Cross-Cultural Dialogues on Homelessness - From Pretreatment Strategies to Psychologically Informed Environments

US Foreword — Creating a Common Language

The “Housing First” movement, like most social movements, grew out of a sense on the part of many that something in society was fundamentally wrong. In Massachusetts, I witnessed the late 1980s and early 1990s from the views of those in the trenches responding to unaccompanied adult homelessness. One had to be particularly insensitive, or wholly blinded by the conviction that they were involved in some noble mission to shelter the poor, to not understand that something had gone fundamentally wrong. Homelessness represents the failure of multiple systems of care, especially those systems meant to serve people whose lives had been impacted by serious behavioral illnesses and disorders.

For me, working those days at Boston Intake, the Newton Overflow Shelter, and eventually Father Bill’s Place in Quincy, Massachusetts, it was a shocking revelation to see the number of people with serious mental illness simply cut adrift. How does one explain the frustration of trying to have a person in the midst of a psychotic episode evaluated, only to be told from the clinician at emergency services that you would have to transport the client to a hospital or a police station because the clinician did not feel safe coming to your shelter?

During those times, people with serious mental illness were being directly discharged to homeless shelters. There were few opportunities for residential programs, and often the subtle or sometimes explicit message was that the person was not “housing ready” or even program ready. They were seen as noncompliant clients. It was painfully apparent that such “clients” would never improve their wellbeing if the system was built around clinicians sitting in clinics waiting for these people to show up and say they needed help.

Over time, this realization grew among many of us serving homeless individuals. We asked: “What if we tried using our various housing resources to house them?” This idea was not grasped by all; there was hardly universal acceptance for such a concept. Those who opposed it felt that these individuals were not capable of sustaining housing. Some argued that an urban shelter was the best you could ever expect for this population. Some even promoted the idea that shelters should be considered an acceptable urban housing niche. Fortunately, a critical mass of homeless providers did not share this view.

Yet, once committed to the cause, then what? How should we reach out, approach homeless individuals and serve them in such settings? What expectations should we place on such tenants? Out of this questioning, our own particular form of “low-threshold” housing grew into place. The Massachusetts Housing & Shelter Alliance (MHSA) advocated for and began an effort to shape a statewide movement to make Housing First a reality in the Commonwealth. MHSA’s founding Executive Director Philip Mangano’s early advocacy for the conversion of resources toward housing and services emerged as the national vision of Housing First. Not only would housing result in a reduction of costly emergency and acute resources across systems of care, it would actually improve peoples’ chances for recovery. Over the past ten years, MHSA, with the vital work of agencies across the Commonwealth, is proud to have been a part of housing nearly 2000 people who were chronically homeless. The claims of cost savings have been substantiated by a number of different studies (Byrne and Smart, 2017; Wright et al., 2016; Buchanan et al., 2009; Larimer et al., 2009).

But, this is not the whole story of how such an approach came to be. The emergence of any great innovation has a complex causal structure. From my perspective, the low-threshold approach to housing would never have emerged in Massachusetts without the long practice of clinicians committed to providing outreach to the very population described above. The core wisdom of accepting people where they are, without judging or pigeonholing them, grew from the work of clinicians engaged with the Department of Mental Health (DMH) Homeless Outreach Team in Boston, or the work of Projects for Assistance in Transition from Homelessness (PATH) Counselors across the Commonwealth, which proved that one could connect, communicate and inspire people to seek the resources they needed.

My own perspective on the possibilities of low-threshold housing was often reinforced by outreach counselors sharing their personal experiences with me. They, too, seemed to know that the conventional and institutional approaches had failed. I think it was their approach, honed in the urban streets and alleys, under bridges, and in the forests of our rural areas, that shaped housing providers’ views on new possibilities beyond the compliance-based, abstinence-based programs that had existed for years, and yet failed to put a dent in homelessness.

As office-based clinicians worked with this population, it occurred to me that many of the existing clinical modalities or treatment models failed to capture the reality of what these dedicated outreach workers were practicing on the streets. Even some of the most progressive social work models that emphasized the experiences and articulated needs of the person did not encapsulate for me, an advocate and not a clinician, the essence of my encounters with homeless individuals experiencing serious mental illness.

It was Jay Levy who finally provided the missing language. The story of the progression from outreach to shelter to housing approaches is, in many ways, his story as well. However, he was one of the first to begin to shape a language to an effective practice or approach.

“Pretreatment” was a concept that anyone working direct care with homeless individuals could immediately identify with. Jay’s development around a “Pretreatment” approach to homeless individuals experiencing serious mental illness opened ways to communicate with them in the midst of crisis. Not only did he practice this approach for many years — his distillation of his learned wisdom and experience in writing resulted in a useful tool for all of those in the trenches trying to move people out of crisis and into housing, or, for that matter, sustaining people in crisis in their housing. His concept of establishing a “common language,” where practiced, was useful to direct care worker and clinician alike.

Now, in partnership with Robin Johnson and others throughout the UK, Jay has begun the first steps toward a cross-cultural discussion on homelessness. This is most appropriate, given the lessons already learned in the United States and the United Kingdom in addressing and prioritizing the needs of chronic homelessness. We learned much from the “rough sleepers” focus of providers in England. What makes this dialogue important is that the discussion of Pre-treatment strategies and the concept of Psychologically Informed Environments (PIE) are shaped out of real-time practice and are most applicable and meaningful to those actually working with this population.

These efforts at such a dialogue constitute an attempt to mainstream practices that could actually end homelessness for people with significant mental health issues and complex needs. Jay displays the fruits of such dialogue by highlighting the importance of the language of systems, and how that shapes various responses to the problem of homelessness. We should not deceive ourselves for a moment here in our country: if the various systems of care accepted such practices, we would see far less homelessness. The inability of mainstream care systems to adjust to this population is one of the primary causes of homelessness.

Make no mistake about it: Jay is not a theorist. His writing comes from his actual work. The philosophers of knowledge might suggest that Jay’s writing is grounded in praxis1. The book is full of his personal experiences, as well as the experiences of his British colleagues; everywhere from the streets of Boston and the woods of Western Massachusetts to London’s urban landscape. If you have actually been in the situation of engaging with homeless individuals such as the ones captured throughout these pages, you will immediately get the sense that you, too, have been there. That is what makes this work so compelling. It is so much more grounded in the realities of homelessness and of serious mental illness than our office and clinic-bound colleagues will ever comprehend. It should be required reading for all in the fields of counseling and social work, or, at a minimum, for anyone who aspires to work with homeless individuals with serious mental illness.

My more direct work with homeless individuals, with a few remarkable exceptions, ended when I assumed the leadership of MHSA in 2003. Most of my work today is dedicated to the development of and advocacy for the resources necessary to house homeless individuals, with a strong emphasis on promoting the dedication of resources toward the low-threshold model of permanent supportive housing. The introduction of Housing First in Massachusetts; the first flexible funding for low-threshold housing; the first model of Medicaid reimbursement for tenant-based services; and most recently, the introduction of Rapid Re-housing and the first Pay for Success (Social Innovation Financing) initiative in the nation for homeless individuals are all great successes that ultimately strive for the same end Jay has dedicated his life to: ending homelessness.

However, it should be noted...