Wellness & A Healthy Social Network
One of the themes that we weave through a lot of our work in Human Services is the importance of creating or recreating a healthy social network for individuals and families that have experienced considerable marginalization, poverty, homelessness and the like.
We also speak about the importance of focusing on wellness instead of illness. If we consider illness to wellness as a continuum as opposed to a either-or construct, then we even further appreciate that achieving wellness is a journey…a process…something that can occur incrementally. We need to move beyond labels and pathology to focus on the individual’s potential and the remarkable ability of the human being to heal – physically, socially, emotionally. Our ability to heal is absolutely remarkable. It is even more impactful if we do not confuse “healing” with “cure” – as they are dangerously considered synonymous by some.
So what is the link between a healthy social network and wellness? Lots. And as you read below, I hope you will become even more convinced that one of the fundamental jobs of support workers is to reduce social isolation by improving access to healthy social networks.
I remember hearing a story – don’t know if it is true – about a doctor who specialized in addressing heart disease and a swami. As a guest of the doctor’s, the swami was asked what the difference was between “illness” and “wellness”. The swami circled the “I” in “illness” and the “we” in wellness.
And it turns out that the swami’s premise is supported by scientific research as well. How a person is situated within a healthy community affects the overall health of the individual considerably. People who exercise in groups (think running groups or gym buddies) are more likely to keep exercising and get healthier together. People who stop using alcohol and other substances are more likely to achieve sobriety for longer with a healthy support network of non-users. In a study of women with breast cancer, those with 10 or more close friends lived longer than those with less than 10 friends. Support groups for psychiatric survivors, cancer survivors and so on thrive because people value the reciprocal feeling of the shared experience in the social network. And the opposite impacts are also true. Fowler’s work proved that having a friend that became obese made you 57% more likely to become obese.
The World Health Organization has also been clear on the importance of healthy social environments and supports, noting that “…social isolation [has] powerful effects on health… the lack of supportive friendships are damaging in whatever area of life they arise. The lower people are in the social hierarchy of industrialized countries, the more common these problems become.” And what problems are we talking about? The WHO indicates higher incidence of heart disease, disability, addiction and other illnesses. Oh, and a much shorter life expectancy.
In 2007 I was part of a research study that looked at the Quality of Life changes amongst people served through Housing First. In the eight QoL indicators looked at there were overall improvements. But the one indicator with the smallest improvements pre- and post-housing? Social interaction. Ever since then I have paid considerably more attention to meaningful daily activities and the need to decrease social isolation while creating social networks. And I am quite emphatic that we need to look at individual interest rather than class. I am sick and tired of social events being planned exclusively for poor people. It ghetto-izes their experience and de-values their ability to integrate into social events shared by others in society – and that is just plain inexcusable.
So what can we do to help promote wellness in social interaction amongst those that we work with? Creating opportunities for people to get out of their housing and into events in the community is important. Leveraging the likes of “Welcome Policies” or similar instruments that allow economically disadvantaged people to access community programs is helpful. Accompanying people to events is great.
And there are lots of phenomenal places to connect to in any community. I love libraries because of the range of programming offered at them. Community centres are great when they have a calendar of social and recreational activities to tap into. Faith groups can also be quite nifty to look into because there are often a number of social events that occur in addition to worship. Support groups, especially for survivors, can also be a terrific way to expand a social network. For clients that are considering AA but don’t know if they are ready to go to a meeting, I like to introduce them to online AA meetings and communities to demystify the experience.
One of the tools that I have used a lot in the past and do a workshop piece on is how to schedule a week of meaningful daily activities with the client. I want them to have activities that take up different parts of the day and most days of the week – and I want these activities to be in addition to other appointments or case plan activities. I purposely set out as many suggestions as possible where there will be a higher degree of interaction with other people rather than solitary activities. Their desire to try new things is want I am trying to nourish and support. And the key to the tool is that I ask people to reflect on the best thing that happened that day and the thing that could have gone better so that we can learn in the support relationship what other ideas we may want to put on the table in the future.
If we focus on the “we” in “wellness” our clients will do better and social networks will be meaningfully (re)created, providing the support necessary for a much more enriching and healthy life.
