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?
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 firstname.lastname@example.org