Speaking Up to Address the Stigma: Challenging The FaceBook Mental Health “Game”

I am a 40-something guy. Included in my friends on Facebook are folks that I have not seen since my high school years. Maybe you have some friends like that too. I like their life milestones and updates on their children. I like hearing stories about their own parents – many of whom I have not seen in over two decades. And I also like that they are a decent barometer of how the general public thinks about issues, given my day to day is entrenched in issues like homelessness, addiction, mental health, trauma, and family breakdown.

Recently, a FaceBook “game” was introduced by one of these high school pals. I have no doubt this is the sort of thing that may have made its rounds in your friend circles on FaceBook too. It goes like this:

You’re in a mental hospital. Use the first 7 people on your tag list in order..no cheating! 

Your roommate: 
Person licking windows: 
Person helping your escape: 
The doctor: 
Person running around naked: 
Person yelling nonsense: 
Person you went crazy with: 

A clean copy for you to fill out is in the comments..let’s see if yours is as true and funny as mine!

And it made my heart sink and angered me at the same time. I don’t hide the fact that I live with mental illness. Goodness knows I have found things to laugh at in my own recovery journey. But that is ME having a laugh at MY mental health. I suspect there are also peer groups that could appropriately share their experiences and chuckles with each other. BUT, it doesn’t reinforce stereotypes nor find delight in the compromised wellness of others. I mean really…person licking windows? Running around naked? The person you went crazy with? That escape is necessary rather than achieving important assistance? (If only people knew how difficult it was in most cities for someone to get admitted for care when their mental health is unwell.)

No doubt some folks are naive when it comes to mental health. Very few folks ever set foot in a mental health hospital or the psychiatric wing of a hospital. Very few very visit a mental health clubhouse or peer support group. Very few ever visit supportive housing for people that live with serious and persistent mental illness. Very few have ever spent significant time doing street outreach or being in a shelter where the shortcomings of mental health systems are so blatant.

Does that condone efforts to make fun of mental illness? No.

So, I pointed out that maybe finding jokes in this type of FaceBook game was insensitive and poor taste. What I encountered wasn’t a response that was considerate of this point of view, but rather, a pushback that I was too easily offended.

And I think that is a problem. It speaks to the ongoing efforts needed to get mental health out of the shadows and into the light, and to address stigma head on. Can you imagine the outrage if there was a FaceBook game that went something like “You’re in the barracks of the plantation” or “You’re on the train to Auschwitz” or “You’re in the Residential School”. Of course that would be completely unacceptable.

It is also unacceptable to make it more difficult for anyone already struggling to come to grips with their mental health or share their mental health with others if there is entertainment that takes delight in reinforcing stereotypes, or mocking people for behaviours that may stem from mental illness.

But this cannot just be people like me that live with mental illness that speak up and say that finding humour in games like this is offensive. It requires everyone to have a sensible discussion to point out that mocking people for their mental illness is not different that mocking people if they have cancer or kidney disease or a heart condition. Sickness is not comedy.

Nice and Ineffective

Let us put an end to people, organizations and communities being really nice, but ineffective. Inappropriately trained and nice is no way to solve a complex social issue. Well-intentioned uninformed people remain uninformed people. And all the niceness of the world does not take us even one step closer to solving a complex social issue.

Shame on any industry that confuses having a big heart with having a big head. Don’t know the theoretical underpinnings of one approach to service over another? Stop practicing. Don’t understand how to collect and use data to evaluate and inform practice? Stop practicing. Don’t know the main currents of thought and practice and how to execute that knowledge? Stop practicing.

Or start learning. Please. A really big heart may be killing people.

