Pretreatment Guide for Homeless Outreach

1. Pretreatment Guide for Homeless Outreach Jay S. Levy, MSW, LICSW PATH Regional Manager Eliot Community Human Services

2. 3 Questions for Consideration • Why is it important to understand people’s stories or What is the advantage of thinking in terms of a person’s narrative? • What is pretreatment and its 5 guiding principles of care? • What are some Pretreatment Strategies for promoting engagement and productive dialogue? Jay S. Levy, LICSW

3. From Homelessness to “Making Meaning” • Outreach takes place at a border that divides one world from another (Rowe, 1999) • We are Interpreters and Bridge Builders: Our Objective is to Utilize Dialogue to Cross Cultural Divides (Levy, 2018) • The Trauma of homelessness and the Process of Transition & Adaptation to challenging environments (Germain & Gitterman, 1980) • Review Old Man Ray’s Narrative – “I am the Night Watchman!” (Levy, 2013, pp. 60-62) • Central Question of Outreach: “How do you help those who are clearly in need, yet communicate no need for help?” (Levy, 2013) Jay S. Levy, LICSW

4. Stages of Engagement • Pre-Engagement – The goal is to facilitate an initial welcomed communication between outreach staff and person experiencing homelessness (Issues of trust & Safety) • Engagement – The goal is to develop a welcomed ongoing communicationbetween worker and homeless person, while setting appropriate boundaries (Issues of safety, trust, autonomy & the challenge of setting professional boundaries by defining roles) • Contracting – The goal is for the worker and client to establish mutually acceptable objectives for their work (Issues of Autonomy/Control & the challenge of promoting client initiative) (Levy, 1998 & 2010) Jay S. Levy, LICSW

5. Pretreatment Principles 1 - 3 1. Relationship Formation – Promotetrust, uphold safety andrespectclientautonomy,while developing goals(Stages of Engagement include Pre-engagement, Engagement, and Contracting) 2. Common Language Construction – try to understand homeless person’s worldby learning meaning of his/her gestures, words, and actions - promoting mutual understanding and jointly defined goals (Levy, 2000) 3. Cultural and Ecological Considerations - Prepare and support homeless person for successful transition and adaptation to new relationships, ideas, services, resources, treatment, housing etc. Jay S. Levy, LICSW

6. Pretreatment Principles 4 - 5 4. Facilitate and Support Change – Via Change Model & Motivational Interviewing Principles; Point Out Discrepancies, Explore Ambivalence, Give Voice, Reinforce Healthy Behaviors and Develop Skills, as well as Supports; Stages of Change include Pre-contemplation, Contemplation, Preparation, Action, Maintenance, Relapse (Prochaska, DiClemente, and Norcross, 2006; Miller & Rollnick, 1991) 5. Promote Safety – UtilizeCrisis Intervention & Harm Reduction strategies(Baer, Marlatt, & McMahn, 1993); These are opportunities for further work! Jay S. Levy, LICSW

7. Pretreatment ‘an approach that enhances safety while promoting transition to housing (e.g. Housing First), and/or treatment alternativesthroughclient centeredsupportive interventionsthatdevelop goals and motivation to create positive change’ (Levy, 2000, 2010) Jay S. Levy, LICSW

8. Costs of Homelessness • Risk of Deathdue to homelessness in combination with Physical, Mental Health and Addiction Issues leading to increased risk of sickness and death (Hwang, S.W., O’Connell, J., et al. 1998) • Financial Burden due to inconsistent treatment leading to numerous high cost emergency room visits and inpatient stays, as well as high incarceration rates (O’Connell, James, 2005, Tsemberis, 2010) • Quality of life issues for people experiencing long-term homelessness, as well as for the communities in which they live Jay S. Levy, LICSW

