Setting the Tone for Successful Home Visits
Once an individual or family has been accepted into a housing support program, the support worker (aka case manager) must work to set the tone for successful home visits. This starts with the very first visit. Practicing the tips below consistently – right from the beginning – and communicating these expectations to the people you are supporting results in more focused interactions and better case management results.
Be on Time & Stay on Time
The home visit is a professional interaction with a client. For the home visit to be taken seriously and to reduce missed visits, from the very start it is critical that the support worker is on time. Time management and not trying to see too many clients in any given day is essential to ensure being on time more often than not.
At the beginning of the home visit it is also important to outline how much time you have for the interaction that day. These will vary in length depending on the amount of material to be covered off during the visit. Once you lay out the time for the visit, do not exceed it.
Outline Your Objectives for the Visit at the Beginning
A home visit is a highly structured conversation in the case management process. It is NOT a matter of showing up, checking in or just seeing how they are doing. It is a purposeful meeting to advance the case plan.
At the beginning of the home visit, remind the client of the three objectives that are going to be covered during the session. These objectives would have been decided upon at the conclusion of the previous home visit. Objective based interactions keep the conversation on track and heighten accountability in the case management process.
Reduce Distractions
Ask that the TV, radio, etc always be off during home visits so that you can hear each other clearly without distractions.
Ask the client to hold all non-urgent phone calls and texts during home visits. Avoid being a hypocrite – leave your own phone alone too!
With the exception, perhaps, of some family members, ask that there be no guests during the home visit. Not only can this be distracting, but it can also present a safety risk. Plus there is the matter of compromised confidentiality if others are within earshot.
Acknowledge When the Interaction May be Difficult or Have Conflict
It is best to express empathy and not sympathy. When we are faced with what may be a hard conversation, we may have a tendency to shy away from it or to sugar coat it. In instances where the topic may be unpleasant for the client, I recommend starting with statements like, “This may be uncomfortable for you but it is important that we talk about (subject matter) so that you don’t lose your housing.”
Know your Role
Your role is to be a case manager, not a therapist, armchair psychiatrist, friend, chaplain, etc. Your job is to keep them housed and get them connected to supports for long-term housing and life stability. Your role is to be a catalyst for positive change. You do the hard support and they do the hard work. If you are confused on your role, home visits are more difficult to get results.
Embrace the Awkward Silence
When moving forward with your objectives for the visit, there will be times when the client does not readily engage in conversation or where his/her answers to questions are short responses without much detail. Do not rush in with the sound of your own voice or a litany of follow-up questions. Sometimes when we embrace the silence it creates a safe place – albeit sometimes an awkward pause – for the client to speak first and reveal more information. Our rush through the conversation may diminish her/his capacity to share. If you do all of the talking during the home visits there is not a tone set for sharing.
Take Care of Your Safety
You are responsible for your safety during a one-on-one home visit. Ensure you have mapped out an escape route from the moment you enter in the event that the unexpected (and highly unlikely) occurs where there is an altercation or other risk to your well being. Do not get cornered into an area of the apartment. Avoid bringing valuables into the home. Do not set backpacks or briefcases on the floor in buildings known to have bed bugs. If there are weapons of any sort, ask that they are always stored before a home visit. Ensure someone always knows when you are going to a home visit, where you will be, and what time you are expected to be completed.
Try practicing these suggestions and I suspect you will find yourself with more focused and more successful home visits.
Mental Illness — Language & Perceptions
I am writing this blog on the day of the tragic shooting deaths of 20 children and eight adults at the Sandy Hook Elementary School in Newtown, Connecticut. Like so many incidents over the past year (and before), this is an atrocious event that leaves us searching for answers. I am experiencing a mixture of both sympathy and utter disgust.
But, I am also feeling anger towards the extensive media coverage that was generated by the event. In the papers, blogs, news coverage, television discussion, etc. – I have repeatedly heard the mental status of the shooter reported in the most derogatory manner.
