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CHAPTER 1
On the Road to Pretreatment
"It is said that the worth of society can be measured by the manner in which it treats its weakest member."
— Unknown Origin
On any given night, there are over 643,000 homeless people residing in shelters and on the streets across America (HUD-Annual Homeless Assessment Report (AHAR), 2010). Every year, homeless people die from hypothermia and/or an array of medical complications, while others suffer from untreated mental illness, addiction, and medical conditions leading to a steady deterioration of their health. Unfortunately, it is not uncommon to meet homeless individuals who have not been housed for 5, 10, or even 15 years. Homeless outreach workers, clinicians, and other human service professionals are needed to provide long-term homeless individuals with meaningful options that can be considered and acted upon to promote safety, housing placement, and ongoing stability.
For too long, the homeless outreach process has been viewed more as freelance art, rather than following a consistent model that is broad enough to address the wide range of issues experienced in the field. This is not to discount the extraordinary talent and dedication of many outreach counselors, nor to suggest that such proven approaches as the Trans-Theoretical Model of Change (Prochaska and DiClemente, 1982) have not been effectively applied. What is lacking is an overarching set of principles that captures the complexity of helping hard-to-reach populations that are reticent to accept services, but are in need of health care and housing.
In contrast, this book introduces a pretreatment approach that addresses a wide variety of outreach challenges, while providing an integration of practice and theory that can guide outreach counselors and other human service providers. Clinical principles based on a Developmental Model of Engagement, Narrative Psychology, and Ecological Social Work, as well as Change Model and Harm Reduction approaches provide the groundwork for developing a pretreatment perspective. This book explores the journeys of outreach clinicians and homeless survivors through the moving narratives of Old Man Ray, Andrew, Lacey, and others. Their stories highlight the different applications of pretreatment principles, while demonstrating creative alternatives to standard clinical methods. This approach provides pathways from the indignities of homelessness toward better lives of restored hope and possibilities.
People with histories of long-term homelessness and a variety of disabilities can and do partake in a meaningful journey back home. They contribute to our society not just as good neighbors, consumers, and family members, but also as individual survivors of the streets, woods, and shelters. It is important that their stories are heard and the hard lessons are learned on individual, societal, and spiritual levels. The simple, yet important lesson of "appreciation," or not taking things for granted, has been driven home on countless occasions through our many experiences with homeless persons. In fact, the more we bear witness to the stories of homeless survivors, the more we are convinced of the strength and endurance of the human spirit, as well as the magnificent healing power that a meaningful relationship can harness.
This book focuses on the issues of homelessness and the specific applications of pretreatment within the context of a helping relationship. However, it also presents a microcosm of the human condition and societal failings toward adequately helping those who are most in need. We have to relearn that reaching out to the poor is good for the soul, and thereby helps society, and in the end ... us.
Current State of U.S. Homelessness, Policy and Initiatives
It is both a moral imperative and a necessity that our efforts to stem the tide of homelessness are supported and improved upon. Across the United States, the emergency shelter system and the streets have become the long-term housing option for tens of thousands of people who suffer from chronic medical conditions and/or mental illness inclusive of severe addictions (Burt et al, 1999; Burt, Pearson, Montgomery, 2007). In fact, a conservative analysis estimates that across the United States, 2.3 to 3.5 million people are homeless annually (Burt and Aron, 2000). This estimate is a combination of persons entering shelters throughout the year, as well as the vast numbers of homeless who, for a variety of reasons, are unsheltered. The U.S. Department of Housing and Urban Development's 2009 homeless point in time count (HUD AHAR, 2010) reports over 643,000 persons, which is composed of approximately 63% individuals and 37% families and children. It is a one-night snapshot of homelessness, so the number is far less than reflected in the yearly count (HUD AHAR, 2010) that estimates over 1.5 million people seeking shelter.
Obviously, the emergency shelter system was not designed to be the answer to long-term homelessness, and the streets (along with other unsheltered alternatives) are not suitable for people with chronic illnesses. It is a sad reality that the richest country in the world continues to be impacted by such large homeless numbers and its negative consequences on our schools, neighborhoods, healthcare system, and future generations. We can and should do better! Advocates, human service providers, and homeless persons themselves have grappled with this throughout the years, but over all this time, the cost of long-term homelessness can be measured in both lives lost and dollars wasted. In fact, the federal government has officially recognized the persistence of long-term homelessness and its associated difficulties by authorizing a definition of chronic homelessness matched with new funding initiatives through the department of Housing and Urban Development (HUD). The HUD definition (McKinney-Vento, 2002) of a chronically homeless person is as follows:
"An unaccompanied homeless adult with at least one disabling condition (includes substance abuse, mental illness, developmental issues, and medical conditions) who has been homeless for at least 12 consecutive months, or has had 4 discrete homeless episodes within 3 years."
