The International Journal of Psychosocial Rehabilitation

Introduction
The homeless population not only lack adequate housing, but experience great difficulty engaging with health providers due to negative past health care experiences, financial hardship, limited access to transport and limited knowledge of available health care services (Johansen et al., 1999; Lynch, 2004; Randolph, Blasinsky, Leginski, Parker, & Goldman, 1997; Commonwealth Advisory Committee on Homelessness, 2001). In addition, the prevalence of mental disorders in homeless people is four times higher than that of the general Australian population, 81% of homeless women and 72% of homeless men having at least one mental disorder (Teesson, Hodder, & Buhrich, 2004).  This population is also at increased risk of experiencing medical problems, substance abuse and dual diagnosis, each of which can contribute to prolonged periods of homelessness (Chamberlain & Johnson, 2001; Commonwealth Advisory Committee on Homelessness, 2001; Johansen et al., 1999; Lynch, 2004; Randolph et al., 1997). These psychosocial barriers and negative experiences result in a reluctance by homeless people to engage in traditional forms of treatment (Johansen et al., 1999; Morse, 1999). Services for the homeless, who have been described as “markedly mistrustful and suspicious of service providers, and (to) highly value their autonomy” (Morse, 1999), thus need to implement creative and innovative approaches to service provision.
 
There are a number of mental health service provision models that are relevant to service provision to homeless populations. These include the assertive community treatment model, the recovery approach and the therapeutic alliance model. Each of these approaches is reviewed briefly below.
 
Assertive community treatment is characterised by the use of multidisciplinary teams that share responsibility for clients (Johansen et al., 1999; Marshall & Lockwood, 2006; Morse, 1999; Rosenheck & Dennis, 2001; Tibbo, Joffe, Chue, Metelitsa, & Wright, 2001). Assertive community treatment teams provide a temporally flexible service that delivers treatment in a direct and assertive manner with the primary treatment goal of reduced psychiatric hospitalisation (Bruce, 2005; Dixon, Krauss, Kernan, Lehman, & De Forge, 1995; Johansen et al., 1999; Marshall & Lockwood, 2006; Morse, 1999; Rapp & Goscha, 2004; Rosenheck & Dennis, 2001; Tibbo et al., 2001). There is an extensive body of research supporting the efficacy of employing this treatment model with homeless clients experiencing severe mental illness (Dixon et al., 1995; Johansen et al., 1999; Marshall & Lockwood, 2006; Morse, 1999; Rapp & Goscha, 2004; Rosenheck & Dennis, 2001; Tibbo et al., 2001). Assertive community treatment clients experience reduced frequency and duration of hospitalisation and reductions in symptom severity (Burns & Santos, 1995; Howgego, Yellowlees, Owen, Meldrum, & Dark, 2003; Johansen et al., 1999; Rosenheck & Dennis, 2001). Additionally, assertive community treatment is associated with higher levels of client engagement, client satisfaction, daily living skills, vocational skills, quality of life, social skills and treatment acceptance (Gerber & Prince, 1999; Herincky, Kinney, Clarke, & Paulson, 1997) and clients are more likely to be employed, living independently and sustaining housing (Marshall & Lockwood, 2006; Rosenheck & Dennis, 2001).
 
Recovery has been defined as “a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with the limitations caused by illness” (Anthony, 1993). The recovery approach thus focuses on the lived experience of mental illness and the ability to restore life’s hope and meaning (Anthony, 1993; Coodin Schiff, 2004; G. Deegan, 2003; P. E. Deegan, 1988; Jacobson & Curtis, 2000; Young & Ensing, 1999). In a recovery oriented mental health service clinicians are responsible for the facilitation of goal development, symptom reduction, role functioning and self development, advocacy and crisis intervention (Anthony, 2000; Jacobson & Curtis, 2000). When an individual’s functional ability is improved to an extent that impairment, dysfunction or disability is ameliorated, it may be said that the individual has experienced recovery (Anthony, 1993). 
 