If you want to learn more about the importance of healthy social networks in supporting people or the connection between social networks and health, contact Iain De Jong atidejong@orgcode.com
Appropriately Using Assertive Engagement
So you have a client that has engaged in case management supports with your organization, but they never seem to be around or seem completely unengaged when you do meet. They have high acuity. They likely have several complex issues and have experienced long-term homelessness. Is the fact that they are rarely around or seem completely unengaged sufficient to “cut them loose”? Should your organization move on to another person who is more eager to actively participate in what you have to offer?
No.
In this blog I talk about how to use assertive engagement appropriately to first engage with people who have accepted case management services and then become unengaged, as well as how to effectively engage with people who are homeless and do not seem interested in having a conversation about housing and case management.
In a perfect world – heck, even in a lot of “normal” therapeutic environments – people seeking service come to a safe support environment. Appointments are booked. People are focused on the support and not distracted. People are sober and have taken medications. People have absolutely embraced that they want support and are going to work their butts off to get better. This is not the reality I work in.
When working with a population with long-term street engagement, this is not the norm. Sometimes the best environment you get is an encampment in the woods or a dry spot under a bridge. In my career I’ve had to engage with people from a boat to the undercarriage of a rail bridge; climb trees; tunnel into the earth; stand out in blizzards on street corners; go into make-shift huts; place my face down a sewer grate; and visit homes in vast arrays of conditions.
Assertive Engagement is best understood as the process whereby a worker uses their interpersonal skills and creativity effectively to make the environments and circumstances that their service users are encountered in more conducive to change than they might otherwise be, for at least the duration of the engagement. We accept in assertive engagement that we are not operating in a “perfect world”. We accept that as service providers it is us that has to change and modify our approach to meet the needs of people we are hoping to engage with rather than vice versa. As service providers, the onus is on us to provide service – in whatever environment that may be.
Also important in understanding this process is that we are trying to create an environment where the individual may be more willing to accept change. Building trust and rapport is too often heralded as the only thing that can be expected in these types of exchanges. Hogwash. Neither trust nor rapport building in my opinion are outcomes. They too are processes. The actual outcomes are the changes that are experienced. To me that most often means accepting an invitation for housing, engagement in client-centred and strength-based case planning, and creating a meaningful case management support relationship. Assertive engagement presupposes:
That there are people who want to, or need to, effect some change in their lives because they recognize, or it is recognized, that aspects of their present lifestyle are damaging in some capacity.
That lives can be changed for the better and that professional support workers can be a part of the process towards change.
That change requires processing, decisions need to be made, and this processing is best achieved in certain circumstances and environments (i.e. environments that are safe, free from stress, supportive, with few other demands and needs to be met – roughly, those environments that we would term therapeutic).
That most vulnerable people do not live in environments and circumstances that are conducive to change. And most workers will encounter their clients in environments that are by and large un-therapeutic.
Assertive engagement is both persistent and active. The persistence is friendly. And it can require a tough skin – always being pleasant and professional even when possibly confronted with colourful language. The active approach to assertive engagement means that it is incumbent upon us to be out and in the field, trying new things and new approaches, unwilling to accept that we have tried everything until we come upon an approach that works. To that end, assertive engagement is a process that frequently takes time, is known to require incremental stages to achieving an end goal and is most likely going to need to adapt and confront a number of coping strategies presented by the individual.
Assertive engagement isn’t for all individuals. Primarily it is designed for work with clients that are in precontemplation or contemplation – in accordance with the Stages of Change. Those individuals that are precontemplative do not see the damage particular behaviours cause, either to themselves or to wider social groups. They are unlikely to see the need for change. On the off chance that they do see the need for change or a glimmer of change, they are unlikely to see the need for change today – and in that case may have only a vague or not completely articulated expectation that change will somehow occur at a later date. Excuses will be rampant for not working towards change, if there is any acknowledgement at all of the need for change.