It may well be that the compromised wellness of the 20 year-old, young adult who perpetrated the shooting contributed to his decision and actions. But, all mental illnesses are not the same. It is like saying that all physical illnesses are the same and clearly they are not. The use of the broadest terms to describe someone’s purported mental state without addressing the type of illness, the impacts of that illness, the treatment options, the access to treatment, potential medications for the mental illness (and the implications of medications), etc. is inflammatory and disrespectful of millions of people around the world who live with mental illness. It doesn’t advance the education about what mental illness is and how best to support individuals and families that are impacted by mental illness. This level of reporting and dialogue takes us backwards in our thinking and perceptions of mental illness. It reinforces and normalizes stigma.
I live with a mental illness. It is depression. My experience with this illness has been a long and storied one. Given the stigma of mental illness, it took me years before I finally received the help that I needed. Since getting the help that I needed, my life has been improving by all measures that are important and my relationship with loved ones and, indeed, myself has improved greatly. For the most part, I feel well on most days.
I am experiencing many of the same feelings that people who do not live with a mental illness have been experiencing. I am shocked. I am distraught. I feel an intense love and renewed sense of protection of my own children. I am in disbelief that someone – anyone – could harm children, teachers and their own mother.
Working in the realm of social policy and planning, mental illness emerges in a range of circumstances, across the entire spectrum from wellness to illness. The stigma that clients of programs experience is, at times, overwhelming. As human service professionals, we promote the need to get mental illness out of the shadows and into the light. We promote dignity and empowerment. We speak a language of wellness. We teach and support practitioners in promoting recovery. We want people who have lived experience with a mental illness to educate others about all aspects of his/her person — they are more than a diagnosis, more than the behavior or feelings of his/her symptoms and definitely more than his/her mental illness.
When mental illness is talked about in a sweeping sense rather than a specific sense, it is a slap in the face to the work and progress over recent years to respect the experience of people with compromised mental wellness. A level of dialogue that uses a broad, stigmatizing position to make a point on the subject casts mental illness as evil.
Let’s consider the facts.
Yes, people with a Severe Mental Illness are in a state where the probability of violence is higher than people who do not have a Severe Mental Illness. This is true most specifically of those individuals that have UNTREATED symptoms of schizophrenia with psychosis, major depression and bi-polar mood disorder. Epidemiological studies and peer-reviewed journals in psychiatry, however, demonstrate some clear facts:
Mental illness is not a major contributor to violence in any community;
Most people with a Severe Mental Illness are NEVER violent;
Most crimes are NOT committed by people with a Severe Mental Illness;
People with a mental illness are more likely to be violent to themselves rather than others, with suicide the most heinous form of violence committed against oneself;
The United States, which has a high rate of homicide compared to other nations, has only 10% of homicides committed by people with a Severe Mental Illness – the remaining 90% are committed by people who do not have mental illness;
People with a mental illness, including those with a Severe Mental Illness are MORE LIKELY to be a victim of violence rather than a perpetrator of violence.
Negative portrayals of mental illness that were reported today by mainstream and social media enhances the stigma and may discourage people from seeking help to treat their mental illness. They have heard, once again, that having a mental illness makes them a deviant person or, based on the horror today at Sandy Hook, a child killer.
And, so I ask that we use the power of our shared grief about this tragic event to better understand mental illness, the differences and variations of mental illness, and the professional supports that are available and necessary. We CAN create an inclusive society where the stigma of mental illness no longer exists.
Make a More Lasting Impact on Homelessness & Housing This Holiday Season
This holiday season I am making a plea that well-intentioned people do more than make a financial contribution to a homeless serving agency, or donate a non-perishable food item to a food bank, or volunteer at a community meal. The spirit of giving this time of year is dandy, but I know that many people want to do more…they just don’t know what to do. Here are some ideas:
Do something for the staff in non-profits working to end homelessness and support people in housing.
These are the unsung heroes in each community. The general community does lots for their clients during the holiday season. But I’m asking you to do something tangible for the staff in these non-profits that support those clients day after day. These folks chose to work in a non-profit. For that, already, they should be commended, most often choosing (yes, choosing) a lesser wage in return for greater social good. You could:
Send them a note signed by all the people you work with or socialize with or worship with (or all three) thanking them for what they do day in and day out.
Get enough movie gift cards for all the full time staff so that they can be treated to a night out at some point during the year.
Sponsor a thank-you lunch for them in, like, February. More impactful? Have all the people you work with serve them lunch.