A therapeutic alliance is formed when knowledge from lived experience is assimilated with professional knowledge and the combined knowledge base enables the development of a collaborative, recovery oriented treatment relationship where clients are active participants in treatment decisions (Coodin Schiff, 2004; P. E. Deegan, 1988; Glover, 2005; Lester & Gask, 2006; Roberts & Wolfson, 2004). Development of a therapeutic alliance thus supports a recovery focused approach to mental health case management, empowers clients in the therapeutic process and provides a contextual foundation to enable change towards recovery goals.
 
There are numerous social, psychological, emotional, and environmental factors that influence the development of a therapeutic alliance (Bambling & King, 2001; Bordin, 1979; Chinman, Rosenheck, & Lam, 1999; Coodin Schiff, 2004; Hewitt & Coffey, 2005; Howgego et al., 2003). These include the personal characteristics of the therapist and the client, the therapist’s unique skills, perspectives and competencies and the client’s level of social support and education (Chinman et al., 1999; Hewitt & Coffey, 2005; Howgego et al., 2003).  However, factors such as psychotic behaviour and substance abuse may impair a client’s ability to develop a therapeutic alliance (Chinman et al., 1999; Hewitt & Coffey, 2005) due to abnormalities of thought and perception and reduced motivation (Chinman et al., 1999).
 
Research has shown that an effective therapeutic alliance has the ability to directly influence treatment outcomes for clients with a mental illness (Bambling & King, 2001; Bordin, 1979; Hewitt & Coffey, 2005; Howgego et al., 2003; Martin, Garske, & Davis, 2000).  Although the development of a therapeutic alliance is often particularly difficult with long term homeless individuals with a mental illness, once the initial bond is achieved their commitment is often stronger than those who have experienced only short periods of homelessness (Chinman et al., 1999).
 
Mental Health Service Provision for the Homeless: New Directions
The Homeless Health Outreach Team (HHOT) is part of the Inner North Brisbane Mental Health Service and operates within the Royal Brisbane and Women’s Hospital Division of Mental Health. The HHOT incorporates assertive outreach, interagency collaboration and a multidisciplinary team approach to best meet the primary, mental health and dual diagnosis needs of the homeless population it services. Established in 2006, the Team addresses the challenge of developing effective service delivery to the homeless community by providing mental health, drug and alcohol, dual diagnosis and primary health care services to this community in an outreach context.
 
In order to provide adequate and effective services, the HHOT recognised the need to address the numerous and significant barriers to engagement that exist for homeless people. Identified barriers include the high prevalence of mental illness, trauma, substance abuse, intellectual and physical disability, ethnic minority status,  incarceration and institutionalisation experienced by the homeless population. Often these issues present comorbidly and compound the risk of disengagement from support services. It was therefore hypothesised that the intensive, team oriented approach of the assertive community treatment model could provide the structural basis for a service delivery method that would have the development of the therapeutic alliance at its core. Recovery goals previously unattainable due to the aforementioned barriers would thus be enabled via an effective therapeutic alliance providing homeless clients with the opportunity to desensitise and learn skills to minimise the barriers to service access. Fostering and supporting an enduring therapeutic alliance was thus seen as a means to enable access to clinical, therapeutic and welfare services as appropriate to the individual’s recovery.
 
Support Enabling Active Recovery (SEAR)
 
The Support Enabling Active Recovery (SEAR) model for service delivery was designed by the HHOT to address the above aims and to enable the re-engagement of homeless people previously disengaged from services. The SEAR model incorporates assertive community treatment and employs a multi layered systematic approach that supports clinicians as they support their clients. The critical element of the SEAR model is the supported therapeutic alliance between the client and the key clinician, which is supported by an integrated network of stakeholders as detailed in Figure 1.

Figure 1: Support Enabling Active Recovery (SEAR) Model

 
A key aspect of disengagement in populations with complex lifestyle issues and co-morbidity is the involvement of multiple service providers, which can be perceived by the client to be superficial and overwhelming. Under the SEAR model, the involvement of the supplementary clinician and clinical specialists is mediated by the key clinician, as illustrated in Figure 1. This strategy streamlines service provision, manages the risk of disengagement and increases the likelihood that the client will remain engaged with the key clinician until recovery goals have been met. The support provided by the supplementary clinician and the clinical specialists is thus employed to facilitate the development of an enduring therapeutic alliance between the client and the key clinician. The SEAR model also provides access to the treating team for the client’s significant others, whilst the key clinician is supported by the internal clinical team and by an external structure that may include government and non government service providers.
 