9. Homeless Narratives: Focus on words, ideas, and meaning • Lacey (B,F,30’s)- “The Birds are innocent and peaceful creatures that can rise above the mischief.” • Butch (W,M,50’s)- “A buddy of mine drowned in these waters and this is his resting place.” • Andrew (B,M,40’s)- 18 years Homeless – First Met at Overflow Shelter – Limited Engagement via outreach – Sometimes talks to self – Isolated from Others Jay S. Levy, LICSW

10. Andrew’s Narrative: Entering the House of Language • Read and Explore Andrew’s Excerpt - “Do you know what it is like to be mentally murdered?” (Levy, 2010, pp. 43-44) • Words, ideas, meaning: ‘Mental Murder’, ‘No Longer Playing the Game’, ’Research’, etc. • How to further Engagement (from pre-engagement to contracting)? • Stages of Common Language Construction- ‘Understanding’, ‘Utilizing’, and ‘Bridging’ Language from one House of Language to another (Mental Murder to Trauma to Disability-SSA) Jay S. Levy, LICSW

11. Conclusion • A Pretreatment approach can help us to engage with People who have long histories of Trauma, Loss and Homelessness. Many are extremely vulnerable and have elevated health risks, so there is a great need for a Pretreatment Approach & Harm Reduction Alternatives such as Outreach and Housing First (Tsemberis, 2010) to promote safety, lower costs, and facilitate pathways to needed housing and recovery. • Pretreatment includes an emphasis on forming a client-centered relationship, the development of trust, respecting a person’s autonomy, while utilizing a common language to negotiate boundaries, mutually arrive at goals and provide ongoing support, thereby avoiding professional ‘power’ and authority dynamics. • Medical Staff, Outreach Counselors, and others may benefit from further training and education on how to develop Pre-treatment Pathways to recovery, acute treatment, and housing. Jay S. Levy, LICSW

12. References • Baer, J.S. Marlatt, G.A. & McMahn, R.J. (1993). Addictive behaviors across the life span: Prevention, treatment, and policy issues (pp. 243-273). Newbury Park, CA: Sage. • Erikson, E.H. (1968). Identity: youth and crisis. New York: Norton • Frankl, V.E. (1985). Man’s search for meaning. New York: Washington Square Press. • Germain, C.B., & Gitterman, A. (1980). The life model of social work process. New York: Columbia University Press. • Hwang, S.W., Lebow, J.M., Beirer, M.F., O’Connell, J.J., Orav, E.J., Brennan, T.A. (1998)Risk Factors for Deaths of Homeless in Boston, Archives of Internal Medicine. 158(13) 1454-60. • Levy, J.S. (2018). Cross-Cultural Dialogues on Homelessness. Loving Healing Press, Inc., Ann Arbor, MI. • Levy, J.S. (2013). Pretreatment Guide for Homeless Outreach & Housing First. Loving Healing Press Inc., Ann Arbor, MI. • Levy, J.S. (2010). Homeless Narratives & Pretreatment Pathways. Loving Healing Press, Inc., Ann Arbor, MI. Jay S. Levy, LICSW

13. References • Levy, J.S. (2000, July-August). Homeless outreach: On the road to pretreatment alternatives. Families in Society: The journal of contemporary human services. 81(4), 360-368. • Levy, J.S. (1998, fall). Homeless outreach: A developmental model. Psychiatric Rehabilitation Journal. 22(2), 123-131. • Miller, W.R. & Rollnick, S. (1991). Motivational Interviewing, The Guilford Press, New York. • O’Connell, J. (2005). Mortality in the homeless population: A review of the literature. NHCHC. ~ Health Care for the Homeless ~ • Prochaska, J.O., DiClemente, C.C. &Norcross, J.C. (2006). Changing for Good. HarperCollins, New York. • Rowe, M. (1999). Crossing the Border. Berkley: University of California Press • Tsemberis, S. (2010). Housing First: Ending homelessness, promoting recovery & reducing costs. In Ellen, I. & O’Flaherty, B. (2010) How to House the Homeless. New York: Russell sage Foundation. ~ Pathways to Housing ~ Jay S. Levy, LICSW

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