Create a mentorship collaborative or learning community with people who work in the non-profit sector.
Turn over your holiday bonus or a portion thereof to the staff at the non-profit. They don’t get a bonus for what they do. Imagine how amazing they will feel knowing that you wanted them to have your bonus for the bonuses they bring to the community at large.
Write letters.
You can do this by yourself, but it is more impactful if you can get together a group to do it with you. Again these could be people you work with, socialize with or worship with – to name a few.
Each person should write his/her own letter. Each letter is going to have the same type of question: How will the recipient (elected official/senior person receiving the letter) help build more housing that is affordable for those with the deepest needs and the supports required to help people be successful in housing?
People to write include your local alderwoman/alderman/city councilor; Mayor; state/provincial representative; federal representative; leader of your country; senior directors in high-ranking bureaucratic positions.
In almost all instances you will first get a written response filled with political fluff about the meager investments being made or how what you have asked is really the responsibility of some other order of government; or that the sort of thing you wanted to know about is outside their purview.
Once you get that response, write again, thanking them for writing you back, respectfully noting that the response was impersonal and without sufficient detail to tell you what they are going to do. Heck, do something wild and ask politicians them to slightly raise your taxes if it means the most vulnerable in your community are housed with supports. When was the last time elected folks had people writing them asking them toraise their taxes?
Organize a four season clothing drive.
‘Tis the season for boatloads full of winter coats, gloves, scarves and toques to be dropped off. And there is good reason for that in communities that get cold in the winter.
If you want to make a lasting difference, though, get together a small group that will undertake a four season clothing drive throughout the year specifically for a non-profit organization that helps people get housing and stay supported in it. Have a place to store the clothing in-between seasons rather than dropping it all off to the non-profit where space is likely at a premium.
Establish a local rent supplement.
Subsidies to help people in housing are scarce and usually come with a litany of eligibility requirements that make some of the most economically desperate people with very complex issues ineligible. Some can get general welfare but not additional assistance. For others it is vice versa. It is one of the great injustices.
While local housing markets dictate rental costs, a rather modest amount can go a long way. Team up with a non-profit that helps homeless people with chronic, complex issues access housing. If you and a group of pals can generate $5,000 in most communities that is a good sized top-up to be matched with whatever other resources are available to keep a chronically homeless person in an apartment for a year. And don’t do this with an expectation that you get to screen the recipient or meet the recipient. The non-profit will be able to undertake a better assessment than you, and this isn’t “homeless people at the zoo”.
Read about the issue.
Homelessness, as well as housing for people with complex, co-occurring needs is frequently sensationalized in media, and not readily understood by the general public. Get yourself a book or two this holiday season and read about the issues so that you are more aware of the dynamic that is homelessness. I suspect many books could be added to this list, but I would recommend:
In the Realm of Hungry Ghosts by Gabor Mate. This will help you understand community amongst marginally housed people and what addiction is and how it works.
Down to This by Shaugnessy Bishop Stall. It’s the story of a tent city and the people that weaved in and out of it. Oh, and it’s a love story too.
Homeless: Policies, Strategies and Lives on the Streets by Gerry Daly. It is a heavy, policy laden read by my fave professor in Grad school.
Start a YIMBY campaign.
Yes in my backyard is of course the opposite to the seemingly ever prevalent Not in my backyard. Find out where there is a public meeting of any sort to discuss a new affordable housing project or program that supports homeless people. Make an effort to show up and speak in support of it. If your community is a lot like others, many of the people in attendance will be against it in some way, shape or form (location, size, amount of funding, urban design, impacts on transportation, misguided opinions about impacts on public safety or property values, etc.) You showing up demonstrates to decision-makers that there are a range of voices to be heard. It also sends a strong message to people experiencing affordability issues and/or homelessness, as well as non-profit service providers that they are not alone in wanting to do this in the community.
Innovatively challenge common stigmas.
You can set up a challenge at your work place or with your friends to challenge some of the common stigmas that are experienced by people that are homeless or live in affordable housing.
One idea is to make an effort to live off the same amount of money that a person receiving welfare gets in a month. Keep a blog about it or write a letter about it to share with others.