When working with a population that is likely to have experienced long-term homelessness, this type of reaction can almost be expected in a number of circumstances. First of all, we need to appreciate that the longer they have been homeless, the more they have adapted to being homeless. Being homeless is normal. Being housed is abnormal. Being in a constant state of survival is normal. Being in a planning stage beyond the present can be abnormal. Safety can be construed as merely being alive for today; whereas the change that is presented may remove notions of safety, being asked to consider the unknown.
Individuals who benefit from assertive engagement usually have a fragile psyche with a range of defences, up to and including lashing out at their worker emotionally. Body language can at times appear threatening. Whereas support workers may see missing appointments or unwillingness to engage as a lack of preparedness to make a decision on whether they want to participate in change, the indecision is in fact a decision.
This is where a keen understanding of the Stages of Change and various tactics that can be used to assist clients work through the Stages is critical. Prochaska’s work tells us that consciousness raising is needed for bridges to be built and the gap between where the client is in their state of harm and behaviour and what would likely lead to life improvements.
In the simplest of terms (and there are many more nuances that need to be understood to practice assertive engagement effectively), the approach to assertive engagement generally follows a particular pattern of behaviour. It starts with information being put forward by the worker. This information may be an invitation to attend a program, understand other support services, explain that they want to help them get housing, explaining why sleeping in a particular location outdoors may be problematic, etc. The key is that the information is actionable and based upon fact. It is not “blue skying”.
Following the information being put forward, the individual is likely going to erect defences. This is reasons – rational or irrational – that the individual sees as making them immune to the information presented by the worker. The defences then must be challenged – respectfully, accurately and factually – by the worker. The intent is not to enter into debate, but it can be confrontational, albeit in a very subdued manner. What the worker is attempting to do is have the individual become more vulnerable to the information so that consequences are understood – at least to some extent.
The pattern is repeated over and over again – at different times of day and in different settings and perhaps using different information until such time as there is a breakthrough. The well trained worker will be prepared for one of four typical responses until the breakthrough happens.
The first is that the individual may deny the issue or minimize the situation at hand. In these instances, the individual is not claiming any responsibility in their life, or the language that they are using demonstrates that they are deflecting or minimizing the impact of their behaviour. Consider the individual who uses language like “borrow” when really they “stole”; the individual who “slept it off in the park” rather than being straight-up that they “blacked out” and really had no premeditated intention to sleep in the park.
The second common response that the individual may use is to rationalize the situation or intellectualize the situation. As a starting point, we need to accept that individuals with complex needs and long histories of homelessness use both rationalization and intellectualization as survival and coping strategies. It is how they internalize their existence of being in need for so long and still being alive. In these situations it is common to see some awareness of behaviour. Consider the individual who does not acknowledge that they consume too much alcohol, but says that they need to drink in order to fall asleep. Or consider the individual who will distort facts – including the possibility of omitting several key facts – in order to defend their current situation.
The third common response is projection and displacement. In these instances the individual is more likely to project the current situation onto others rather than accepting person responsibility. They will be inclined to blame others for their behaviour, even when they did actually have control over their actions. Again using an alcohol example, consider the individual who says something to the effect of “Johnny kept giving me the bottle and telling me to have another swig.” In this example, the individual could have told Johnny no. Or they could have accepted the bottle but not actually consumed anything. However, in how they project and displace, the individual makes it sound like these were not options.
The fourth common response is to internalizing the current situation to the point where the individual tries to often convince the worker that they are unworthy of attention or assistance. The individual will say things like, “I am such a bad, bad person. I don’t deserve any help. I am worthless. I should be left alone. I don’t deserve all you try to do for me. You shouldn’t even try.” And this may be followed by a suggestion on their part that the worker assist someone else instead – someone who in the eyes of the individual is more worthy of attention or more likely going to need help. In my experience of outreach, I have been duped by this defence more than ones by long-term hardened rough sleepers who will even go to great lengths to do outreach on their own when you are not around to round up other suitable candidates instead of themselves.
Understanding what assertive engagement is, how it works, when to apply it, how it relates to Stages of Change and the predicted defences and how to break through them can be the difference between managing homelessness and ending homelessness; between effective and engaged case management and workers spinning their wheels trying to chase individuals down; between community integration and a brighter future and repeated patterns of disengagement and homelessness.