Today in your city, if I were to go to an emergency room, I bet there would be people in a waiting room of some sort. Goodness, I hate that. It is so sad. Don’t worry. I have seen my share of House, MASH, Doogie Howser, and ER – plus I love TLC medical shows. I will throw on a lab coat or some scrubs and go down and start practicing medicine immediately. No? What do you mean I should be trained first? I have had my gall bladder out and my appendix, plus my hip has been reconstructed. I am a person with lived experience. Not enough expertise? But c’mon, people are suffering there waiting. No? You want standards of care? Certification of expertise? Years of practice and experience? I am NICE, dang it! I care! No? Not enough? Huh.

Yet arguably there are people experiencing homelessness, economic poverty, domestic violence, housing insecurity, immigration hardships and the like in your community that have deeper, more in-depth needs that the folks that I would encounter in an emergency room. And who do you turn to for help? Sadly, in too many cities, well-intentioned, big-hearted but untrained volunteers and untrained staff. Well-intentioned but uninformed people. There is no doubt in my mind this makes matters worse, not better. It exacerbates the complex social issues. It ruins people’s lives when people try to provide service when the service providers are untrained. When someone confuses “common sense” with “education, practicum experience, and standards of service” we are essentially suggesting that we don’t care if people receive quality, professional services to alleviate their issues.

And what happens? People get worse, not better. Voluntary responses grow, not shrink. People get band-aids instead of solutions. I think it is about time we invested in the services people deserve and invest in professionalizing services rather than remaining nice, but ineffective.

Sheltering Shelters

Sometimes shelters are amazing. They do incredible things to help people achieve housing quickly and appropriately. Sometimes shelters are the antithesis of ending homelessness. It is healthy to create a voice for people on the frontlines that are confronted with these challenges to share their experiences so that we can all understand where to support and push for reform. I invited Jessica Douglas to contribute to this blog based upon a recent experience. I hope it is illuminating for you and leads us all to greater examination and professional change in sheltering services when it is warranted. Thanks Jessica for such an important guest blog.

I’ve gone back and forth in my head all afternoon with different ways to go about writing this blog. Since this is my first blog, I wasn’t sure what was acceptable or what would get someone’s attention. But then it dawned on me – honesty. Yep. That’s what I came up with. Sounds pretty boring, but I’m going with it.

Let me start out by saying, I’m a pretty approachable person. Recently described by a co-worker as being calm and centered, today I was pushed to the brink of going completely unprofessional on another provider. In all of my professional adulthood, I have never wanted to go completely “postal” on another person. When is it acceptable for a provider to “shelter”, and I don’t mean put a roof over their head, an individual to the point where they can’t leave the facility to go have lunch with someone?

For a few months now, I’ve been out in the field, meeting with clients and other providers! I love it! It’s where I’m most comfortable: interacting with individuals on the streets and those who have been recently housed. What I do not like is providers who feel as if they are “protecting” their clients by monitoring their every move. How is this benefiting those individuals? Well, in my professional opinion, it’s not. It is, however, benefiting the facility because they are able to count them as widgets.

It’s not allowing them to grow as a human being, to give them the opportunity to obtain a job, meet new people (outside the facility), to find an apartment or a home. SAY WHAT?!? A JOB? A HOME? It’s as if those are words not to be discussed, because as I heard a resident say today in the lobby of this shelter (as he was signing 3 pages of rules), “This is my home away from home”.  How sad is it that this facility has residents thinking this is their final destination?

Today I was told I was not allowed to pick up a client because she didn’t have prior permission to leave the shelter. Mind you, this person did have permission to leave with me 2 hours later than when I tried to pick them up. I was told that she was not allowed to just leave whenever she wanted to that it had to be approved. Yep, you heard that right, a person who is not in JAIL or on HOME CONFINEMENT, has to have permission to come and go. Oh, and yes, this person is 18 years or older. This isn’t the first time we’ve had issues with picking this person up and taking them out to enjoy a nice day away from the shelter. Every single time she is dropped off she is interrogated by staff, and other residents, who want to know if she was given money and/or what did she do.