Another stigma faced by many people can be compromised mental health. Host a “Check up from the Head Up” event. Take mental health out of the shadows and into the light.
Yet another idea to tackle stigma is the notion that people choose to be homeless and live outside as a lifestyle choice. Research generally does not support this. Host an event that gets a group of people together to sleep outside to raise awareness for homelessness and affordable housing in your community.
Create an entry-level job or paid internship at your place of work for someone moving out of homelessness.
Most people that experience homelessness for a longer period of time become dislodged from the work force. Trying to get back into it often comes with great difficulty. Some employment programs are even more stigmatizing than the experience of homelessness.
But imagine if where you worked was absolutely accepting of holes in a person’s resume, lack of recent references, and patient to accept that learning new skills or becoming reacquainted with old skills can take time and mentorship. The opportunity you provide can be the permanent path out of economic poverty and housing instability.
Invite a frontline worker from a non-profit to your place of work to explain what a typical day is like for them.
Work in the homelessness and housing sector is an often misunderstood profession. People who don’t work in the field frequently fail to realize the professionalism of the work. While much is made of how the private sector can help teach non-profits lessons, there is an overlooked opportunity for private enterprise to learn from non-profits. Start by inviting a frontline worker in a non-profit over to your place of work for a “lunch and learn” where they can explain what they do, how they do it, and lessons learned that may be transferable to your place of private business.
Learn to express empathy instead of sympathy.
Do not feel sorry for the plight of others. Do something about it. Do not just acknowledge that others are “worse off” than you; try to meaningfully put yourself into their shoes. Attend a “sleep out” event; or try to live on less money for a week or two (or a whole month); or observe how a homeless shelter or street outreach program operates; or any other activity that allows you to come closer to the emotional experience of homelessness and affordable housing.
Perhaps around your holiday table a blessing or prayer may include a tidbit to “remember people less fortunate than ourselves”. Challenge yourself to change this year to something like “to better understand homelessness and housing needs in our community and to be actively involved in solutions”. The social return on investment of doing exceeds that of simply remembering.
Does Everybody that Experiences Chronic Homelessness Need Permanent Supportive Housing?
I have heard many well-intentioned service providers speak of Permanent Supportive Housing as the only housing option for persons that have experienced chronic homelessness. Permanent Supportive Housing is an important housing option for all communities to have, and many persons that have experienced chronic homelessness may choose this option. But let me repeat: may choose this option.
Let us also be clear about chronic homelessness and use the HUD definition:
An unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more OR has had at least four (4) episodes of homelessness in the past three (3) years. The individual must have been on the streets or in an emergency shelter (not transitional housing) during these episodes.
Where there is error is thinking that Permanent Supportive Housing, whether it is through a scattered-site model of supports or a congregate model of supports, is the only housing model that will work for people that have experienced chronic homelessness. That type of mentality reinforces a housing placement mindset rather than a housing choice mindset. If we believe in client-centered service delivery then we need to wrap our heads around what it means to offer meaningful choices, not on thinking we know what is best for the people that we serve.
A 2007 study examined what Housing First means to people served through a Housing First program. It shows a very strong relationship between housing satisfaction and whether the individual felt they had a choice in where they live. Altogether, 55% of service participants that felt they had a choice in where they live were very happy with their housing. By comparison, 15% of the respondents that felt they had no choice in where they live reported being very happy with their housing. Only 2% of those surveyed in the report that felt they had a choice in where they live reported being very unhappy in their housing.
Some service providers will make statements that sound convincing as to why people that have experienced chronic homelessness require Permanent Supportive Housing.
One of the claims is that many of these individuals have a mental illness. As a person who lives with a mental illness, this line of argument doesn’t personally ring true for me. I don’t live in Permanent Supportive Housing. Lest you dismiss my line of reasoning because I am only a sample size of one, consider that most people with a mental illness do not experience chronic homelessness. That is a fact. Many people that have experienced mental illness may engage in some form of supports for the rest of their lives, but those supports are most often found in community, not through Permanent Supportive Housing and housing case managers.