Elements of the SEAR Model
The key criterion for implementation of a SEAR based therapeutic intervention is the client’s motivation to attain at least one goal, which may or may not be congruent with the goals identified by the therapeutic team, but which allows a central focus for engagement and purpose within the therapeutic context. Exclusion criteria for engagement within a SEAR framework have not yet been defined. However, if the client has difficulty forming bonds the therapeutic team employs a persistent and creative approach to evaluate their potential to engage therapeutically prior to making a final determination of their suitability for a SEAR based intervention.
 
Initial engagement with the client is through assertive outreach, during which period individual clinicians are introduced to the client as a means of determining which team member should become the key clinician. Clinician suitability for this role is also based on their expertise, interests and individual characteristics (e.g., age, gender and culture) in order to enable the ‘best fit’ with the client. If a therapeutic alliance is not successfully developed with one clinician, additional clinicians will be introduced to the client until ‘best fit’ is achieved. Thus, alliance formation between client and clinician determines the role of key clinician. The key clinician does not necessarily have to practice within the lead agency, as lead agency clinicians can assume supplementary and specialist roles whilst coordinating care as appropriate via the key clinician.
 
The supplementary clinician has graded interaction with the client. Optimally, the supplementary clinician has specific expertise related to the client’s identified goals, therapeutic issues and/or demographic background. The purpose of the supplementary clinician is twofold. Firstly, they undertake the role of key clinician in the key clinician’s absence. This guarantees continuity of care, ensures ongoing engagement with the service and provides optimum management of risk and other complex issues. Secondly, the supplementary clinician provides additional clinical knowledge and perspective, thus providing a venue for informal clinical review and interdisciplinary support.
 
The role of significant other is allocated to people who provide support or who have significant input into the client’s life. This may include, but is not restricted to, family and friends, paid or unpaid carers, and non specialist agency service providers. Unless therapeutically contraindicated, the role of significant others is viewed as a critical component of the SEAR model. It is specifically recognised that a client’s significant others are likely to continue a sustained relationship with the client well beyond recovery and the cessation of case management. With this goal in mind from the beginning of the supported recovery process, the significant others are provided with support and education by the SEAR treating team to enable them to support the client after case management has ceased.
 
Specialist clinicians are temporary members of the team recruited to provide goal-specific interventions and support to the client, their significant others, the key clinician and the supplementary clinician. They provide specific skills and resources to enable the key clinician to implement interventions which might normally be initiated by external specialists or by other agencies to which client barriers preclude access. Their input is determined by the client’s specific needs at the time of engagement and may include expertise provided by psychiatrists, drug and alcohol workers, child and youth workers, primary health care specialists, allied health professionals and multicultural health specialists. Specialised support may also be sought from government and non government agencies representing child safety, housing, disability, corrections and social services.
 
The SEAR Model in Operation
As selection of the key clinician is based on the quality of the therapeutic relationship rather than clinician or service availability, the issue of individual clinicians being more frequently nominated as key clinicians and thus potentially carrying too high a caseload must be carefully managed. This is achieved by ensuring that staff characteristics and skills are aligned to the demographic characteristics and needs of the serviced community. For example, ensuring the availability of male and female clinicians of varying ages and possessing a broad range of skills, expertise and interests will optimise the chances of individual clients forming effective therapeutic relationships.
 
Whilst the core treating team consists of all team members relevant to a specific issue at any point in time, the concept of a more broadly based ‘interagency treating team’ is central to the SEAR model. Depending on the specific clinical and quality of life issues being faced by a client, this larger team may include mental health specialist clinicians and representatives of external relevant agencies such as social services, in addition to the client, their significant others and the key and supplementary clinicians.
 
