Pretreatment Guide for Homeless Outreach & Housing First - Helping Couples, Youth, and Unaccompanied Adults

Chapter 1 – 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.

Table 1. Pretreatment Principles & Applications

Principle

Application

Promote Safety

•  Engage with homeless individuals in order to reduce the risk of harm and enhance safety (e.g., provide blankets on cold night) •  Stabilize acute symptoms via crisis intervention and utilize opportunity for further work.

Relationship Formation

•  Attempt to engage with homeless people in a manner that promotes trust, safety & autonomy, while developing relevant goals •  Stages include: Pre-Engagement, Engagement, Contracting.

Common Language Construction

•  Attempt to understand a homeless person’s world by learning the meaning of his or her gestures, words and actions •  Promote mutual understanding & jointly define goals •  Stages include: Understanding, Utilizing, and Bridging Language.

Facilitate & Support Change

•  Prepare clients to achieve and maintain positive change by pointing out discrepancy; exploring ambivalence, reinforcing healthy behaviors & developing skills, as well as needed supports •  Utilize Change Model & Motivational Interviewing Principles •  Stages include: Pre-contemplation, Contemplation, Preparation, Action, Maintenance.

Cultural & Ecological Considerations

•  Prepare and support homeless clients for successful transition and adaptation to new relationships, ideas, services, resources, treatment,...