WORK AS A PRIORITY - Issues Brief #4: From Outreach to Employment: Enhancing Motivation to Change
Outreach is an essential component of the service continuum, especially for people experiencing “chronic” or long-term homelessness. These individuals are usually disconnected from mainstream services and resources. They often live with multiple, serious problems including mental illness and substance addiction; as a result, they require specialized and more intensive interventions to help them end their homelessness. As experience has shown, outreach alone is not enough. To be successful, outreach teams must have access to important resources that may be accessed through “low threshold” approaches that people who are experiencing chronic homelessness are more willing to use. Needed services include access to housing and jobs as well as health insurance, mental health and addictions treatment, and public assistance benefits.
This brief will outline the essential components of successful outreach, including strategies for working with people at different stages of readiness to change and building motivation; the principle of low threshold interventions; and underlying philosophical underpinnings for these strategies, such as consumer choice. Our focus is on how these components may be used to connect people – even those experiencing long-term homelessness – to employment opportunities.
Outreach has been defined by Morse as workers contacting homeless people in nontraditional settings for the purpose of improving their mental and physical health, social functioning, or utilization of human services and resources (Morse et al 1996). Clearly, if you are really serious about helping people who are experiencing chronic homelessness, it is necessary to get out of the office and frequent places where they tend to be found. The nontraditional settings that Morse mentions include public parks, meal sites, shelters, drop-in centers, and – for the well-equipped and adventurous outreach team – abandoned buildings and remote campsites in sparse wooded areas.
Morse’s definition also highlights the purposeful nature of outreach. It is an inherently casual activity that can look and feel like “hanging out.” It is, however, hanging out with a two-pronged purpose. The first “prong” is to work with the person to build trust, hope, and motivation. The second prong is to work to minimize institutional barriers to accessing services and resources when the person shows interest. The following brief will highlight each of the two prongs in turn.
Working with the System: Low Threshold Approaches and Beyond
Successful outreach involves more than preparing the individual to accept services or to actively seek helpful resources. It is also essential to ensure that these resources are actually accessible. The idea of “low threshold” or “low demand” interventions has emerged in recent years as a successful approach to helping people access the support they need to end their homelessness and rebuild lives in the community. Best conceived as an extension (or companion) of outreach, these low threshold approaches include Safe Havens and “Housing First.” Both these models have taught us to loosen our attachment to a readiness model of service delivery, which assumes that people must demonstrate readiness for housing or employment before it can be made available. Demonstrating readiness usually requires progression through a preordained sequence of steps such as detox, six months of sobriety, mental health stabilization, day treatment, then at last….a waiting list for housing and employment training (!).
The problem is that people experiencing long-term homelessness are often unable or unwilling to meet the basic threshold criteria. This is a big part of the reason that they remain homeless for so long. It is unfortunate that such individuals have commonly been labeled as “noncompliant” and “not housing-ready” by staff in mainstream programs and even in many homeless service provider agencies. This view amounts to having only a hammer in your tool box and criticizing everything that is not a nail. If people have not done well in programs that operate with a readiness model, the crucial question to ask is: “what kind of an approach would be successful with these people?”
There is strong evidence that low-threshold interventions such as Safe Havens and Housing First do work to house people experiencing long-term homelessness. The same approaches can help people to seek, choose, find, and keep jobs as well. These models have been described in detail elsewhere. For our purpose, the most salient components are:
Immediate access to important resources without requirements for sobriety or treatment,
Separating clinical indicators from functional ability, and
Providing supports (potentially intensive and flexible) that are chosen by the person receiving services.
When these principles are combined with strategies for enhancing motivation (or hope) described above, they form a powerful means to creating employment opportunities for people who are homeless, even those with the most serious problems.
It is common and useful to think of outreach as occurring in relational stages. The first of these – which must be successful for other stages to occur – is usually called the engagement stage. Engagement has been defined by Cohen as “the process of establishing mutual respect and trust in the helping relationship, which reduces fear and enables the real work to begin” (Cohen 1989). Cohen noted that the engagement process is central to beginning work with people living with mental illness who are homeless. Her point may be generalized to most people experiencing long-term homelessness.
The process of establishing trust is more art than science. In general, it involves the following approaches:
Establishing a familiar and nonthreatening presence in places frequented by the people we are trying to engage;
Beginning with nonthreatening conversation;
Being respectful of the person’s pace, priorities, and need for independence and control;
Taking seriously and being responsive to what they say they want; and
Doing these things consistently over time.