The core premise in implementing an interagency treating team is that representatives of all agencies servicing a client are part of the team. Whilst this presents a subtle difference in approach when compared to standard practice, the practical implications are significant. Although this coordinated approach may require more interagency communication than standard practice and more clinical time to establish, there are very significant benefits that flow from the development of streamlined and timely access to external agencies. Where the client has been disengaged from services the improved access enables barriers to be broken down and provides opportunities for the client to acquire skills that will enable future independent service utilisation. Cohesive interagency team interventions can also be initiated at the critical time of need rather than being delayed by inefficient interagency processes, thus saving case management time and facilitating efficient outcomes for each agency. 
 
Co-case management is a feasible option to address the needs of the homeless, particularly in light of the inherent risks associated with their physical environment, the complexity of their lifestyle issues and the acuity of their mental and other health concerns. The SEAR model therefore employs co-case management as a strategy to support enduring therapeutic alliances that will facilitate ongoing client engagement and thus improve health and quality of life outcomes. Co-case management ensures continuity of care, provides a forum for multidisciplinary clinical judgement, creativity and perspective, and is an effective risk management strategy. Through co-case management and other strategies the SEAR model provides clinicians with ongoing clinical review and debriefing opportunities, and the opportunity to manage dynamic therapeutic relationship issues and complexities by sharing therapeutic roles. It also provides newer graduate clinicians with opportunities to gain critical skills and experience in complex case and risk management through shared involvement in cases with experienced clinicians. Further, the SEAR model provides a forum, via the supplementary and specialist clinician roles, for clinicians to utilise discipline-specific skill sets that are not often afforded specific roles in generically staffed mental health teams.
 
The efficient provision of the structure and support required to facilitate co-case management is a core issue in the operationalisation of the SEAR model. The essential doubling of caseloads for individual clinicians is managed by sharing caseloads and responsibilities via daily workload reviews. A daily intake and review meeting at which all significant clinical issues from the preceding day are discussed and daily management plans are allocated involves the entire HHOT team in clinical case review. The team addresses any crises and acute issues requiring immediate intervention and designates clinical duties based on client need. As each clinician is key clinician and supplementary clinician to a number of clients the team operates as a dynamic web of clinical service providers, the form of which changes on a daily basis depending on the clinical needs of the clients. The ongoing communication between team members, coupled with the flexible service delivery approach, facilitates timely and responsive crisis and acute care interventions.
 
The essence of the SEAR model is the dynamic process by which the therapeutic alliance between the client and the key clinician is employed to facilitate progress towards recovery goals and access to services where barriers previously existed. The trust established by the therapeutic bond enables the key clinician, with the assistance of team members, to intensively support engagement with health services and government and non government support agencies by providing the client with opportunities to desensitise and to acquire skills that minimise past barriers to service access and recovery.
 
Conclusions
The purpose of this paper has been to introduce the SEAR model as an alternative recovery based framework for service delivery to marginalised populations. Although formalised inclusion and exclusion criteria are yet to be formulated and implemented, SEAR has been successfully established within a major government health service provider to the homeless as a framework for service delivery and as a model of assertive community treatment. A formal evaluation of SEAR’s effectiveness is now required in order to determine its efficiency, efficacy and sustainability as a practical system of service delivery to marginalised populations. Evaluation of the model’s effectiveness for people experiencing significant social disengagement, negative psychotic symptoms, severe depression or unremitting positive psychotic symptoms is required, as is an assessment of the applicability of the SEAR model to other disengaged and/or marginalised groups such as refugee, dual diagnosis, transcultural and mainstream mental health populations. Ultimately, the extent of the SEAR model’s applicability and efficacy can only be tested by implementing and evaluating it against current models of service delivery across the range of potential application settings.
 
The SEAR model offers a distinct alternative to current models of service provision, which accommodates recovery focused service delivery and provides a more holistic therapeutic approach for the homeless population. However, understanding and implementing the SEAR model will require a significant shift in perspective from traditional mental health service delivery models. Debate, discussion and collaboration are therefore to be encouraged. 
 
Enabling recovery can be as simple as providing “two bucks for the bus”. Metaphorically, this equates to providing “currency”, in the form of stable therapeutic relationships and mediated access to service providers, which in turn facilitate access to the “vehicle”, that is, the skills to engage and connect with the wider community, that ultimately “transports” the client towards recovery. 

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