OrgCode offers a three hour training course on effective use of assertive engagement, as well as a training course on the use of the Service Prioritization Decision Assistance Tool (SPDAT) to be more effective in the use of assertive engagement. For more information about our work helping people practice assertive engagement, or the use of the SPDAT to help with assertive engagement, please contact Iain De Jong at idejong@orgcode.com
Another Teaching Year Around the Corner
Can you imagine being a student of mine?
I am a thinker first and foremost. Over the years teaching in the Graduate Planning Programme at York University in Toronto students have been subject to my out-loud thinking about various social issues.
Every year I teach a course called Community Planning and Housing. Gerry Daly used to teach the course. He is one of my heroes. He wrote a book called Homeless: Policies, Strategies and Lives on the Street, which should be in the library of every person who does this kind of work. He had a huge impact on me when I was in Grad School. Big shoes to fill indeed. But here I am teaching the course more than 6 years later so I must be doing something right.
Some years I also teach a course on Public Participation. Other years I also teach a course on Social Policy. This year (as far as I know) I am only teaching the Community Planning and Housing course.
I love being a professor…teacher…educator…thought provoker…facilitator of knowledge. It is a privilege and an honour. I remember when Dr. Barbara Rahder first approached me to teach before she became the Dean of the Faculty of Environmental Studies at York University. I was so nervous. Many years before she was the Supervisor of my Graduate work. How do you say no to a mentor like her?
What I love most about teaching are the students. Every year there are 12 or more Graduate students who think it is worth their time and energy to spend 3 hours with me per week. I find myself challenged by their questions and motivated by their quest for knowledge. I find it helps my professional work as well, as they keep me current on research methods and emerging research.
My students and I don’t always agree. I tell them starting on the first day that part of my job is to provoke. They actually don’t know what I think about the subject matter until the final class. Why? Because I think it is important to keep an ongoing healthy debate. It also forces me to consider the “Devil’s Advocate” position in what is mainly a left-leaning faculty.
The next year starts in just over a week. I am stoked. What questions await me? How many will show up to class the first day and never return again? How many will know lots about housing and homelessness? How many will appreciate the connection between what the current reality is and our shared historic reality? Will they be prepared to be challenged – write a great paper and do a phenomenal presentation?
Teaching helps me be a better person. I can assure you it is not for the money. In fact I donate much of the salary to causes and community based efforts that are aligned with who I am as a person. Being a teacher makes me a better student – a student of the community and people and world that surrounds me. Being an instructor makes me thirsty for knowledge. I yearn to find out how the world can be made a better place. I don’t want to miss any opportunity to gain insight on how that may happen. I am eternally grateful to almost every student I have ever had the pleasure to teach.
If you are interested more in Iain’s teaching activities or want to see a course syllabus, send him an email at idejong@orgcode.com. You may also want to check out www.yorku.ca/fes – one of the premier interdisciplinary faculties and non-traditional planning programmes that are offered world-wide.
Importance of Team Leader Training
This week we launched our re-vamped two-day Team Leader training program. Through the Introduction and 9 modules, we try to set the stage for excellence in program delivery. Through analysis and synthesis of the main currents of thought and practice in leadership and management across the public, private, non-profit and non-governmental sectors, the Team Leader training covers:
Maintaining program fidelity
Being technically and tactically proficient
Making sound and timely decisions
Setting the example
Knowing your team and looking out for their welfare
Training your people as a team
Knowing the boundaries of your leadership
Balancing management & leadership
Using data to improve your team
Several things struck me this week in ways they haven’t as profoundly in other Team Leader training we have done:
We need to invest more time and energy in developing Team Leaders early on in the development and delivery of programs rather than doing it after the program has been running any great length of time.
We need to help people better understand the differences between leadership and management.
Team Leaders need a safe space to explore ideas, network, expose deficiencies and ask their peers for help and guidance. This won’t always be successful when their funder is present.
The right combination of real life situations and theory are core components for Team Leaders to soak in what they are learning.
The uniqueness of the Team Leader position needs to be better understood and embraced by the organizations that they work for and the staff that are supported by them.
