"Jay S. Levy's book is essential reading to both people new to the movement to end homelessness and folks who have been in the trenches for many years. Learn how to do effective outreach with the chronic homeless population, and the ins and outs of the Housing First model. The personal stories and the success cases will give inspiration to work even harder to help both individuals and for ending homelessness in your community."
Michael Stoops, Director of Community Organizing
National Coalition for the Homeless, Washington, DC
Learn more at www.JaySLevy.com
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Pretreatment Considerations for Homeless Outreach & Housing First
"The most important human endeavor is the striving for morality in our actions. Our inner balance and even our very existence depend on it."
– Albert Einstein (1950)
Over the past 20 years, efforts have become more focused toward significantly reducing, or perhaps even ending chronic homelessness among unaccompanied adults. This began on a national level with the development of outreach teams across the US, which are currently supported by both federal and state dollars – most notably via PATH outreach teams (Projects for Assistance in Transitions from Homelessness) and Healthcare for the Homeless projects. Tireless advocacy by groups like the National Coalition for the Homeless and the National Alliance to End Homelessness have been crucial toward galvanizing support for proven practices and policies necessary to end or significantly reduce homelessness. These efforts have continued, and in many respects have matured via the US Interagency Council on Homelessness and the Department of Housing and Urban Development (HUD). Targeted federal and state funds have been used to develop affordable housing resources, Housing First initiatives, and the formation of community based regional and/or Continuum of Care networks. Communities and larger geographical regions now have specific plans that address resource, access and prevention issues, as well as supporting and utilizing research to inform best practices. In many places, outreach teams and shelter staff have direct and improved access to housing resources. Some strides have been made toward providing housing plus support services for those most in need. Nevertheless, serious challenges remain and every day the health and safety of many people experiencing homelessness are at considerable risk.
Throughout my career, I have worked very closely with outreach teams, shelter staff, residential programs, and Housing First initiatives. There is a fundamental relationship between Homeless Outreach and Housing First. Homeless Outreach is an essential step toward meeting people experiencing long-term or episodic (multiple episodes) homelessness. It is the means for developing the critical trusting relationships necessary for supporting transitions to affordable housing and/or needed treatment. The greater our success in implementing Housing First, the more our need for high quality outreach-based support services that promote housing stabilization. We have seen a major shift over time. Some of the formerly hardest to reach folks are now successfully housed, but still have chronic medical, mental health, and substance abuse issues that negatively impact their overall sense of health and wellbeing, including their ability to effectively connect with their neighbors and community.
Whether we are providing Homeless Outreach or housing stabilization services for people with longstanding difficulties, the central challenges remain the same. It all begins with the formation of a trusting relationship. Whether outreach is done on the streets or in an apartment, the helping process is always interpersonal. Our hope is that two people, who are often from vastly different worlds and experiences, can come together to successfully work on mutually agreed goals to bring about positive change. It is important that we recognize that it is the client who has ownership of the objectives that are at the center of our work. Ultimately, much depends on building a trusting relationship that respects client autonomy, while developing a common language based on the words, ideas, and values of the people we are trying to help. This is at the foundation of a pretreatment perspective that can guide the outreach counseling process. A pretreatment approach is particularly relevant for people who are either formerly or currently among the long- term homeless and highly vulnerable, and who are also reluctant to participate in treatment and/or recovery based options. Its applications are far reaching and useful with an array of hard to reach and underserved populations that are in dire need of additional resources and services. Pretreatment is defined (Levy, 2010) as an approach that enhances safety while promoting transition to housing (e.g. Housing First options), and/or treatment alternatives through client centered supportive interventions that develop goals and motivation to create positive change.
Five basic pretreatment principles (see Table 1 on p. 5) guide our work:
1. Promote Safety – Apply crisis intervention and harm reduction strategies
2. Relationship Formation – Promote trust via stages of engagement
3. Common Language Construction – Develop effective communication
4. Facilitate Change – Utilize Stages of Change Model and Motivational Interviewing techniques
5. Ecological Considerations – Support the process of transition and adaptation.
An outreach model based on a pretreatment philosophy affords us the opportunity to become both interpreters and bridge builders. It is critical that we provide clients with real options that can be fully considered, as opposed to pre-programmed choices that don't respect their individuality. Potential resources and services are therefore reinterpreted and reframed so the client can more fully consider these options and their potential impacts. This is the first major step toward building a bridge to needed resources and services, including housing and treatment options. It is a bridge consisting of a safe and trusting relationship between worker and client, as well as a common language that fosters a communication of shared words, ideas, and goals. Developing a client- centered relationship and providing essential community resources and services are the mutual goals of Homeless Outreach workers, Housing First staff and their clients. In essence, these are the central challenges that are shared by both the Homeless Outreach and Housing First communities.