Over the past few years, there has been a sea change in both homeless policy and in efforts at promoting an organized approach for reducing chronic homelessness. During his tenure as executive director of the Federal Interagency Council on Homelessness, Phil Mangano led the charge for developing a nationwide initiative that challenged the leaders of individual states and their sub-regions to develop action plans to end chronic homelessness.
Currently, Ten Year Plans are being developed and implemented in an effort to end chronic homelessness, and thereby reduce social and financial costs (All Roads Lead Home, 2008; The Commonwealth of MA, 2003; National Alliance to End Homelessness, 2000). Ultimately, these plans are based on collaborative efforts between concerned individuals, advocacy groups, local city and town employees, politicians, policy makers, non-profit service providers, charities, businesses, etc. These collaborative networks are being established to address fundamental issues such as developing affordable housing with support services, promoting better access to community-based resources and services, and implementing strategies of prevention in order to reduce future homelessness. Advocates and policy makers now understand that addressing access, resource, and prevention issues are paramount, if we are to be successful in turning long-term homelessness into a rare or unusual phenomenon. This has culminated in the Obama administration's recent unveiling of the first National Strategic Plan to Prevent and End Homelessness (US Interagency Council on Homelessness, 2010).
Meeting Future Challenges
Clearly, innovative approaches such as housing first models are part of the solution to long-term homelessness (National Alliance to End Homelessness, 2000; Tsemberis, Gulcur, and Nakae, 2004). A Housing First approach recognizes that the critical intervention is to house people as rapidly as possible, while simultaneously offering support services, but not require treatment as a prerequisite to getting housed. This approach has shown some initial success by demonstrating housing retention and reducing the financial costs associated with homelessness (Stefancic and Tsemberis, 2007). Unfortunately, these programs are too few in number, and can't be expected to replace the ongoing need for affordable housing and livable income. While nationwide collaborative efforts continue to have a positive impact, poverty and homelessness remain interlocked for the foreseeable future.
The question is whether the gains made by addressing access, resource, and prevention issues can outstrip the current and future rates of homelessness. Regardless of the outcome, a guiding set of pretreatment principles is warranted for providing quality services that can make inroads with the most vulnerable and hardest to reach among homeless individuals. A pretreatment philosophy will give outreach clinicians and Housing First program staff a better understanding of how to assist chronically homeless individuals in creating pathways that lead to housing, treatment, and stabilization. The outreach counselor is uniquely positioned as an interpreter between the world of the homeless person and the world of human services. The goal of the outreach clinician is to serve as a bridge between these two disparate worlds.
This book presents a pretreatment model that guides us on how to meet this critical challenge. Five pretreatment principles and their applications (see Table 1, p. 129) are detailed through the examination of several homeless narratives. Successful application of these principles is dependent upon the strong foundation of a trusting relationship between counselor and client. This is facilitated by developing a common language of ideas, words, and values that is understood and shared by both parties.
It is my experience, and in essence my story as an outreach clinician and program manager, that proper application of pretreatment principles can make a critical difference in the lives of the people we serve. The goal is to effectively integrate theory and practice so that outreach counselors, other human service staff, and policy makers are provided with an approach that captures the complexities of the homeless person's world, while giving helpful feedback and an overall sense of direction to their work. The homeless narratives offered here emphasize direct care challenges and homeless realities, while demonstrating the application of pretreatment principles. Ultimately, we must effectively reach out to those most in need and achieve a successful journey home, rather than continue to tolerate prolonged homelessness and instability. In essence, these are vital and necessary steps toward stemming a seemingly endless homeless cycle.
CHAPTER 2
Old Man Ray's Narrative: First Lessons
"I am the night watchman! If you want to know what goes on around here, all you got to do is ask."
