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Dealing with death in the homeless sector

This site is a repository for a variety of resources relating to a study undertaken between 2009 and 2010 exploring how homeless sector workers deal with and respond to death and trauma of people with whom they work. The site hosts a video of homeless sector workers talking about their experience, handouts and articles relating to the study.

Lakeman, R. (Producer). (2010). Expecting the unexpected. [video] Retrieved from

A 16 minute high definition streaming video in which homeless sector workers discuss their experiences dealing with the deaths of homeless people.

Lakeman (2010) Dealing with death in the homeless sector: Quotations and questions relating to death and trauma in the homeless sector. Self-Published

'Working with people to improve their health, welfare and wellbeing can be exceptionally rewarding. These rewards can be even greater when working with vulnerable people or those who for complex reasons have not been reached or helped by mainstream services. One can make a great difference to those who find themselves homeless or disconnected from other natural and health sustaining supports. Our hopes and dreams for people's recovery, or to improve their situation are often realized and this is wonderful. However, sometimes they are not, and few events wound and damage our professional esteem than the death of a service user whom we hoped to help and could not. Such events, and more particularly, the ways they can wound and adversely effect the worker are rarely discussed. This project stemmed from a personal interest in how people deal with traumatizing aspects of work.. I undertook a study exploring the processes involved in dealing with the death of service users, and this package of resources (video, slides and discussion documents) is a way of sharing some of the findings. I hope that the direct quotes of people from the homeless sector and the questions posed in this document will stimulate discussion, assist in service improvement and help people cope with the death of service users so they can maintain hope, move on and continue to provide a necessary and good service to people without being harmed in the process.'

This resource is a product of a collaboration between Dr Richard Lakeman and Dr Evelyn Gordon of Dublin City University and numerous people who work in the homeless sector in Ireland including the initial research participants (quoted throughout, but whose identities remain anonymous), their employers, and advisory group who generously gifted their time (Ciaran Maquire, Erin Nugent, Jimmy Goulding, Grainne Lynch, Barbara Corcoran, Niamh Cullen, Susie O'Keeffe, Anthony Bagnall and Stephen Doyle). This project has been supported by the Homeless Agency and a grant from ESB ElectricAid Ireland.

Lakeman, R. (2011). How homeless sector workers deal with the death of service users: A grounded theory study. Death Studies, 35(10), 1-24.

Homeless sector workers often encounter the deaths of service users. A modified grounded theory methodology project was used to explore how workers make sense of, respond to, and cope with sudden death. In-depth interviews were undertaken with 16 paid homeless sector workers who had experienced the death of someone with whom they worked. Transcripts of interviews and field notes were analyzed using the constant comparative method and a theory that described the positive framing of death emerged. Dealing with death and trauma is not something that most workers expect when they begin work but exposure to the death of a service user heightens expectations that other service users may be harmed. How workers cope or positively frame death depends on several interlinked processes. These include how the death is encountered; how the worker and others mark the death; and the extent that the vulnerability of self, peers, and service users is recognised and responded to. Successfully framing death enables the worker to continue working in the sector whilst maintaining enthusiasm for the work and compassion for service users.

Lakeman, R. (2010). Maintaining wellbeing when a service user dies. The British Journal of Wellbeing, 1(2), 28-33.

People who work with the homeless are likely to be exposed to the trauma and death of services users. A theory of how workers deal with sudden death was developed through grounded theory analysis of in-depth interviews with people who had worked in the sector. Maintaining well-being involves positively framing the life and death of the service user and homeless sector work. This involves a number of related processes and factors, such as the nature of the encounter with death, responding to death emotionally and procedurally, and being involved in the marking of death and memorials of the person's life. Being able to recognise and respond to the vulnerability of self, peers and service users is also important. Successfully framing death enables workers to stay in the sector while maintaining their own wellbeing, enthusiasm for their work and compassion for users.

Lakeman, R., & Fitzgerald, M. (2008). How people live with or get over being suicidal: a review of qualitative studies. Journal of Advanced Nursing, 64(2), 114-126.

Aim This paper is a report of a review of qualitative research to address how people live with suicidality or recover a desire to live. Background. Suicide is a pressing social and public health problem. Much emphasis in suicide research has been on the epidemiology of suicide and the identification of risk and protective factors. Relatively little emphasis has been given to the subjective experiences of suicidal people but this is necessary to inform the care and help provided to individuals.
Data sources Electronic searches of CINAHL Plus with full text, Medline and PsychArticles (included PsycINFO, Social Services Abstracts and Sociological abstracts) were undertaken for the period from 1997 to April 2007. In addition, the following journals were hand searched (1997–2007): 'Mortality', 'Death Studies’, 'Archives of Suicide Research’ and 'Crisis: The Journal of Crisis Intervention and Suicide Prevention’.
Method A systematic review of the literature and thematic content analysis of findings. The findings were extracted from selected papers and synthesized by way of content analysis in narrative and tabular form.
Findings Twelve studies were identified. Analysis revealed a number of interconnected themes: the experience of suffering, struggle, connection, turning points and coping.
Conclusions Living with or overcoming suicidality involves various struggles, often existential in nature. Suicide may be seen as both a failure and a means of coping. People may turn away from suicide quite abruptly through experiencing, gaining or regaining the right kind of connection with others. Nurses working with suicidal individuals should aspire to be identified as people who can turn people’s lives around.

Lakeman, R. (17-21 Oct 2011). Making sense and moving on: Dealing with the death of a service user. Paper presented at the World Congress of the World Federation for mental health, Cape town International Convention Centre, South Africa.