This book explores not only the shared mission of Homeless Outreach and Housing First, but also highlights what we've learned. Basic truths are reinforced, like the importance of a client-centered relationship, the need for affordable housing, and the necessity of combining it with support services, and meaningful structure or activities that promote housing stabilization. It also explores both subtle and intricate aspects of helping by applying pretreatment principles of care. I draw upon my experiences doing Homeless Outreach, supervision, and instituting Housing First initiatives to illustrate the challenges, success stories and the many lessons learned. Case illustrations help to bring the material to life and can hopefully start an authentic conversation on how homelessness and our attempts to abate it are really a microcosm of the human condition. Beyond survival, we seek meaning and a greater sense of connection to our world. For people experiencing long-term homelessness, positive relationships and stable housing can be the pretreatment pathway toward achieving this reality, thereby reducing the risk of unforeseen trauma, serious injury, or premature death. The compelling narratives of Ronald, Lacey, Anthony, Julio, Janice and Michael demonstrate this, as well as provide a striking reminder of our own human frailty. I hope that these stories will help connect us to the plight of our homeless neighbors, and thereby serve as a call to action. Even though homelessness continues to take a heavy personal and societal toll, I remain optimistic that with proper guidance, dedication and advocacy, great things can and will be accomplished.
Ronald's Narrative: The Original Housing First
"Think of it this way, if you had valuable information I mean something really valuable like the cure to a deadly disease. What would others do to bring you down?"
Homeless Outreach and the Seeds of Housing First
During the autumn of 1992, before the term Housing First was widely used, I did outreach at a homeless shelter in Boston, Massachusetts. This is not to say that outreach counselors did not periodically try to quickly house chronically homeless individuals with significant disabilities including untreated mental illness and addiction. We did, and the results were decidedly mixed. One could argue whether or not this was truly Housing First. After all, we didn't have prescribed housing stabilization services and the housing was not always subsidized or readily available. Instead, we simply did the best we could through our continued efforts to provide outreach and housing placement to those most in need. At the time, there was very little support and acceptance of this practice. We made the decision to prioritize housing out of our deep-seated concern for the most vulnerable among us. We grew tired of being told that our clients weren't ready to enter independent housing or didn't qualify for residential programs. People in dire need were turned away for not meeting eligibility requirements such as six months of continuous sobriety, or not matching the right diagnostic category. Other times, our clients adamantly refused to enter programs or participate in treatment and therefore remained homeless and at risk to a variety of major health issues. Throughout the many years prior to formal Housing First initiatives, outreach workers across America took chances out of necessity.
This is the story of the original Housing First, as put forth by numerous outreach workers and expressed through Ronald's narrative: how the best ideas can arise from the midst of our day-to-day challenges. As with any good story, we are taken on a journey that divulges much more than the title implies.
Ronald, an African American male in his mid-thirties, sat at the dinner table seemingly oblivious to the bleak and noisy environment of the homeless shelter. He slowly rocked his head forward and backward with a close-eyed grin and an impish laugh. He did this repeatedly, like some odd kind of ritual, while simultaneously finishing his snack of potato chips. Most of the chips made it into his mouth, though several crumbs escaped onto his straggly unkempt beard. I casually walked over to his table and pulled up a chair. Ronald continued with his repetitive behavior and showed no real response to my close proximity. I could smell a sour odor of alcohol and noticed the evidence of a recent outside nap: his partially torn and faded gray tee shirt had some old blades of grass mixed with small brown crackly leaves clinging to it. A bit more disturbingly, a small black bug quickly sprinted across Ronald's forehead before returning to the confines of his curly black hair. Despite feeling a bit reticent, I gave my best efforts to greet him in a friendly and non-threatening manner. For a brief moment Ronald responded with a one-word acknowledgement, before quickly resuming his focus on his internal world. Although I felt a little stuck, squarely in the pre-engagement phase (see Table 2 on p. 26), I was hopeful of beginning a new and interesting relationship. Ronald was definitely aware of my presence, but rather than make an attempt at forced conversation, I felt the best strategy was to try again on a different day. I visited the shelter three nights a week to provide outreach-counseling services, so there were bound to be other opportunities.
Over the next two weeks, I approached Ron on three separate occasions. My first two attempts met a similar fate. Ronald appeared much more interested in upholding his privacy, and showed little or no interest in conversing with me. My third approach was guided by the anonymous Homeless Outreach adage: "If you want to get to someone's head, begin with their feet." I offered Ronald a new pair of socks! This immediately got his attention. I introduced myself as a Homeless Outreach worker and asked Ronald if there was anything else he needed. Ronald smiled and said that he was all set, yet very appreciative for receiving the socks. I left him with a pamphlet that listed meals, shelters, clothes, and medical services for the immediate area. We successfully met the challenge of the pre-engagement stage (Levy, 1998, Levy 2000) by establishing an initial welcomed communication that promoted a sense of trust and safety.
