Supporting People that Have Complex Challenges and Have or are About to Lose their Accommodation: When is it Okay to Say “That’s enough, we’ve done all we can?”

The OrgCode team get asked this question a lot. As communities find themselves housing and supporting more and more people with higher acuity and unique personalities and behaviors, they are facing an increasing number of challenges. Amidst those challenges, there is a desire on the part of some service providers to draw a line in the sand…a threshold that cannot or should not be passed, and if there is, comes with a consequence of retracting housing and/or support. In performing due diligence in these difficult situations, I think the following questions can provide good guidance:

Are your staff to client ratios sufficient?

Some organizations have started serving higher acute people without adjusting their staff to client ratios. They are still using old ratios of when they had a greater mix of people to support or lower acuity people to support. Maybe the reason the person/family is struggling with maintaining their housing is that there are not enough work hours in the week for you to adequately support people with higher needs. Adjust your caseload and the problem may be fixed.

Do you know whether or not the person/family still wants housing?

Choice is paramount to our work. Too often I have seen well-intentioned service providers make assumptions about a person or family wanting housing or continuing to want housing when there are difficulties. As painful as this may seem, it is still the person/family’s choice of whether or not they want to continue with accessing or maintaining housing. Don’t assume – ask. If they do still want housing, fantastic. If they don’t still want housing, don’t pressure them to accept or want something they have rejected.

Do you believe in Housing First?

Here, I am talking about Housing First as an intervention, not as a philosophy. One of the core tenets of the Housing First intervention is that a person does not lose their supports if they lose their housing, so long as they still want to be housed. As such, there are no limits on the number of times a person/family can be re-housed, so long as they still want supports. There is no “enough is enough”.

What types of cases are you prioritizing through Coordinated Entry for Permanent Supportive Housing?

Imagine a situation where the very people you are struggling to keep housed are, in fact, the same types of people you are making a top priority for Permanent Supportive Housing…why would you keep prioritizing a type of household you don’t know how to support?

What is the nature of the difficulty in sustaining the tenancy – and have appropriate measures been tried to address these issues?

Not all disruptions or issues with a tenancy are equal. And each has different strategies and techniques that can be used to address them. For example, non-payment of rent can potentially be addressed by having a payee. Relatively simple. Another example, a person who performs arson in their own unit may be okay if moved to an older unit made of cinder blocks without other flammables. Relatively hard. Then there are those situations in between. Take for example, a person who uses substances in a challenging or chaotic manner. Perhaps putting harm reduction strategies in place can modify when they use, where they use or who they use with, thereby decreasing impacts on the tenancy. Guest management is also a frequent issue named. Personal guest policies can work, but are not foolproof. Perhaps a move to a 24/7 PSH building with onsite staffing, a concierge, and or restrictions on the number of guests allowed at one time or defined hours for guests would make the difference.

Were program expectations clearly communicated in multiple formats?

There have been instances we have evaluated where the central problem is that program participants never had a conversation regarding what it means to be a responsible tenant before they moved in, didn’t understand (or even review) the lease, or if there were other expectations of participating in the support program, this was not done in advance. We recommend that time is spent discussing or role playing elements of being a tenant in advance of being a tenant. We also recommend that we try to communicate these expectations in different formats – at least in writing and verbally. We have even seen some programs use pictures to demonstrate acceptable and unacceptable ways of meeting expectations. Lastly, when it comes to the lease, we strongly recommend people do not just sign on the bottom line without understanding what they are signing. To that end, we have encouraged many programs to take standard lease clauses and have them rewritten in plain language that program participants have a greater likelihood of understanding.

Was the match to the type of unit appropriate?

Let’s say the program participant likes to party until 4am with their friends. While rare, it may be possible to find an accommodation where this is entirely okay as opposed to, say, a traditional multi-unit residential building filled with families and senior citizens. We have seen instances where the matching process was improper in the first go-round, but having the person move to a trailer in the country was fabulous; and other instances where a person was moved to a building where seemingly all of the tenants would also be up to 4am on a regular basis with their friends, and adding one more to the mix didn’t upset the apple cart.