Taking seriously what people say they want often means giving people on the streets blankets, sandwiches, warm beverages, and other items that people living outdoors tend to value. This strategy not only helps people to survive on the streets, but also provides an opening for engagement. It gives outreach staff a valid reason to initiate contact and to begin a conversation. As we shall see in below, however, the experience of implementing “housing first” approaches has given new meaning to this principle of outreach. Not only is it important to take seriously when people say they want a blanket or a sandwich, it is also important to listen when people say they want housing or jobs – whether we think they are ready or not.
Using Outreach Tools to Explore Employment
Outreach workers know that developing a trusting relationship with a person living on the streets begins by offering something the person wants “with no strings attached.” This is easy to see when we are talking about offering food, a shower, a blanket, etc. But how do we use those principles when it comes to offering work at the earliest stages of engagement? It could begin by talking in a nonjudgmental way about the work that the person is doing now. In fact -- whether they are collecting bottles, panhandling or selling blood – they are engaging in some type of work for pay. Part of the conversation could be: “What do you need to do every day to prepare for this work?” “Where do you need to be and at what time?” “ Who are your best customers and why?” Our purpose here is threefold:
We are attempting to deepen the relationship by talking about what matters to the person in his or her daily survival.
We are gently instilling the thought that despite their fears about working, they already do, in fact, work for a living. The implied comparison between what they already know, need to know, and do and mainstream employment options may make it easier for the individual to consider such employment.
We are using the acknowledgment of their strengths and skills to being to build the tenuous acceptance that with the right opportunity and support, moving from the job they do to a more formal job is not as long a leap as they may believe.
The expected outcome from establishing work-related discussions is to begin to create personal awareness about their present work-related skills and provide a foundation for providing more information about jobs and an invitation to participate.
It must be stressed that at this stage, it would be unfair to take an expression of interest in work as a chance to refer the person to a job opening at say, the local Radio Shack. Much more work needs to be done for this to occur, because we have all of the other compounding factors of street homelessness to resolve before the person may be able to hold down a nine-to-five job to their and the employer’s satisfaction. The next step may be to offer a flexible, low-impact job at the agency as a “slow entry ramp to employment” in which the person tests the work environment and gets some pay. You can then continue the conversation about what job the person really wants, where it is located, what they need to do to qualify, and when they want to start. In the same way that outreach workers can offer immediate access to permanent housing in a “housing first” program, the important thing would be to provide access to work – now, not after some criterion for readiness meaningful only to the counselor or outreach worker has been met.
Two key principles underlie the process of successful engagement on employment issues:
Consumer choice, and
Separation of clinical indicators from functional abilities.
The Powerful Principle of Consumer Choice
The principle of consumer choice instructs us to release our own judgments about what people need – in particular, our attachment to a particular sequence of recovery (detox, mental health stabilization, six months of sobriety, etc.). Instead, we ask the crucial question: “What do you want?” And…we listen. Then, we join with the person to help make those things happen – even if these things do not seem realistic to us.
We can introduce the idea of housing and employment from the very beginning stages of engagement while people are living outdoors, over a sandwich. We can ask: “Would you like to work? Would you like a place to live? What would you like to do? Where would you like to live?” It is important that we take their answers seriously. As described above, when they are ready, we can help them to consider what it would be like to pursue their goals, to develop a plan, etc. From this perspective, mental health and addictions treatment can still play an important role. The crucial shift in emphasis, though, is that people must choose such treatment because they believe it will help them to reach their goals. People are far more likely to engage in treatment in order to attain an employment goal than for its own sake. However, their participation must be on their terms.
Separating Clinical Indicators from Functional Abilities
This principle is most useful for addressing our own expectations. We often assume that we can judge what someone is capable of based on how the individual appears in his or her interactions with us. We should keep in mind that the setting in which we see someone may not be the best one for accessing the person’s abilities. When people are on the streets, they have little opportunity to do more than display their (often impressive) survival skills. The best way I have of elaborating this point to share examples from my personal experience.
I was involved in the development of a Safe Haven program in Boston that was meant for a cohort of women who had been living on the streets for well over a decade each. They all lived with mental illness and about half also used alcohol regularly. They were familiar to outreach staff, local residents, and business owners, all of whom knew them by name. Despite these connections, they would not accept offers of shelter or treatment.
They were willing to come indoors and use the Safe Haven because of the low threshold entry criteria. They were not required to accept treatment, they did not have to stop drinking (although they could not bring substances inside with them), and they could come and go from the program as they pleased. I think the fact that it was a women-only program also made it accessible. Other attractive factors were the laundry, showers, lockers, and telephone access.