For anyone in a helping role, there are few events more professionally wounding than the unexpected death of a service user. People who work with homeless service users are often exposed to the trauma and death of those whom they try to help and this can take a toll both professionally and personally. This presentation outlines findings from a grounded theory study which explored how people in the homeless sector make sense and move on from the death of a service user and ultimately maintain a positive view of their work. A brief video of workers talking about their experience was developed to assist workers in the field better prepare to deal with death. The stories of these workers will have resonance for anyone who encounters the death of service users in their professional lives. This presentation encompasses an outline of the theory, a screening of the video and a brief discussion of its evaluation.

Lakeman, R. (4-7 Oct 2011). Wounding Healing: Understanding the process of dealing with trauma and death in the helping professions. Paper presented at the "Swimming between the flags?" The Australian College of Mental health Nurses 37th International Mental Health Nursing Conference, Marriott resort, Surfers Paradise, Gold Coast.

Jung suggested that ones own suffering and vulnerability contribute to the capacity to heal others. However, sometimes service users are not healed but fail to improve, experience trauma and even die. Few events are more wounding for professionals than failing to protect a service user from preventable harm or failure to intervene to prevent death. The toll of vicarious and direct trauma can be immense and challenge the capacity of the helper to continue in a genuinely helping role. There are few markers or flags to help navigate the best course and the helper may find themselves 'all at sea' or a long way from safe shores. Drawing on the findings from a grounded theory study exploring how homeless sector workers deal with the deaths of service users, this presentation considers the issue of trauma and the processes by which would-be helpers might deal with death and trauma, acknowledge and treat their wounds and continue in helping roles.

Lakeman, R. (2009, 3rd-5th September). Has anyone seen Paddy? Making sense of sudden death in the homeless sector. Paper presented at the British Sociological Association Medical Sociology Group 41st Annual Conference, University of Manchester.

Few groups experience such high levels of morbidity and mortality as the homeless. Those that work in the front-line delivering health, welfare and other services to homeless populations are likely to be confronted by the death of service users. Death may be intentioned (as in suicide), unintentional (as in accidental overdose), the end point of some pathological process (as in liver or renal failure), entirely unexpected, and often violent. Working with populations with such high risk profiles for sudden death and direct or vicarious exposure to such traumatic events taxes the coping resources of frontline staff. This presentation presents some preliminary findings from a grounded theory study which explored how front line staff cope or deal with sudden death of those whom they aim to help. Particular emphasis is given to social processes people engage in to deal with death and to how discourses around homelessness and addiction are drawn upon and reinforced through these processes.

Walsh, J., Lakeman, R., & McGowan, P. (2009, 15-17 April). Outside in to inside out: The assimilation and attenuation of the service user movement. Paper presented at the Alternative futures and popular protest (14th International Conference), Manchester Metropolitan University.

Here we extrapolate and expand on arguments made in a published paper written by the three speakers (Lakeman, McGowan and Walsh, 2007). During the 1960s and 1970s the mental health service user movement was united with other human rights movements associated with the emancipation of women, racial equality and the general promotion of liberty. Public demand to reform the care and treatment of patients was underpinned by principles of universal human rights and equality. The public gauze turned towards mental hospitals/asylums and other social institutions (outside-in) with an increasingly critical eye. Over time partnerships and collaborations between service users and public health bodies have been established whereby change is promoted from within services (inside-out) and this apparent collegial/collaboration between service users/staff lends a veneer of respectability to mental health services. The hard edge of the service user movement has been 'softened' as an ever increasing number of activists have moved from the streets into the board room (often into paid positions). Barker and Buchannan-Barker (2001) suggest that a consequence of this might be that service users have become ineffectual in their attempts to instigate change as they have become assimilated into a system they once resisted. Campbell (2001) suggests that service users lost their sense of citizenship during this period of transition and for many service users their social position, prospects, and health outcomes are unimproved since the era of the asylum. We point out that a hierarchy of power and influence has evolved between the 'professional’ and ordinary service user that parallels that of the health 'professional’ and service user. We believe that the power to resist and instigate change has been weakened and that there remains a place for public protest independent of services and would-be gurus.

Barker P, Buchanan-Barker P (2003) Death by assimilation. Asylum. 13, 3, 10-12.
Campbell, P (2001) The role of users of psychiatric services in service development - influence not power. Psychiatric Bulletin. 25 (3) 87-88.
Lakeman, R., McGowan, P., and Walsh, J (2007) Service users, authority, power and protest: A call for renewed activism. Mental Health Practice, 11 (4) 12-16

Lakeman, R. (2010, 7-9 April). Working on the margins: Confronting death in the homeless sector. Paper presented at the British Sociological Association Annual Conference: Inequalities and Social Injustice, Glasgow Caledoinian University.

Working with homeless people entails working on the margins of society. Workers are frequently exposed directly and vicariously to the many traumas, indignities and injustices that characterises the lives of homeless people. Workers are confronted by marginalised lives and also frequently the sudden deaths of service users. The marginalised positions of both homeless person and homeless sector worker is a complicating factor that colours the experience and challenges the capacity of the worker to make sense of the death, work through the trauma and frame the death and ongoing work in a positive way. This presentation derived from a grounded theory study of homeless sector workers and sudden death will explore how workers resolve the problem of framing death and moving on drawing particularly on the narratives of homeless sector workers themselves.

Lakeman, R. (2007). Book Review: 'Humanizing Psychiatry and Mental Health Care: The Challenge of the Person-centred Approach'. Journal of Psychiatric and Mental Health Nursing, 14, 827-829.

This year marks the twentieth anniversary of the death of Carl Rogers and the commencement of my nursing training. It was during my training that I was first formally introduced to the philosophy and techniques of 'person centred' counselling. Indeed, for years I thought unconditional positive regard and counselling were synonymous. Our course was saturated with Roger’s philosophy and a number of my most inspiring teachers regarded Rogers with quasi-religious awe….

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