al. 1998).
Self psychology’s use of the empathic stance as its pri-
mary mode of observation allows the worker to understand
and appreciate the inner world of the chronically homeless
person and help elucidate the person’s full experience of
homelessness. This mode of observation allows for the
continued unfolding of self experience through the ambient
tone set by the worker, which builds the therapeutic rela-
tionship. It is the worker’s empathic understanding of the
homeless person’s experiences that allows for the full
expression of self experience, even in a life of homelessness.
This empathic immersion does not obscure objective inter-
pretations, but only enhances it, as the worker is in an
excellent position to weave into and out of the person’s
experiences to accurately reflect and interpret the wide array
of self-sustaining and maladaptive patterns of behavior.
Chronically homeless people do not typically suffer from
the levels of severity and persistence of untreated psychosis
experienced by Ms. Z. The vast majority of people who
experience chronic homelessness are not psychotic. While
people who are chronically homeless suffer from greater
mental health issues and substance abuse issues than people
who are episodically and transiently homeless, the main
issue remains the lack of affordable housing. The basic lack
of affordable and supportive housing is the primary con-
tributor to the large numbers of people who are homeless
despite the reallocation of housing resources for the
chronically homeless (O’ Flaherty 1995). In recent years,
with local, state, and federal governments aligning their
resources to end chronic homelessness, the overall number
of people who remain chronically homeless has seen a
moderate decrease (US HUD 2010).
In this paper, I provide a self psychological framework
for understanding how and why people who are chronically
homeless may remain homeless. I do not suggest that
chronic homelessness is, in itself, a pathology. Rather, it
hopes to enlighten homeless service workers to enable
them to better understand the motivations of people who
remain chronically homeless. Further studies are needed to
clarify the inner lives of these people, and the basic tenets
of self psychology provide a good fit for qualitative studies
directed to better understanding of the lives of chronically
homeless people.
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Author Biography
Daniel Farrell is the Vice-President of Programs at HELP USA.
Daniel is also an Adjunct Professor at the Hunter College School of
Social Work, a graduate from the New York Institute for Psychoan-
alytic Self Psychology and a doctoral candidate of Social Work at
New York University.
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