I remember an afternoon about six months after the program opened. I had gone to meet with the program manager, and during the course of the afternoon, I was struck by what I was seeing. I saw the women cooking, setting the table, doing dishes, and washing, drying, and folding laundry. They displayed a level of competence I would never have suspected. They had skills – useful skills. An important point is that they continued to display symptoms of mental illness. They seemed to hear voices and remained cautious of those around them. But despite these and other symptoms, they did the job in front of them and did it well.
I realized that they had no opportunity to display these skills on the streets. We created an environment in which these skills could emerge. This is instructive for our attempts to create employment opportunities. A person displaying symptoms of mental illness may have useful skills and may be able to develop other skills. Recovery does not have to wait for symptoms to disappear.
Moving on from Outreach: Facilitating the Stages of Behavior Change
The need to build a trust-based relationship cannot be emphasized enough. Without establishing a basic level of trust through the outreach relationship, the work of accessing services and resources is unlikely to occur. More positively, once trust is established, it becomes possible to become more goal oriented. The Stages of Behavior Change and Motivational Enhancement models are often used by outreach teams because they provide such a useful framework for thinking about the dynamics of readiness (Miller and Rollnick 2002; Prochaska, Norcross, and DiClemente 1994). This framework not only helps us think about where people are in terms of willingness to pursue resources but also suggests how we may be helpful at each stage.
We will describe the stages of behavior change sequentially, but it is important to realize that in practice it is not a linear process; people typically cycle between stages. Also, when working with people who are homeless, it is important to recognize that motivation levels may differ for different areas of need. Often, we don't consider helping people work towards other goals until they demonstrate high motivation for treatment. However, a person who is not prepared to pursue addictions treatment may be highly motivated to work for a few hours or to seek housing. The areas of need that receive priority are determined by the person on the street, not by us.
The Centrality of Restoring Hope
At the heart of the issue of whether to change or not is often a crucial question: “Why should I?” or perhaps, “What would be different this time?” People struggling with addictions and symptoms of psychiatric disorders, including those experiencing long-term homelessness, have often tried to change many times, and, in their minds, have failed. Pat Deegan, a consumer advocate, clinical psychologist, and self-proclaimed survivor of the mental health system, reminds us that people sometimes relinquish hope as a strategy to survive. With this in mind, in some ways it might be at least as accurate to say we are working to help build hope as to build motivation. Perhaps when people have a real reason to hope, motivation comes more easily.
The Power of Immediate Access to Resources. While we are on the subject of hope, it is relevant to slip in one lesson learned from the experience of implementing “housing first.” There may be no more powerful means to restore hope than to provide immediate access to fundamental resources such as housing and employment. Many people do not seem to us to be motivated when we offer services and the chance to be on a waiting list. Our approach has often been: “services now, housing and jobs later.” Repeated experience has taught many people that “later” means “never,” so we should not be surprised when they do not seem excited by our offer. However, when we take a person from the street, show him or her an apartment, and announce that this can be theirs – often, the individual suddenly shows motivation. The person may be willing to work with a case manager and even have a representative payee.
From Pre-contemplation to Contemplation
The initial goal of engagement may be thought of as helping someone to move from a state of “pre-contemplation,” in which there is little or no perception of a need to change, to “contemplation,” in which there is an emerging, though ambivalent, awareness of the negative consequences of a behavior such as alcohol abuse. These stages are also applicable to a person’s willingness to pursue employment opportunities.
Pre-Contemplation and Employment. If it is determined that someone is in pre-contemplation in regard to employment, there is still useful work we can do to facilitate change. In regard to persons in the pre-contemplation stage of recovery from substance abuse, the model suggests that we may actively work to develop trust, implement harm reduction strategies to minimize harm from risky behavior, and work to create a promising level of ambivalence about the issue at hand (CSAT 1999).
We can apply this model to persons who have not seriously considered formal employment. For example, we can provide education and information that is inconsistent with the view that there is no problem with their current approach to meeting basic needs, thus developing an awareness of discrepancy that can prompt change. We can provide information that helps build hopeful expectancy about employment. In the context of a supportive relationship, such education can bear fruit. Ambivalence, meaning mixed and fluctuating feelings about an issue, is considered a positive sign because it means the person has at least begun to recognize and grapple with an issue, whereas before, it was not even on the table.