Engagement and Contracting
During our next encounter, Ronald and I reviewed the pamphlet. He mentioned that he had been homeless for many years and already knew most of the area's service and resource options. He even cued me in on a meal program that was not listed. I thanked him for the information and promised to pass it on to others in need. At the end of our meeting, I quickly mentioned that we could see if he qualified for benefits ranging from food stamps to emergency assistance and Social Security. Ronald didn't say much, so I stated, "We could always talk about this or other ways of getting income at another time." Ron looked up and said, "That'd be fine." Though it wasn't very clear how he perceived my offer, further contact around assessing Ron's eligibility for benefits was a distinct possibility. At least our conversation ended with the expectation of further meetings. Our challenge, which is central to the engagement process (Levy, 1998, Levy 2000), was to form a mutually acceptable ongoing communication that promotes trust and respects individual autonomy, so that Ron could be empowered toward discussing and setting goals.
Approximately three days later, I approached Ronald at the shelter. He was once again sitting alone and rocking his body back and forth. He then slowly reached out his arm and appeared to pick up an imaginary small object (between his thumb and pointer finger) and proceeded to gently move it thru the air. I asked him what he was doing and he replied, "I am playing chess." I then asked him what piece had he moved and he responded in flawless chess language, "The white knight to queen-bishop's 3." Surprised and delighted by Ronald's apparent interest in chess, I asked if I could join him for the game's opening moves. We proceeded to play imaginary chess for two or three moves, at which point I had difficulty visualizing the position of the chess pieces on the board, though Ronald appeared enthralled. I then stated, "Perhaps one day I could bring in my chess set and we could play a game." Ronald smiled and nodded, while stating that he used to play chess on a regular basis. We both agreed that chess is a great way to stimulate the mind, and then I asked if he had any thoughts about my offer to look into benefits or other ways to establish an income. Ron now showed improved eye contact and in a very sincere voice said that he really appreciated my concern, but didn't want to be a bother. He also stated that he was currently focused on finding a place to live, though he did not indicate a need for my assistance. Ron now showed greater connection. He was more easily engaged in conversation and expressed an interest in finding a residence. Considering that I had not yet observed him talking with others, this level of engagement seemed significant. I thought about an immediate offer to fill out housing applications, but didn't want to push things too fast and thereby appear overly directive. Instead, I clearly stated that he was not at all a bother and reinforced that my work (defining roles) was centered on helping people to pursue their goals inclusive of affordable housing.
Afterward, I reflected on Ronald's world. He seemed to value his privacy and showed indications of considerable difficulty connecting with others. He came across as intelligent and exceedingly polite, while concerned about being a "bother" to others. His mental status reflected both substance abuse and mental health issues as evidenced by the smell of alcohol on his breath, as well as his level of isolation, talking to himself and his repetitive rocking behaviors. In addition, he was among the hardcore homeless, meaning that he had been homeless for a long period of time and it was not unusual for him to sleep outside. While there was a great deal I didn't know about Ronald's interests, strengths and difficulties, it was already clear to me that our continued engagement would remain tenuous unless we developed goals that could serve to motivate and invest Ron in our meetings. We were in need of a guiding purpose that could resonate well in his world, even if this differed from my initial inclination to help with applying for benefits or offering a treatment referral.
Excerpted from "Pretreatment Guide For Homeless Outreach & Housing First"
Copyright © 2013 Jay S. Levy.
Excerpted by permission of Loving Healing Press, Inc..
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
Tables and Figures,
Foreword – The REACH Housing First Pilot,
Preface – Unveiling the Message: From Monograph to Book,
Chapter 1 – Pretreatment Considerations for Homeless Outreach & Housing First,
Chapter 2 – Ronald's Narrative: The Original Housing First,
Chapter 3 – Moral, Fiscal, and Quality of Life Reasons for Ending Chronic Homelessness,
Chapter 4 – Janice & Michael's Narrative: The Challenges of Helping Homeless] Couples,
Chapter 5 – Making Meaning and the Art of Common Language Construction,
Chapter 6 – Lacey's Narrative: Trauma, Loss, and the Need for Safe Haven,
Chapter 7 – Youth Homelessness: Freedom, Rebellion, and the Search for Camaraderie,
Chapter 8 – Anthony's Narrative: Navigating Tumultuous Waters,
Chapter 9 – Housing First: From Concept to Working Models,
Chapter 10 – Julio's Narrative: The Trials & Tribulations of Housing First,
Chapter 11 – Supervision: Pretreatment Applications, Staff Support and Sharing Stories,
Chapter 12 – Conclusion,
Appendix – Homelessness in America,
About the Author,