In this multi-part blog series we are examining the essential elements of successful housing programs that focus on ending homelessness. We pick up here in Part 2 looking at the Service Orientation that is necessary.
PART TWO: Service Orientation
The secret to a successful housing program? Meet people where they are at in their life journey. Don’t set up barriers or unattainable expectations. Accept the decisions that people have made in their life and how they became homeless at face value, help them achieve housing, and then provide the supports necessary to help them achieve long-term residential stability.
In case you missed the subtlety – house people, then support them. If you put together an elaborate service plan or case plan prior to helping someone get housing you are doing it “bass ackwards”.
House people then support them. The evidence is clear that people achieve better long-term housing outcomes and achieve a more positive quality of life when this is the sequence of evidence. While it remains popular for there to be life skills training, budgeting classes, skills upgrading, addiction treatment, etc prior to helping people achieve housing, the evidence would suggest that this is unwarranted and actually results in poorer housing outcomes long term.
We shouldn’t have different standards of behavior for people who access human services compared to others in society generally. For example, sobriety is not a precondition for successful long-term housing. Statistically, most people who are alcoholics or who use other substances are housed, not homeless. Any housing program that requires people demonstrate sobriety for any length of time prior to gaining access to housing is lengthening a person’s homeless experience for a reason not supported by fact. Furthermore, any program that drops support services because someone has started using again is, in my opinion, doing a better job of creating homelessness than ending it.
We need to wrap our heads around what harm reduction is and why it is important for the population that we are working with. We are trying to focus on ways of reducing harm to the individual and community/society at large. We are looking at things like substance use and sex work from a community health and public health perspective. Harm Reduction is not an approach that demands the client achieve sobriety over time. While it can be effectively blended with approaches that decrease involvement in harmful activities, first and foremost a harm reduction approach tries to decreases risks associated with use. For example, using with friends instead of alone or with strangers; use of condoms; use of clean needles and safer crack use kits; drinking palatable alcohol instead of non-palatable alcohol. Some clients may have a goal of abstinence, but this is not a requirement. A harm reduction approach is pragmatic. Not only does it increase the health and stability of the client, it also has public health benefits, decreases policing costs, and also decreases emergency room, ambulance and hospital costs.
As someone who lives with a mental illness (depression) I know I can have strong opinions about how many organizations view and support persons with compromised mental wellness. In the context of creating and maintaining successful housing programs I would urge you to understand, embrace, support and practice recovery-oriented practices with individuals that have experienced compromised mental wellness. I would suggest that everyone learn about the practices and work of the likes of Mary Ellen Copeland and Patricia Deegan. I want people to know how to support individuals who have experienced mental illness in having a hopeful orientation towards the future, with an increased understanding of symptoms and triggers, with thoughtful crisis planning and awareness of resources and approaches that can be used. I want people to know how much survivors of psychiatric services have come to emphatically embrace these practices and experience better housing and quality of life outcomes as a result. I want people who have experience mental illness to feel empowered to have a voice in their care and supports.
For housing programs to be successful, punitive approaches when people relapse – whether that is in their substance use, medication management, housing stability, etc. – should be replaced with approaches that try to focus on what lessons can be learned and how to achieve stability and housing success in the future. People will relapse and it is natural. Sure, we would love to prevent it as much as possible and support people as necessary to try and mitigate it from occurring. But relapse will happen.
Related to this is a relapse into homelessness. Not everyone supported by a program is going to remain housed despite all of the efforts a housing team puts into it. But let’s not rip away their supports or refer to them as a failure or make them go to the bottom of the waiting list if they lose their housing. NO! Let’s re-house them, learn what we can do better and focus on how greater sustainability can be achieved the next go around.
We also need to move away from program models that are coercive if we want to have a successful housing program. Clients should never be tricked or forced to do anything that they don’t want to do. I urge people to be fully transparent on what the housing program and supports are that we are offering and let people choose if that is right for them.
A critical component for a successful housing program is client choice. This starts with empowering the people we work with to choose where they want to live. Some people may want permanent supportive housing while others may want scattered site housing with supports. Some people may want an efficiency or bachelor unit while others will want a one-bedroom. Some people may want housing close to the downtown while others want to be as far away from downtown as possible. Housing programs need to stop thinking that they place people into housing and start thinking that they provide meaningful housing choices for people. We don’t know what is best for people. What we should know is which options we can present that are affordable, actionable (reason to believe the landlord will rent to us) and appropriate (e.g., there are no legal restrictions on where they can live; it isn’t a four storey walk up and the person uses a mobility assistance device). Then we need to respect the housing choice that the client makes and support them in that housing.