Strategies for the contemplation stage. When we see that someone has progressed from “pre-contemplation” to “contemplation” (as evidenced by ambivalence), the model suggests that the work transitions to a set of strategies that are appropriate to that stage. The basic strategy for working with someone who is in contemplation is to work to move mixed feelings in the direction of desiring change. To do this, we help in a nonjudgmental way to tease out both sides of the ambivalence. We help the person to think about the advantages and disadvantages of changing, as well as the advantages and disadvantages of staying the same. Slowly, we supportively encourage the person to work towards change. For example, a person may have many fears associated with work and going back to work. How do we tip the balance towards ambivalence and the next stage? Celebrating successes, no matter how small, is one tactic. If a person is able to attend to a job for a steady hour and that’s more than they had done the day before – that is a success that should be recognized and built upon as we talk about next steps.
It is essential to keep in mind that all of this occurs in the context of a trusting relationship. Engagement is not a one-time event but an ongoing accomplishment that cannot be taken for granted at any stage. All of the principles of engagement continue to apply at each stage, including being respectful of a person’s pace and priorities and taking expressed needs and priorities seriously. However, it is also true that in later stages of relationship development, it is often possible to “push the envelope” a bit more than was possible earlier. Once we know a person well enough, we may be stronger in encouraging them to take the risk of change for the sake of benefits they value.
The motivational enhancement model is instructive about the factors that lead to behavior change:
People change when they perceive a need to – because they become aware of a significant negative consequence of current behavior.
People change when they believe that change is possible.
People change when they believe change will be positive.
Often the people that we work with on the streets and shelters are reluctant to open the door of hope again. It has been shut tight for a very long time. It is up to us to persist in providing realistic reasons to hope for a better life, in the context of a supportive, trustworthy relationship. (We will elaborate on how to do so below.) Clearly, our task is to help people perceive the beneficial possibilities of employment – to foster the realistic belief that it is both attainable and would be positive for them. This includes honest validation of their strengths and abilities. At the same time, we need to be honest about the real challenges ahead and provide support for addressing them.
One answer to the question “What would be different this time?” is that we can offer people the opportunity for a more informed, skilled, and supported attempt to seek employment, where most of their previous attempts have been without support and with a black-or-white perspective that generates statements such as, “I tried and failed. I can’t do it.” We can help foster an approach to change that is more nuanced and realistic.
From Contemplation to Preparation
Prochaska, Norcross, and Di Clemente (1994) caution against moving too quickly from contemplation into taking action. There is an important stage between contemplation and action that is called “preparation.” This stage should take some time and is characterized by planning.
Together, a worker and person living outdoors try to anticipate and prepare for what it would really be like to work – in both positive and negative ways. As in the substance abuse world, we often speak of identifying “triggers” that elicit the behavior we want to change, and this way of thinking can be directly applied to concerns about employment. We can help a person to think through work-related “triggers,” which may include receiving directives from a boss, feeling attracted to a co-worker, or experiencing depression in the work place. The best way to handle these “triggers” can be discussed in more detail in the context of a specific work environment as we enter the action and maintenance stages (below) and plan to address the challenge of relapse prevention. While discussion of work-related triggers can be included in earliest stages of engagement, planning around addressing them might be more likely to occur after a person has entered into a more structured employment program.
From Preparation to Action
Once a plan has been developed, it is possible to take action. It is important to appreciate, however, that there is a cyclical, feedback quality to the plan’s implementation. The plan itself is an evolving one. First, the person takes an action step and then comes back to his or her support system to evaluate how it went, sharing what was learned about the process. That learning gets incorporated into the plan, and we keep moving in that fashion. This is a more realistic model for change and reflects how people who do succeed in making significant changes in their lives are able to accomplish this. It is important that people eventually break the habit of black-or-white thinking and replace it with this more flexible understanding of how change occurs.
Applying this understanding to employment, we can think of all employment experience as potentially valuable – even, and perhaps especially, those experiences that do not ultimately work out. We can support people in taking steps forward without the expectation that it will be a “zero-sum” game. To the extent that a work experience is difficult, we can reflect with our clients about what these experiences are teaching them. Such experiences can be invaluable for helping people identify difficult situations that they will have to learn to deal with, as well as helping to identify skills they will need to develop. Most importantly, they will be learning about what they like to do and are good at, as well as what they really don’t like to do. This learning then informs the plan and next action steps. If most of us were to reflect on our previous work experience, we could identify valuable lessons we learned from our worst job experiences.