Some organizations are not investing in full-time Team Leader positions, which can affect team performance.
We can’t look at Team Leader training as just a two-day event and need to better position it as a worthwhile online casino investment as part of the learning culture and professional casino development within each organization.
If you’d like to learn more about our Team Leader training, drop me a note at idejong@orgcode.com
National Alliance to End Homelessness Conference 2011 – aka #naeh11
My last tweet from the conference claimed that #naeh11 rocked harder than KISS on a stadium tour.
I stand behind that even as the days pass since the conference ended and reflection sets in and turns in part to wisdom. I think what made it rock for me this year was different than past conferences.
From my vantage point there was a bit of an edge amongst conference delegates. The edge wasn’t defiance. It wasn’t even anger per se. It struck me that there was frustration.
The source of the frustration? I heard over and over again the impact of the economy on local communities and state governments and decreased fundraising efforts. I heard over and over again about increasing demand for services. But I actually don’t think it was solely either or limited to both of those things.
I think there are communities that entered into 10 Year planning fully committed to seeing homelessness ended. But now they see the 10 Year Plan sit on a shelf or the local leadership shift or the resources made unavailable.
I think there are people and organizations that understand truly what effective approaches and evidence-based practices are and work hard to implement them, only to find other organizations still questioning Housing First, Rapid Re-housing, Critical Time Intervention, Harm Reduction, Trauma Informed Service Delivery and the like. They feel it is a constant, up-hill battle.
I think that the misuse of phrases and terms is stoking the frustration. There was Sam Tsemberis – the Mac Daddy of Housing First in the US – delivering a Keynote Address, and yet I heard “Housing First” misused at least a dozen times over the three days. I suspect that makes Sam cringe as much as it does me. Another overused, misused term was “case management”. I’d like to think it was only misused by those without formal training in social service delivery, but I am probably wrong on that front. I could go on and on and on. But as this relates to frustration, one of the things that makes the housing and homeless service delivery system so hard to explain to people is that we keep changing the language or have senior managers use language incorrectly and the like. Kind of makes it hard to communicate to other systems. (And as a related aside, can we PLEASE agree that we work with “homeless people” or “homeless individuals” or “homeless families” and respect that they are a heterogeneous group rather than saying “the homeless”? Thanks.)
I think we are feeling the effect of leaders amongst the boomers retiring or moving on to other challenges. Now is the time to provide Leadership for Outcomes (which coincidentally is a training series we offer – not that I am trying to make a plug in the blog). But I think we need to realize that it is frustrating when people mistake management for leadership…when the people looked up to in local communities do not have the tactical nor technical proficiency to be pull off what they are asked to lead.
I think we are looking to new energy and change-drivers to make things happen locally and that some places just need renewed energy. As Becky Kanis of the 100,000 Homes Campaign shared with me, a lot of the individuals driving the local boot camps and registry weeks are not the usual suspects or even who might be expected to take on such a role given their position.
I think the edge was even there with some of the speakers and presenters. For example, I absolutely loved how Sam defined this as the “decade of impatience”. I loved how Mark Hurwitz from Project Renewal in NYC presented figures on rates of incarceration and the inherent problems with sledgehammer force and precision in a session on working with ex-offenders. Then there was Elaine deColigny from EveryOne Home in Alameda County who did a sensational job talking about targeting prevention and essentially telling people to stop the guess work on prevention efforts and become data driven and evidence-informed. I loved her quote, “Data is like crack. Get a taste & you’ll want more.”
I felt the frustration amongst people who attended the sessions that I provided. One was on Data and Performance Simplified and the other was with Susan McGee, Amanda Sternberg and Kim Walker on creating an approach to Performance Measurement at the System Level. As usual, I brought the funny but didn’t get nearly the same energy from the attendees. In fact, for the first time ever I had two different people tell me to stop being funny at the sessions because it was distracting. Aside from jokes, people shared their stories with me about trying to take data and performance measurement seriously back in their organization or community only to have little or no support. I heard anecdotes about senior managers ignoring data whenever it told them something they didn’t want to hear.