Another of the claims is that many of these individuals have experienced addiction to alcohol or other drugs. Let’s take a poll: raise your hand if you or someone you know has had one or more drinks of alcohol in the last 30 days. Most survey data on substance use would reveal that most of you probably raised your hand. I’m not asking for the keys to your place. Even when you consider persons with problematic substance use, most of these individuals do not experience chronic homelessness. Those who choose sobriety may be linked into an array of community resources to help support them in this regard for the rest of their lives, but that does not mean they need Permanent Supportive Housing in all instances.
My last example is related to life skills. Often I have heard service providers claim that one of the reasons chronically homeless individuals require Permanent Supportive Housing is because they lack the life skills to be housed without permanent supports in community. While some people will take longer than others to learn and retain skills, it is untrue and defeatist to think that chronically homeless people cannot (re)learn the life skills necessary for more independent living. Some may want and benefit from the additional life skills support available in most Permanent Supportive Housing, but not all chronically homeless people that have compromised life skills have to be in Permanent Supportive Housing.
Fundamentally, in a lot of instances the focus on having people move into Permanent Supportive Housing rather than an approach with supports that promotes greater independence over time is because we are so fixated on the deficits in the lives of a chronically homeless person that we fail to see the strengths that they possess. Having a disabling condition and a history of long periods of homelessness fails to see future potential nor does it embrace recovery.
No doubt, some individuals have rather substantial life issues such as frail medical conditions, reduced cognitive functioning, developmental delays and the like. But what do each of these – and others – bring to the table that we can build off of in our service delivery and then put this in the context of a service plan offer that focuses on housing stability rather than thinking our mission is to somehow fix or heal people? I would argue that one of the major impediments is that the assessment tools used in many communities (those that have assessment tools anyway) glob onto a deficit orientation rather than a strength-based orientation. Higher acuity should not be a life sentence to Permanent Supportive Housing if that is not what the individual wants. Furthermore, any acuity assessment used in housing programs should focus to areas where people have strengths that can be built off of for housing stability.
None of this is an argument against Permanent Supportive Housing. It is an awesome, life-changing experience for many who choose it. There are some phenomenal Permanent Supportive Housing providers in the world. And I hope there are more of them. More Permanent Supportive Housing can and should be created in every community. This is why so many of the Alliance’s resources on re-tooling Transitional Housing (which does not have discernibly different housing stability outcomes and costs upwards of 10 times more than permanent housing) hold such promise. In fact, even when an individual is choosing to go the Permanent Supportive Housing route it is best to offer choices amongst different models and approaches to Permanent Supportive Housing.
What I don’t want is a very narrow mindset that sees Permanent Supportive Housing as the only option to chronic homelessness. We cannot and should not pigeonhole people in that way. (Plus, if we look at the numbers of chronically homeless people there is absolutely no way to financially afford Permanent Supportive Housing as the only option.)
Undoubtedly, Permanent Supportive Housing tendencies in many communities reinforce that there can be a difference between what we think and what we know. I also think that it demonstrates why, in some communities, there is a difference between being committed to ending homelessness and simply wanting to end homelessness. I’d ask communities that have Permanent Supportive Housing to best determine how to maximize the potential of this type of housing when they are working on coordinated access and common assessment tools. And I would beg communities to reinforce Permanent Supportive Housing as a choice for people that have experienced chronic homelessness, but not the only option.
Be Grateful
At one point in my life I was an angry practitioner. Why? I spent pretty much all my time frustrated about what I could not do or things I could not control instead of grateful for what I could do. I had to learn to change my perspective to one that embraced gratitude.
For example:
I’d dwell on the past and live in history or find myself anxious about the future rather than focusing on the present, yet the present is where I can exercise the greatest influence.
When clients lost their housing I’d think of the housing work of our program as a failure rather than being grateful that there was an opportunity to learn and re-house the person.
I’d lament external reviewers of the program rather than being grateful that there was another set of eyes that could offer a different perspective.
I’d get lost in despair about the poverty that people experienced, rather than being grateful that they could be housed and still be poor rather than living in economic poverty and still being homeless.
When my staff team seemed to be less energized I’d get frustrated with what I saw sometimes as weakness or apathy, rather than being grateful that some of the most talented people I had ever met were sticking with the work during the low times and that I had the opportunity to express my gratitude for all that they do and re-energize them.