I was also told that I couldn’t just move her out whenever I wanted to, proper staff had to be present to make sure nothing left the shelter that wasn’t hers, meaning she couldn’t leave during the weekend. Without given a chance, they already expect the worst of the every person who walks through their door looking for a safe place to stay. They expect to be stolen from. They label everyone who enters, possibly in the midst of the worst crisis they will ever experience; being homeless and having no one must indicate that you are a thief.

The most disturbing thing I was told today, the thing that pushed me over the edge, is that we were “going behind their back”. We went behind their back to do what is best for this individual, move her out of a situation where they are hindering her ability to grow as a young adult, and moving her into STABLE HOUSING. SHOCKING, right? Why the best interest of this individual isn’t their top priority, I may never know. What I do know, we at WVCEH are doing the right thing, we are moving her out, into her own apartment at the end of the week where she will receive intensive case management by people who truly care about her and success.

Moving the Needle with Reluctant Funders/Politicians

This week we got two separate notes asking for a blog. They are related themes.

In the first note it asked for a blog about when communities have to make tough decisions on funding to move the needle forward. In that community they are taking loads of flak politically and in the media for changing funding to focus on ending homelessness. City Councillors are considering a motion to continue to fund services for another year to allow impacted organizations to transition. This after consultation and community engagement for the past 18 months to prepare for the transition.

In the second note it asked for a blog about what to do when communities have been moving forward to align funding to end homelessness rather than ineffective programs, but that those organizations most impacted have strong political connections, and those politicians are now exerting considerable pressure to reconsider what is best.

MOVE THE NEEDLE!

Consequences suck. Political involvement/interference sucks. Backlash from service providers sucks.

Sometimes “suckage” and “rightness” are directly related. The more “suckage” there is sometimes directly indicates that you are doing the EXACT RIGHT THING.

Service managers and COC leads have a responsibility. The responsibility is to achieve the greatest amount of effectiveness through service providers in the amount of funding available. They are also responsible to ensure that there is monitoring and oversight. When things are awry it is the service manager/COC best positioned to move the community towards system change.

There are good change processes and bad change processes. But let’s face it – change is always hard. What service managers need to appreciate is that the interest of a politician is different than the interest of a service manager. A service manager wants to end homelessness. A politician wants to keep constituencies happy – including non-profit organizations in many instances. Service managers live and breathe data and evidence and best practices. A politican lives and breathes optics, public image, and community engagement. Does that make one right and the other wrong? No. It does, however, means that there is not always alignment.

If you want to figure out how and why the politics of the right and just decision plays out the way it does, answer me this question: on a scale of 1-10, what is my favourite color in the alphabet?

You guessed it – it makes no sense.

In an era of believing (continuously) that we can charge less taxes and get better services, public servant after public servant; CoC lead after CoC lead is being asked to do more and better with less. They research. They go to conferences to learn. They consult. They consult again. They agonize internally on how to go about making huge changes. They educate. They put out information. They host information meetings. The form committees. And then form committees that come out of committees. And still? Politicians seem hell bent on maintaining the status quo or spending even more money to work through the change.

A weak public servant or COC lead caves to the pressure. They continue to fund the status quo. The give up. Change that was meaningful was in their grasp. What they don’t know is that political issues have a cycle. The one year of additional funding is about saving face in the present. Two years from now, political leaders will be patting themselves on the back for the decisions made at your pay grade.

A mentor of mine once pointed out to me that which I see more and more the older and more experienced I become: if you cannot critique content, you critique process. Chins up, my friends. Moving the needle is the bravest thing you will do in your entire careers. And it is the right thing to do. They only want to come up with transition funding or question what you have done because they know you are actually doing the right thing, but they need some political cover.

Yes, the VI-SPDAT & SPDAT Meets HUD’s Coordinated Entry Expectations

As you may already know, the VI-SPDAT and SPDAT (and variations related thereto) on the most widely used assessment tools in homeless services. They also meet all of HUD’s expectations for coordinated entry, if you have read what HUD has recently shared. Let me walk you through it.