Is transfer to a different type of support program possible?

Not ideal at a large scale, but possible with individual cases, is transferring people from one type of support program to another. This is not about pushing a “problem” ahead, this is about improving the match. Maybe Rapid Re-Housing isn’t enough and the person would benefit from Intensive Case Management or Permanent Supportive Housing. Maybe Permanent Supportive Housing isn’t enough and the person meets the criteria for an Assertive Community Treatment program or a Long-term Care Facility of Hospice Care. The more communities function as systems of care, rather than a collection of projects, the easier it is to make these sorts of housing-support transitions.

Are there variations in success across different service providers?

This is where a common assessment tool and good data can be your friend. Let’s say you have two (or more) service providers who generally serve people of comparable acuity with comparable staffing levels. If Agency A is achieving long-term housing success with most of its program participants and Agency B is not, what can Agency A teach Agency B so they have similar success?

Do you have the right training?

There are many instances we have encountered where the issue is NOT the program participants, it is that the service staff were never trained on how to adequately, and in many instances proactively, address the types of situations and behaviors that place the tenancy at risk. Every organization needs to review the core competencies required for housing support positions and ensure staff have access to the training that allows them to meet those core competencies.

What types of tools and information are you gathering to enhance supports?

Whether using the SPDAT (not just the VI-SPDAT) or other type of objective assessment tool, mine the information for direction on where best to proactively support people. Couple this with information that is gleaned through the intake process and home visits. Proactively put together a support plan or use tools in your toolbox that can decrease the likelihood of permanent disruptions to the tenancy. Consider things like a Risk Assessment, the Honest Monthly Budget, Crisis Planning, and using the SPDAT to support Stages of Change.

Is there a community table to case conference challenging cases – preferably with the program participant present?

Some of us are usually smarter than one of us. Put together a structure in your system of care where a broad range of service providers and allied professionals come together at set intervals to brainstorm ways to better support program participants that are struggling. The answers may be found in the minds of those around the table. And when the program participant is welcome at the table, they have a direct voice in expressing their current and future needs.

A Gathering for Senior Leaders

One of the great joys of my career has been the Leadership Academy on Ending Homelessness and Master Class. Ann Oliva and I are shifting things up a bit this year, focusing on having a gathering exclusively for senior leaders…Managers, Directors, Executive Directors, Presidents, Vice-Presidents, CFOs, COOs, CEOs, CPOs and Board Chairs – or comparable positions within your respective organization.

The gathering is set for Pittsburgh November 13, 14 and 15, 2019. It is three full days. Attendees will be placed in a cohort with 9 other people of comparable experience and work through six modules: Leadership Capacity and Momentum; Funding; Awkward Conversations and Conflict; Navigating Politics and Community Interests; Performance; and Relationships. Each module is a half day. Each module has its own senior leader as a facilitator. There are also plenary sessions on Equity, the Psychology of Change, and Why is This So Hard?

Registration is limited to 60 people. First come, first served. Registration up to July 31, 2019 is $779 and you can sign up through our friends at the West Virginia Coalition to End Homelessness www.eventbrite.com/e/orgcode-senior-leadership-gathering-tickets-61821604082 OR wvceh.eventbrite.com If three or more people from your organization are planning on attending, please contact academy@WVCEH.org for a reduced rate.

A block of rooms is available at a discounted rate at the Sheraton Pittsburgh Hotel at Station Square. Call 1-800-325-3535 to make your reservation.

Attendees do not have to have completed the Leadership Academy or Master Class. However, attendees must be in a senior leadership position within their organization, and believe that ending homelessness, while daunting, is possible. You will be a good fit for this event if, even in your position and given your experience, there are still leadership challenges that you are confronted with where skill development and creation of a peer network would be helpful to you.

We are creating a safe space for senior leaders to build a network with other senior leaders that will last beyond the event. It is our intention to delve into each of the topics from a senior leadership perspective, and to equip senior leaders with tools, strategies and critical questions that help propel their work forward. We know that this work is difficult and that those in senior leadership positions are often without a peer group to explore challenges and opportunities.