— Old Man Ray
I remember my first entry into the world of homeless outreach. The year was 1988 and homelessness was on the rise. I was fresh out of social work school, and like so many other new graduates, I was an idealist who was ready to rescue people from calamity. Little did I know that working with the homeless would become my lifelong profession. During my first days of outreach, I was immediately puzzled by the deceptively simple task of helping an elderly homeless man who lived at New York City's Port Authority. He was a short, stocky white male of 67 years with a long white beard. His mobility was somewhat hampered, but he could move slowly by using a cane to get around to the shops throughout the building. He spent most of his time sitting on a milk crate and observing the multitude of people making their way to work and other activities, while quietly having a quick nip. You could count on him to be there on a daily basis along with the variety of shops, newsstands, and commuters. He called himself "Old Man Ray" and had become a fixture at the Port Authority.
The first time I approached Old Man Ray, he surprised me with his outward sense of satisfaction and connection to his environment. In fact, while I was still transitioning to my role as an outreach worker, Ray had long been adapted to his life at the Port Authority. During our first meeting, he said to me, "I am the night watchman! If you want to know what goes on around here, all you got to do is ask." He then went on to ask how he could be of service to me. In my mind, he had immediately reversed the tables. My offer to help him did not resonate in his world and I left our meeting feeling a little stuck, yet excited about the challenges of outreach and what appeared to be the enigmatic world of homeless individuals. I was left with an important and, at times, the central question of outreach: How do you help those who are clearly in need, yet communicate no need for help? Had I taken the liberty to assume too much by thinking that an elderly man who lives on a milk crate at the Port Authority is in need of help?
I quickly learned that Ray was not prepared to accept any help I could offer. In fact, on several occasions, I offered access to a homeless shelter, housing resources, and other related services, including one desperate attempt of inviting him to a detoxification facility. Ray quickly dismissed my attempts to provide help by simply stating that he was doing fine. Nevertheless, he was more than happy to teach me about American history, and to inform me about the daily happenings at the Port Authority. Also, and most importantly, he seemed to enjoy my company. When I was in his vicinity, Ray often called out my name, thereby initiating contact. Out of necessity, I decided to take it slow and get to know him. Over time, Old Man Ray shared more about his life and what he valued. He was proud of his Veteran status and World War II deployment. He valued his own personal independence and freedom, much as he believed in America's standing of strength, independence, and freedom throughout the world.
It was during one of our prolonged conversations that I noticed that Ray's ankles appeared swollen, so I inquired about how his ankles and feet felt. Surprisingly, Ray was receptive to this question and disclosed that sometimes they felt uncomfortable, but he was getting along with the help of his medicine (vodka) and the cane. I explained to him that if his ankles and feet ever gave him cause for concern, I could bring him to the Veterans' Administration (VA) clinic for medical services. To my surprise, Ray reacted swiftly and showed notable anger directed at the VA system of care. I quickly added that I also knew of a nurse who did not work for the VA, and she could address this issue in order to improve his comfort level when walking. I went on to explain that the nurse has an office at a drop in center located at a local church and she provided foot soaks and other services to anyone for no cost.
Although Ray declined my offer, he certainly listened and indicated that he was willing to take it into consideration if his condition worsened. I felt heartened by our conversation, but went home that night knowing that Ray would spend another night sitting on a milk crate. Fortunately, two major goals were accomplished during our last meeting. Firstly, Ray actually shared a personal problem with me (his swollen ankles and feet) and secondly, seeds were planted regarding the availability of medical care. From this day onward, I learned an important, yet paradoxical lesson of homeless outreach (anonymous teaching) that states, "If you want to get to someone's head, begin with their feet!"
Over time, Ray's ankles and feet worsened, as evidenced by noticeable increased swelling and his own admission of increased discomfort and lack of mobility. Nevertheless, Ray remained reluctant, and instead, he drank more, complained little, and was hesitant to see the nurse. A few days later, things reached a crisis point. As usual, Ray called me over, but this time with considerable agitation. He reported that someone had stolen his cane. His ankles and feet had worsened to the point of him being unable to walk. Old Man Ray had spent the day confined to his milk crate feeling alone, confused, and scared. He was now prepared to access help, but was the system ready to respond?
(Continues…)
Excerpted from "Homeless Narratives & Pretreatment Pathways"
by .
Copyright © 2010 Jay S. Levy.
Excerpted by permission of Loving Healing Press, Inc..
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