When people would ask pointed questions about why housing homeless people is a good idea from a policy and fiscal perspective, I’d find myself angry with their value orientation or lack of ability to see the big picture rather than being grateful that I had an opportunity to educate and influence.
I’m not a huge personal fan of the pseudo-science and incomplete psycho-social connections that dominates so much of the self-help genre. I have never personally been able to be happy through positive affirmations or follow a simple step-by-step guide to happier living. My own journey through depression and interactions with others offers a personal perspective where that doesn’t work for me (and no disrespect intended if it works for you).
But what I do know is that we can shift our orientation on what happens around us. We can focus on gratitude. We can be grateful for all that we are able to achieve, rather than being lost, confused, frustrated or angry by the limitations that are often outside of our control. Personally, I know that once I started paying more attention to what I could do and the strengths that I did have my worldview changed to one of gratitude. Gratitude most certainly trumped the deficit orientation that I had focused on before. I became a better leader and manager. I became a better mentor. And I became truly passionate about ending homelessness as a real possibility, rather than an empty promise.
Therapeutic Incarceration
A dozen times in the past few weeks I have found myself speaking about therapeutic incarceration. It has nothing to do with jails or prisons. It is about how some homeless and housing service providers treat their clients. I didn’t coin the term (see The Therapeutic Incarceration of Homeless Families Naomi Gerstel, Cynthia J. Bogard, J. Jeff McConnell and Michael Schwartz Social Service Review Vol. 70, No. 4 (Dec., 1996), pp. 543-572) though I wish I had. And it sounds like something I would say.
When I use the term, I am talking about those non-profit (and sometimes government) programs that go out of their way to hold onto the households that they serve. They smother them with service plans more oriented on trying to heal or fix people that trying to house and support them regardless of their imperfections. They keep them in life skills programming, for example, refusing to talk about housing options until they have demonstrated success in the program. Or they have them stay in a compliance-based a transitional housing model. Or they keep providing case management services to them years from when they first encountered them, unfortunately (naively?), thinking that their supports are necessary to keep them housed.
News flash – and it can suck to hear – that ain’t what the job is supposed to be.
When it is more about our desire to hold onto people then it is wrong.
When we think we can intervene to prevent any mistakes from happening, then it is wrong. (Aren’t mistakes a learning opportunity? Don’t we all make them?)
When a case manager doesn’t want someone to “graduate” (I hate that term, but I don’t have a better one, so it will do for now) from their program, what does that say about their orientation towards helping people achieve greater independence over time? (We shouldn’t be paying for “friends for life” programs.)
When anybody suggests that allowing people to fully make their own decisions is a set up for failure, it is wrong.
When dependent awareness is worn as a badge of courage rather than focusing attention on how we can get people to a place where they are fully integrated with other community services and can be interdependent, it is wrong.
I can hear some critics now. What about the young mom without parenting skills? What about the youth that has run away from home? What about the person with mental illness? What about the person who has experienced repeated institutionalization in hospital, mental health facility and/or prison?
A mistake is just another way of doing things. Sure, it comes with consequences. But we have all made mistakes, right? Isn’t that an essential aspect of free will?
Are you going to be in the young mom’s life until her child is 18? No. Provide a good foundation and let her make mistakes.
Are you going to stay in the youth’s life until their synaptic firing and wiring is advanced enough that they make decisions like a full-fledged adult? No. And, by the way, grown-ups make poor decisions too.
Do we really think every person with mental illness requires a substitute decision maker? Have you never heard of the concept of recovery? Oh, and allow me to introduce you to lingo we people with a mental illness use in our circles – nothing about us without us.
And I could go on.
If anybody suggests that a client surrenders their free will in order to engage with a homeless and housing service program, then it is time to take away all of their funding and focus our investment on those programs and services that would rather see homeless individuals and families empowered. Keeping homeless individuals and families stuck “in the system” is an indictment on us all. People attached to an organization years later isn’t a sign that the organization is doing a good job – it is, in fact, the exact opposite.
So, let us promote greater independence. Let us support people in re-integrating with community. Let us realize that the true value of our work is in realizing that it is not about us – it is about the people that we serve. Let’s stop imprisoning human potential.