Prior to the event, each registrant will be required to complete an online survey to help match them to the most appropriate cohort of other attendees. It is not a particularly long survey. You will receive it when we are a couple months out from the event.

If you have questions about content of the event, please contact me (Iain) at idejong@OrgCode.com OR if you have questions about registration or coming as a group, reach out to academy@WVCEH.org 

Don't delay - register today!

Is Harm Reduction Enabling?

In our field we talk frequently about applying harm reduction to our practices. There are a range of strategies that can be employed, from making sure people have safe storage of their alcohol, drugs and related works to provision of clean needles, pipes and screens; from education and focused conversations on change in use to safe injection sites; from managed alcohol programs to workshops. Even though many of us employ harm reduction strategies in our everyday life (wearing a seat belt while in a car, using a crosswalk to get across the street, wearing a helmet when on a bicycle) the thought of employing harm reduction strategies to people who use substances is still often seen as taboo. Erroneously people think it is enabling, an attempt to legalize substances, or even encourages use.

When wrongly applied, maybe some of these sentiments creep into harm reduction practices when they should not. I would argue that some of the critiques of harm reduction can be valid when harm reduction is misinterpreted and applied incorrectly. For example, I have seen practices that may be better described as harm maintenance rather than harm reduction, and I have witnessed conversations between helping professionals and people who use substances as enabling. But thinking that these shortcomings are widespread is not true. There is no point giving up on harm reduction just because it is sometimes practiced wrong. Let’s face it – many people in our industry are asked to practice harm reduction with the people they support without having ever been trained on harm reduction.

I like the way that the Centre for Addiction and Mental Health responds to suggestions that harm reduction is enabling:

…by respecting these choices and being available to deal with their consequences, the therapist intentionally strengthens the therapeutic alliance. Rather than seeing this as enabling the client to keep harming himself, the therapist understands that he or she cannot realistically prevent a client from making particular choices at the given moment. But by keeping the door open and helping to ameliorate adverse consequences when they occur, the clinician can strengthen the motivation of the client to behave in a less harmful way, and facilitate their engagement in further treatment when the client is ready to move closer to a less harmful pattern of use or abstinence.

In very practical ways, harm reduction is about truly meeting people where they are at, with radical acceptance of the choices they are making in their own life. Good rapport in present reality leads to opportunity for reduction in harm in the future. For every organization that claims to be person-centered, non-judgmental and trauma-informed, practicing harm reduction is an extension of all three of those sentiments.

Harm reduction is a very pragmatic approach to working with people who use substances. I have heard it described as, “It ain’t what’s pretty; it’s what works.” The truth is, substance use in various forms, is part of written and oral history for many cultures. While the drugs may be ever changing and new, drug use is not. We need a range of approaches to respond to drug and alcohol use – especially problematic use – rather than a one-size-fits-all approach. Harm reduction should always be one of the options for people that experience homelessness given the higher propensity of people who are homeless that use alcohol or other drugs. In so doing, we are being responsive to real, in the moment needs. That type of engagement is practically required of us, not an exercise in enabling.

While cessation and abstinence are a choice for some, I reject the notion that we will ever have a drug-free society. I love pulling data from the SAMHSA Behavioral Health Barometer when working with American communities. It clearly demonstrates time and again that slightly less than 10% of the population of any given State has problematic alcohol use and under 5% have problematic use of other drugs – and in both instances, the majority of people in the community receive no treatment or counselling for their problematic use. Closer to home, the Policy Lab at UCLA has analyzed tens of thousands of VI-SPDAT records and found that 51% of the unsheltered homeless population state drugs or alcohol were one of the reasons they lost their housing, and 50% believe their drug or alcohol use limits their ability to be housed. Rather than thinking a treatment or enforcement approach is going to help all of these individuals achieve sobriety, it seems practical to me that harm reduction is the vehicle by which more people will find access to housing and learn to stay housed while also using substances.

This Work Is Hard

Originally written for my friends in WV, this is a shout out and high five to all those who work their butts off on the frontline.