And lastly I think there is a certain frustration with the sheer magnitude of change that people and organizations have experienced without yet having the opportunity to enjoy the “new normal”. My good pal Dr. John Whitesell introduced me (and others at conferences) to the great quote from Bartlett and Ghoshal’s The Leader’s Change Handbook, “The metaphor of a caterpillar transforming itself into a butterfly may be romantic but the experience is a highly unpleasant one for the caterpillar. In the process, it goes blind, its legs fall off and its body is torn apart to allow the beautiful wings to emerge.” I think some people and organizations are frustrated that they are still in the going blind-leg falling off-body torn apart stage and still haven’t got to the beautiful wings moment.
But lest you think the frustration is bringing me down, it actually gives me a lot of hope. See, people are frustrated because they care. If there were indifference, people would be checking out, not being frustrated. I think the Alliance is doing the right things through knowledge dissemination and certainly through the HEARTH Academy to try to challenge and harness that frustration into something positive – a force for good. I think social media will allow people the opportunity to vent their frustration and find like minded souls from around the world that share their approach and feelings to wanting to end homelessness even if they cannot always be nurtured locally. I think that through collective impatience that revolution – dare I call it a permanent revolution…but no, not “that” permanent revolution – is entirely possible. I think new initiatives and campaigns give people something to focus on and invest in to turn frustration into favourable energy. I think attending a conference with some 1,200 or so delegates that more or less also believe that ending homelessness is a good idea provides a safe, comfortable place to be frustrated – and I’ll take that frustration over the brand of frustration likely found in other communities large and small that still resist a change in focus to ending homelessness – the type of place that puts the “fun” back in “dysfunction” with the dynamics of how they relate to one another.
I can’t wait to share the journey with these frustrated folks over the next few conferences – assuming I get invited again in the future. Seems to me that if handled right this frustration is a sign of greater things to come.
If you want a copy of Iain’s presentations from the conference, send him a note at idejong@orgcode.com
Making Sense of Data
On one of my recent hotel stays, this is what the dashboard showed inside the elevator:
Now, there are a few interesting tidbits that make this story even better. First, when I checked in I was told I was on the 1st Floor, which is AKA “L”. Second, 5 is really the second floor. Third, there are only four floors to the hotel.
I suspect to the people that work at the hotel and use the elevator daily, this number series makes complete sense. To me, well, it reminded me of those times that I have been parachuted into homeless management systems to help make sense of what is going on. In most instances, they have a collection of data points – sometimes with peculiar labels like this elevator dashboard – and an assumption that everyone knows what the starting point is. Truth is, for any information system to have meaning, it has to be easily understood and be logical.
Next week I will be in Washington, DC speaking at the National Alliance to End Homelessness conference. One of the sessions I am doing with Amanda Sternberg, Susan McGee and Kimberly Walker is on performance measurement. During that presentation I will be stressing these key points:
Begin the design of your performance measurement system with the end in mind. Too often organizations or communities have been collecting oodles of data without knowing why they are doing it or what it is going to tell them. I say articulate in one sentence what your organization intends to do and the change it seeks to create.
Have solid strategic objectives. If you have good objectives and good measures for those objectives then you are actually testing whether the change that you want to see (say, ending chronic homelessness) is actually happening.
Create a data loving culture. Believe it or not, with enough cheerleading data collection, analysis and use to improve performance can be motivating and – dare I say it – fun! I look for data to be used and performance measurement to occur top to bottom and bottom to top within an organization. I love seeing Boards use data to make decisions and staff wrestle with what information is saying to that they drive improvement.
Ensure the data collection and performance measurement has value. If frontline staff don’t see themselves reflected in the system, they simply won’t use it or they will lie or a combination of both. Recent surveys we have done show that at least 1 in 5 organizations have had staff that have felt this way. Oh, and do clients see value in having their information collected and analyzed?
Focus on getting better and better and better. A solid incremental approach is better than starting with a monstrous performance measurement design that fails because of its own weight. Building over time and getting better over time is entirely acceptable – and encouraged.
Iain learned to embrace his inner-nerd a long time ago, and as a result has found that between his experience as a practitioner and data-geek a fine balance can be formed to help organizations out in a meaningful way.