HUD says the assessment tool should be phased and situationally applied. If you have attended any training on the VI-SPDAT and SPDAT, you know the situations in which the tools should be applied, when they should be avoided, how to triage, and how to assess further.

HUD says the assessment tools should not result in a homeless household having to tell their story over and over again. We totally agree. There is nothing trauma-informed about a homeless person or family having to re-live their homeless story over and over again. The assessment should follow the person. If you are providing service and assessment using the VI-SPDAT and SPDAT, you know that one of the fundamental aspects of the tools is that the assessment follows the person and is shared across providers.

HUD says the assessment tools should only capture necessary information, and that the information collected should be based upon evidence. The VI-SPDAT and SPDAT rely on almost 300 peer reviewed published pieces of literature, government reports that have a sound methodology, rigorous testing, and a range of data points. They are intended to result in informed, objective understanding of current vulnerability and future risks to housing instability.

HUD says people being surveyed should have the autonomy to refuse to answer questions. Not only does the VI-SPDAT and SPDAT rely upon informed consent to complete, the opening script for the VI-SPDAT and the structure of the questions are clear that participants can skip or refuse any question they do not wish to answer.

HUD says the tools should be person-centered and help inform consumer choices. We totally agree and are frustrated when any community uses the tools incorrectly. The VI-SPDAT and SPDAT provide data. They help inform decision-making. They do NOT make decisions. They do NOT force people into one type of housing or program.

HUD says assessment tools should be culturally competent. Almost 900 different households have been directly involved in the creation of the tools, incorporating a broad range of races and ethnicities. The tools have also considered and involved a range of different experiences as it relates to gender identification, sexual preference, citizenship status, etc.

HUD says the tools should be user-friendly and capable of being applied by non-clinical staff. Both the VI-SPDAT and SPDAT have been created so that non-clinical staff can be used. And because so much of the language of the tools has been informed directly by people experiencing homelessness, the words used and results are intended to be user friendly to program participants.

HUD says assessment tools should provide meaningful recommendations and avoid long waiting lists. The VI-SPDAT and SPDAT recommend the type of housing and support intervention that should be considered. These tools do NOT make decisions, they provide decision assistance (it’s even in the name of the tools!). That decision assistance is data for recommendations and consideration. We also, as anyone knows that attends VI-SPDAT or SPDAT training, are against assessment for assessment sake. Action should follow.

HUD says the tools should be sensitive to persons with lived experience. How is this reflected in the VI-SPDAT and SPDAT? As previously mentioned, people with lived experience have had a direct voice in the creation of the tools. They have also been informed by a broad range of experts to ensure sensitivity to lived experience. Finally, experts in trauma and abuse were retained to review the VI-SPDAT and SPDAT, and inform the components on Trauma and Abuse to help decrease the likelihood of anyone being retraumatized through the experience of being assessed.

VI-SPDAT and Rapid Re-Housing Recommendations

We are reprinting this piece this week from previous content on the OrgCode Facebook page (which you should like by the way). Questions continue to come up on how and why the VI-SPDAT suggests people should be considered for certain groups of people. This attempts to answer that question.

One of the most popular questions we have been asked – especially with the growing use of the VI-SPDAT and the 25 Cities Initiative with homeless veterans – is a repeated variation of “How can rapid re-housing be an effective intervention for…???” – and then finish the sentence with “people unattached to services” and/or “people with a serious mental illness” and/or “people living outside for many years” and/or some variation related thereto.

Before diving too deep into the answer, there are a few important things to address: the purpose and approach to Rapid Re-Housing; the purpose and intent of the VI-SPDAT; the relationship between the VI-SPDAT and SPDAT; and, how it is possible to meet the definition of chronic homelessness yet still be recommended for a Rapid Re-Housing intervention.