This work is hard. Really hard. It can burn you out. Make you curse to the point where you make yourself blush. Lead you to question why you ever started down this road.

Units will get trashed. Landlords will be angry. Some people you are supporting will die. Needles will be found. Overdoses will happen. Every now and then you may be surprised to find something weird…a snake frozen in a freezer…a two gallon jug filled with urine…Simpson’s-themed porn…

Don’t give up, you wonderful helper, you. Don’t give up.

Rents will not always be paid on time and in full. Case management goals will not always be met. Some days will be spent jumping from crisis to crisis rather than doing proactive work. Every now and then you find what you think could be the poster-child for what success looks like (for today anyway).

Co-workers will engage in office politics. Case notes will need to be done. Data must be entered. A drop-off of donations will happen at the least best possible moment.

Don’t give up, you wonderful helper, you. Don’t give up.

You’ve told yourself to practice good self-care. You still have days, well, you don’t. An extra glass of wine here, a little intrusive imagery when trying to sleep there.

Program participants will complain. Community partners will complain. The general public will complain. Most days you will never serve enough people adequately in a way that keeps others happy. Or for every happy person there are several others who do not seem to be.

Don’t give up, you wonderful helper, you. Don’t give up.

You went into this work for a reason. Maybe you forgot why. Maybe the reason has changed. Find that reason. Hold that space. Breathe in. Breathe out.

You didn’t go into this because it was easy. Maybe you didn’t go into it because it was this hard. But you always knew this wouldn’t be easy. Our success will not be measured by how easy we made the work. It will be measured by what we achieved in difficulty.

Don’t give up, you wonderful helper, you. Don’t give up. You have epic shit to do.

Service Restrictions and Barring in Shelters

In congregate settings, like shelters and drop-in centers, there has to be some expectation of behaviour. One could argue that the larger the building or operation, the more important it is to have staff consistently apply expectations of behaviour. The good news is that most guests will be in compliance with the guidelines most of the time. The part that becomes difficult is what to do when people do not consistently meet the expectations of behaviour? This is where service restrictions and barring come into play.

While we talk plenty about trying to neutralize the power dynamics that exist between staff and guests, when it comes to meting out consequence of not meeting an expectation of behaviour, staff hold the power. Occasionally there are power hungry staff that abuse this power. Thankfully this too is rare. On the other hand, there are some staff who never want to hand out a service restriction. This too is rare.

In our work with transforming shelters to become more housing focused, one of the areas that needs to be tackled is service restrictions and barring. It is hard to house vulnerable people if you kick them out of services. Being lower barrier, which is a key to success for being housing-focused, requires a sober look at your existing expectations or rules and a revamping as necessary to help ensure staff are safe and guests are safe.

The starting point, therefore, in ensuring you have fair service restriction and barring policies is to review what the actual expectations and rules are, how they are communicated, and whose job it is (and how) to determine if a guest is not meeting those expectations. Here is an example of some guidelines developed by a large shelter we have been working with:

All guests of the shelter, both community and those accessing sleep programs are asked to adhere to a list of building guidelines.

1. All individuals are responsible for their personal belongings. The shelter is not responsible for any personal belongings.

2. To not have any unlabeled or mixed medication or medication belonging to someone else while a guest at the shelter.

3. To not buy/sell anything or collect debt while on the premises

4. To not participate in inappropriate intimacy on the premises

5. To not take any photo, video or audio recording while on the premises without administrative approval. This is to protect the privacy of everyone at the shelter

6. To not bring any weapons (real or replica) onto the property

7. To not vandalize any of the shelter property

8. For the safety of all guests the shelter requires all bags entering the building to be searched. Individuals may have bag searched by staff or they may opt to conduct a self-search.

It is far easier to explain 8 expectations at time of intake and have people understand what you are requesting of them than having 8 pages of rules that are quickly forgotten, ignored, or unequally applied.

Barring someone should always be a last choice when confronted with a complex behaviour situation. When an expectation is not being met, the first step should always be dialogue. The expectation that is not being met should be explained again. Once that (re)explanation is provided, an expectation should be set regarding what happens if the expectation is not met again in the future. Nonetheless, there will still be instances where a service restriction is necessary for the safety of the individual, others within the building, or the facility itself. 