Preventing Relapse at the Maintenance Stage
Significantly, the dynamic view of learning and change discussed above extends to the notion of relapse as well. In both the stages of behavior change and motivational enhancement models, relapse is viewed as a part of the recovery process, not something that occurs outside of it. It is not viewed as a failure or an aberration; rather, it is viewed as something that is to be expected, planned for, and used as an opportunity for growth, change, and learning. We can share this understanding about relapse or setbacks with our clients from the beginning.
There are two different sets of activities related to discussions about relapse. The first is planning for what the experience of relapse might be like for this particular person. The second is actually planning to prevent relapse.
Planning for the experience of relapse. One common example related to relapse that also applies to many unsuccessful employment experiences is that people feel shame. Perhaps the experience will feed into a longstanding sense of hopelessness or seem to validate a deep-seated self-image as a “failure.” It is important for us to remember that it is one thing to intellectually agree with the idea that relapse is not a failure, but a learning opportunity, when we are sitting with our counselor in an office; however, it is another thing entirely to strive not to feel like a failure when it actually occurs (particularly early in the process). This is something else that can be anticipated and planned for. It may take time before someone fully buys into the idea that relapse is a learning opportunity. A person who has relapsed may want to isolate himself or herself to avoid facing anyone. If this happens, it is important to help the person identify the easiest way to build a bridge back to the support network. This might involve assistance from a particular friend or a favorite twelve-step meeting.
Planning to prevent relapse. The second set of tasks includes those designed to actually help prevent relapse from occurring. The principles are similar to those discussed above. In this connection, it is often productive to help people identify various internal and external “triggers” that precipitate substance use. We can think of internal and external triggers. External triggers are generally people, places, and perhaps things that are associated with substance use. Internal triggers are habitual thought patterns and emotional states that enable substance use. We can help a person to identify internal and external triggers in the context of the work environment by anticipating, in as much realistic detail as possible, what the employment experience will actually be like for this person at this time, identifying potential problem areas, and planning for them.
Outreach workers know what tools and strategies to use to encourage participation in treatment services. They know that the years of homelessness and concomitant deprivation, disability and despair can only be remediated with time, trust, and opportunities. Helping people realize that having a good job at a living wage can be part of their future also takes time, trust, and the right opportunities. For too long, conversations about work have only occurred when the system felt people were “job ready.” We know from the success of “Housing First” that those preconceptions about readiness are no longer supportable. As in the Housing First model, we must begin by asking people what they want and why they want it, and then work with them to meet their needs and achieve their goals. From that point onwards, we and those we serve can continue the partnership that we hope will lead to a permanent escape from homeless to a new life with a home, a job, and a future of hope and dignity.
Tom Lorello, M.S.W. and John Rio, MA, CRC
About the author: Tom Lorello is Executive Director of Shelter, Inc., a nonprofit agency based in Cambridge, Massachusetts and dedicated to ending homelessness in the lives of individuals and families by providing effective shelter, housing, and supportive services and by promoting policy and practice necessary to change those conditions that create homelessness. He has provided technical assistance and training to PATH State administrators and PATH grantees across the United States.
John Rio has over 30 years of experience in rehabilitation and vocational services in a variety of settings in several states. He is the Co-Director of the US DOL supported Chronic Homelessness Employment Technical Assistance Center. His work has focused on developing materials, delivering technical assistance, training, and designing strategies to help increase the capacity of supportive housing and service organizations to offer employment services to formerly homeless people with disabilities.
Center for Substance Abuse Treatment, Enhancing Motivation for Change in Substance Abuse Treatment. (1999). Treatment Improvement Protocol (TIP) Series 35. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA). This TIP is available at no charge by calling SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI), 1-800-729-6686. All TIPs can also be accessed online at www.kap.samhsa.gov.
Cohen, M. B. (1989). Social work practice with homeless mentally ill people: engaging the client. Social Work 34(6): 505-509.
Miller W. R., Rollnick S. (2002). Motivational Interviewing: Preparing People for Change (2nd ed.). New York: Guilford Press. This classic work is useful to anyone who works with clients in the process of change.
Morse, G. A., Calsyn, R. J., Miller, J., Rosenberg, P., West, L., & Gilliland, J. (1996). Outreach to Homeless Mentally Ill People: Conceptual and Clinical Considerations. Community Mental Health Journal, 32(3): 261-274.
Prochaska, J., Norcross, J., and DiClemente, C. (1994). Changing for Good. New York: Avon.