In the VI-SPDAT and SPDAT tools, Rapid Re-Housing is seen as a specific type of intervention. Aligned with the overall philosophy of housing first, Rapid Re-Housing focuses on identifying people with a moderate level of needs. These individuals are then provided time limited financial and/or case management assistance, along with assistance accessing housing. Rapid Re-Housing is NOT simply access to an apartment nor is it just a subsidy. Given the flexibility of case management supports within this time-limited period (usually 3-6 months with some possibility for extension), some people will need a light to medium “touch” to stabilize in housing and access other mainstream services.

That said, there is nothing that precludes a case manager in Rapid Re-Housing from providing a more intensive level of support for a shorter period of time to help the person get connected to resources that will support ongoing housing stability. An example might be the person that has serious mental health issues impacting overall wellness, but is not currently connected to mental health resources in the community. A mental health diagnosis or a psychotic episode does not mean a person will necessarily require intensive supports for the rest of her/his life regardless of how they present at time of initial engagement. Everything we know about Mental Health Recovery proves this time and again. However, if a case manager is not trained on how to appropriately provide Rapid Re-Housing supports aligned with best available evidence and current proven practice, they may very well be stymied by the seemingly complex presenting issue(s) and think a more intensive service is required.

One of the other issues we come across is that people fail to understand exactly what the VI-SPDAT and SPDAT assess for, and therefore start making assumptions that are inaccurate. These tools examine current state of vulnerability and future risk of housing instability. They are born from peer reviewed published literature, considerable data, and a large number of government documents. They have been carefully tested and examined to ensure they do what they are supposed to do. Even with that said we sometimes hear things like “But the tool doesn’t examine how engaged they are with current services – and that’s a priority for us”. That may well be a priority – and may even be an appropriate one for your program – but connecting to services and a determination of whether those connections are effective is a function of case management (it gets at the very theory and practice of case management). If/when case management is done well, people that are disconnected from resources and have profound needs are connected to the best available resources in a meaningful way, can and do attach well and get positive outcomes. I stress “outcomes” here because it is not just making a referral or a scattered shot approach to seeing what will stick (that has more to do with how one might measure outputs) – what we want to know is if those attachments make a difference.

It also bears repeating that the VI-SPDAT and SPDAT are intimately related, but are different instruments. The VI-SPDAT is a triage tool. It looks for the presence of an issue. The SPDAT is an assessment tool. It looks at the nuances of the depth and impacts of what is happening in the person or family’s life. We always encourage people that use the VI-SPDAT to also use the SPDAT whenever possible. Why? One of the main reasons is that if you are ever in doubt of the self-reported response or depth of needs reported through the VI-SPDAT, you can explore deeper using other methods in the full SPDAT instrument. The analogy we most often use is this: the VI-SPDAT is the triage station in an emergency room, determining whether or not there really is an issue, the severity of the issue in comparison to all others that have issues at the same time, and the sequence/priority of serving people; the SPDAT is what happens when the physician sees the patient after triage, exploring a complete history, context, co-occurring issues, and the most appropriate treatment pathway. Both the VI-SPDAT and SPDAT inform the work of prioritization. It is providing objective, evidence-driven advice to the assessors on who should be served next and why. If a community had more staff, time, money, housing or other resources than it knew what to do with the matter or prioritization would not be necessary. Both the VI-SPDAT and SPDAT move service providers out of a mentality of first come, first served to a thoughtful, deliberate strategy that objectively determines who needs to be served in which order.

Lastly there is the matter of how a person can meet the definition of chronic homelessness and be recom- mended for Rapid Re-Housing instead of Permanent Supportive Housing or a more intensive intervention. There are several circumstances under which this may occur:

• There is a bottleneck in service delivery, and the individual has met the time requirements of the definition for chronic homelessness because there is a lack of capacity or other deficiencies in the service delivery system, rather than because the individual is dealing with complex, co-occurring issues that impact his or her ability to maintain housing;

• The person has a small number acute issues that seriously impact his or her housing stability, rather than a larger number of complex, co-occurring issues; the cumulative impact of these issues may result in the person meeting the definition of chronic homelessness even though he or she has lower overall acuity.