We also need program participants to choose the type, duration, frequency and intensity of the service supports that they receive. If we do this in the right way we can remain truly client-centered and support people through the stages of change. This doesn’t mean we are client-directed. It also doesn’t mean that we are system-centered. It means that we are going to take the necessary steps to ensure that our service delivery and organization remain centered on opportunity for growth and positive change.
We need to know under what circumstances it is prudent to create intentional conversations, practice respectful persistence and engage assertively with the people we work with. We are agents of change; navigators of resources. We don’t heal people. We don’t fix people. We aren’t directly responsible for the decisions that people make in their lives. But we should do the best we can to provide access to information and opportunities that will allow people to engage in activities that will provide the greatest likelihood of quality of life improvements.
We need to think of our work as professional work. Damien Cox, a writer for the Toronto Star, said of my beloved Maple Leafs (and I am paraphrasing) “Stupid and nice is no way to run a hockey team.” I know and appreciate that people get involved in delivering services to homeless people for a wide range of reasons. But they need to know the limits of what they can do versus what experts need to do. I think of, for example, the Sisters of St. Joseph and their involvement in health care and development and administration of hospitals. The Sisters knew the difference between their role and the role of trained medical professionals. They didn’t try to do things that they were neither qualified nor trained to do. They knew that doing so would hurt or even kill more people than it helped.
Given the populations that we are serving, it is necessary to orient program delivery such that it happens in the community. Supports cannot meaningfully be delivered by text message or email or phone call. We need to go meet them in their housing. We need to see the condition of their housing. We need to see their adjustment and skill implementation first hand. We need to respect and support people’s natural settings. We can’t do this in an office. We need to go to the people.
As support functions go, I find it is best when organizations embrace their role as teacher, model and resource specialist. I strongly suggest staff make themselves available to accompany people to appointments. We need to be willing to do a load of dishes or load of laundry with people to teach them the skills. We should demonstrate the likes of budgeting by taking people grocery shopping. We need to be prepared to roll up our sleeves and clean toilets and showers and the like until people have the skills to do it themselves. We need to know whom else within the community we may recommend that the client connect to and for what purpose.
Deficit-based approaches to working with people are not as successful as strength-based approaches. I appreciate that sometimes finding the strengths beneath a rough exterior and years of hard living can present some challenges. Truth is, a lot of the people that we work with may not have traditional strengths. We need to be creative in how we work with and look at the life experience of people. The will to survive after years of living under a bridge may be seen as a strength. Considerable stubbornness may actually be viewed as a strength. Managing one’s basic needs while dealing with active psychosis may be seen as a strength. And I could go on.
Our job when we work with people to support them in housing is to orient our approach such that we enhance dignity and empowerment by making the people we serve the center of all planning activities and goal setting. I suggest transparency and a small wins approach, with the patience to accept that people will change their minds. I want the people we serve to think about the obstacles that may come up and how they will tackle those challenges before they ever happen.
For many years some of the people with the most complex needs have been subject to compliance based programs. This means that they have to do things like demonstrate sobriety for a fixed length of time, take medications, agree to see a psychiatrist, agree to take anger management courses, etc. in exchange for having a roof over their head. Anytime compliance faltered, the individual was subject to a “three strikes and you’re out” or “contracting” process or else asked to leave immediately. Too often this meant a return to homelessness. Evidence suggests that compliance-based service delivery does not achieve impressive housing outcomes, especially in the longer-term.
We need to help the clients we serve understand what our role is and the length of time we are available in their life for. I want clients to achieve greater independence over time. This helps inform the approach used to case planning and supports. It also makes me critically aware at all times that establishing a dependent relationship is not going to be helpful or sustainable longer term. I suggest as many connections as possible to mainstream services with a strong focus on community integration.
There are only six types of homeless people: Someone’s mother. Someone’s father. Someone’s sister. Someone’s brother. Someone’s daughter. Someone’s son. I really love when I see compassionate service providers who never lose sight of the humanity of our work. It is these organizations that exemplify the non-judgmental attitude that I think we need…the same sort of acceptance without criticism that I would love to receive should I ever find myself homeless.
Iain provides extensive workshop training and keynote addresses on changing ideological approaches to truly focus on ending homelessness in a way that accepts people where they are at. Comfortable with his many own imperfections, Iain has found that the focus on the right service orientation not only improves housing outcomes, it also shakes up some of the underpinnings of homeless service delivery systems by encouraging critical analysis of why some programs operate the way that they do.