When it gets to the point where a bar is going to be issued, it is important that these are clear and transparent to all guests, and applied consistently by all staff. Therefore, organizing types of service restrictions can be helpful, and keeping the number of categories small makes interpretation easier. Here is how one shelter transformed their barring infrastructure into four simple categories:

Category 4 - 3 months

• Violence requiring more than first aid medical attention

• Sexual Assault

• Arson

Category 3 - 14 days

• Property damage over $1000

• On-going drug trafficking

• On-going predatory behaviour

• Violence requiring first aid

Category 2 - 24-48 hours

Repeated breach of Category 1

Category 1 - 10 min-2 hour break from building

Breaches to the guidelines of the Emergency Shelter

Notice above that there is no such thing as an automatic lifetime ban. However, at the end of each bar period there can be a meeting between the guest and the shelter staff to assess where the person is at in wanting to meet the expectations moving forward. While in most instances the end of the bar duration is the end of the service restriction, there can be instances where there is no intention to meet the expectation and the bar is extended.

A shelter must also decide which staff under which circumstances can issue a service restriction. For example, Category 1 can be issued by any shelter employee, but a Category 4 restriction requires a Director level sign-off.  For shelters that have multiple staff on per shift, there may even be a process by which peer review goes into issuances of the likes of Category 2 or 3 issuances.

In the end, the service restriction process should not be punitive. It should be rehabilitative. It should support and help people meet an expectation over time.

Street Cleaning Does Not End Homelessness

This week, yet again, someone forwarded me an article about a new employment initiative for people that are homeless. Hold on to your hats, this employment initiative focused on street cleaning in the downtown of a major metropolitan area. Tell me whether you have heard of such a thing before. (As an aside, why does every community that does this think they are the first to think of it and that doing so will put an end to panhandling?)

A deficit orientation towards assisting people who are homeless or formerly homeless re-entering the labor force needs a critical re-think. Here are five big problems I have with initiatives like street cleaning done by people who are homeless:

1. Match people to jobs based upon strengths

Problem is – and here is a broad brush stroke argument – we don’t take time to learn what people are good at and match them to jobs and careers related to that match. We assume people who are/were homeless can only handle entry level menial jobs like street cleaning. For certain this is totally aligned to skills, aptitudes and interest of some, but far below the intellect, capabilities and desires of most.

2. “Practice jobs” do not guarantee or prepare people for “real jobs”

While the evidence is clear that supportive employment is the way to go for those with the most complex, chronic histories, we continue to use day labor and employment readiness schemes rather than lasting, sustainable employment. For those that claim that initiatives like street cleaning are the first step towards achieving this, I call bullshit. To me it is like saying transitional housing is necessary prior to having permanent housing.

3. It is housing first, not employment first

The key to success is housing first, not employment first. We should house people then focus on employment, not focusing on employment as a pathway to housing. Undoubtedly, a stable income source will be very important for ongoing housing stability. If that income is employed income, then even all the more reason to ensure the employment is sustainable.

4. An address (or lack of one) is a discriminatory job prerequisite

Homelessness should not be a job prerequisite. Homelessness should not be seen as a qualification. And just because one may spend a lot of time on the street, that does not make them qualified (or even interested) in cleaning a street. That’s like saying, “Iain spends a lot of time in airports therefore he would make a great air traffic controller.” It doesn’t work that way. On top of this is a vexing presupposition that it was people who are homeless who made the streets dirty, therefore they should clean them up.

5. This should be about social justice, not charity

We need to examine labor force participation through a lens of social justice, not charity. A number of these initiatives that do the likes of street cleaning do not pay a livable wage, may not even consider it real employment (providing people an honorarium or stipend rather than formal paid employment with tax deductions, etc.), and rarely if ever offer protections to injured workers. Let us also remember that these schemes are almost always created by non-homeless individuals who believe they are giving back and creating opportunities for people through this type of initiative when it is really their own self-interests that are being taken care of in the process.