• Note: Most people that live in your community who are coping with issues like extreme poverty, substance use, or compromised mental health will never experience homelessness – that is a statistical fact, and as such it is better to understand what those individuals are able to do in order to access and stay housed, rather than acting on an assumption that homeless persons with the same characteristics MUST have permanent supportive housing in order to be successful in housing.

What the Data Shows

We have been able to pull comprehensive data from three test-site communities that have used the VI- SPDAT and SPDAT where:

• each community was trained on effective Rapid Re-Housing strategies by OrgCode Consulting,

• where we have thorough demographic data, and

• where housing retention data on the households is available and complete.Two of the communities are from Michigan and one is from California. In each test community we pulled a random sample, weighted by proportionate size of homelessness in the community, as per the last PIT Count. Each is a different size community with remarkably different characteristics.

Data on Households Recommended for Rapid Re-Housing Intervention

1 This includes any return to homelessness with current homeless or unknown status since time of initial housing access. Lengths of time since housed for households included in this data analysis were a minimum of 1 month (representing less than 5% of all households included in analysis) to households housed greater than 1 years (43% of all households included in analysis).

2 There is the presence of a mental health/cognitive functioning issue, substance use issue and physical health issue within the same person.

3 The Family VI-SPDAT and Family SPDAT were used for assessing these families.

4 If a family is noted as “Known to Have” a mental health, physical health, or substance use issue – it can be any member of the family, not just head(s) of household. Tri- morbidity in these instances means it is the same family member that has all three conditions, but still does not necessarily mean it is a head(s) of household.

5 These families represent 3,011 people.

6 None of the Youth Households were families, nor were any veterans.

Veterans Non- Veterans

Discussion

As is the case in almost every community where data has been shared with us, the single greatest group of people requiring Rapid Re-Housing are non-chronic households, but there are, to varying degrees, a percentage of people in each community that meet the HUD definition of chronic homelessness, yet are recommended for a Rapid Re-Housing intervention based upon acuity level. Chronic homeless house- holds have been homeless longer on average; however, they do not consistently have higher acuity than their non-chronic counterparts.

Both chronic and non-chronic households have a percentage of households that lose housing and return to homelessness. It seems inevitable that this will happen for some of the households served. While chronically homeless households are slightly more likely on a percentage basis to return to homelessness, in absolute numbers this is a rather small number of households.

Furthermore, in digging deeper into understanding the characteristics of those households that lost housing, there is no significant relationship between losing housing and any particular presenting issue, whether that be mental health/cognitive functioning, substance use, physical health, or even tri-morbidi- ty. Overwhelmingly, a household with any one or combination of these issues is more likely to stay housed than to lose their housing.

What is not known from this data is the impact the training delivered by OrgCode Consulting on effective Rapid Re-Housing strategies had on the overall outcomes. As previously noted, each of these communi- ties received the training in addition to using the tools. There is no untrained control group in any of these communities to compare the results against.

Moving Forward

There is a regular cycle for updating the VI-SPDAT. During the update cycle, any community using the VI-SPDAT is welcome to provide input for consideration on future versions of the tool. Analysis of all the input provided will provide a course of action for future amendments.

Increasingly, communities are seeking additional training on the VI-SPDAT – how to apply it; how it relates to prioritization; the best approach for engagement; etc. We encourage communities to go this route, especially if there is any doubt on its application or effective engagement locally. At a minimum we recommend that communities effectively use the VI-SPDAT Manual to ensure the application of the tool is sound.

Furthermore, many communities forget or did not know that they can add other questions to the VI- SPDAT, so long as they are non-scoring questions. Most often this occurs at the end of the survey. If there is a specific local or program interest that you want to inquire about, by all means add the other ques- tions. If that has a direct tie into program prioritization or priorities for a particular funding initiative, it allows for data sorting to occur in a meaningful way, staying true to the VI-SPDAT and your specific needs at the same time.