Section 3: Meeting People Where They Are At

Years of on-the-ground experience delivering services have distilled numerous approaches to maximizing the opportunities provided by the PATH program. Rigorous research confirms anecdotal evidence of the effectiveness of many of the approaches described in this section.

Training

To knowledgeably and compassionately carry out their responsibilities, PATH staff should be trained on a variety of topics.

Outreach

PATH’s success depends on reaching people where they are, both physically and emotionally. For the former, that means safely conducting outreach to people experiencing homelessness. This may involve exploring wooded areas, railroad lines, areas under overpasses, and abandoned buildings, as well as visiting libraries, laundromats, churches, soup kitchens, shelters, drop-in centers, and other such safe public spaces. PATH providers might also consider reaching out to community partners such as hospitals, emergency departments, and mental health agencies for individual referrals, in addition to connecting with community code enforcement officers and other resources for locating transient camps.

Keep it safe. Take these precautions to stay safe:

• Let a supervisor know where you are going, and travel in pairs.
• Dress for the environment (dress casually, wear closed-toe shoes and long pants or weather-appropriate clothing, have gloves and hand sanitizer available).
• Identify yourself clearly, listen thoughtfully, and recognize when it is time to leave.
• Practice respect for those you serve.
• Seek an invitation from someone in the community that you are trying to engage.
  • Most encampments have a de facto leader; try to determine who that is and arrange to meet and explain what you are trying to do. Ask for help.
  • Plan a regular schedule for visits and inform the camp’s residents of it. If you promise to visit, be on time. Keep your promises; you may not have another chance to build trust.

Engagement

Engagement comes with time, persistence, and patience. Little will change in the absence of trusting relationships. The ultimate goal is to connect individuals with long-term supports, but—particularly in the beginning—you will need to respond to immediate needs. Engage by expressing caring, warmth, humor, sympathy, empathy, and understanding without judgment. There will be time to do assessments over the course of your visits, and that is when you will begin to learn about a person’s needs, from the most basic—food, water, and warmth—to glasses, dental care, and mental health treatment.

Keep it real. To build trust with potential clients, consider:

• Maintaining awareness of each person’s “three homes:" personal space, living space, and community.
• Showing up ready.
• Getting to know the community.
• Being present with intent—develop relationships by listening and responding.
• Offering something, such as food, water, sunscreen, or socks.

Keep returning, so that you are regarded as dependable. Even if you cannot fix something right away, it is nonetheless important to be present at any given moment.

Client choice

Critical to providing any service during PATH is recognizing client choice. Staff should encourage clients to “drive the bus,” empower them to achieve their goals, and recognize their strengths. Services are typically more intense at the beginning and taper off as the client accesses needed services and begins building other relationships.

Motivational interviewing

Motivational interviewing is counseling style that relies on collaborative conversation and attention to a person’s intention to change.

In motivational interviewing, a therapeutic professional works together with individuals to process their commitment to change, while also acknowledging any ambivalence they may have about change. Ambivalence, or having mixed feelings about something, is usually a primary barrier to change. Motivational interviewing’s evidence-based, person-centered approach can be used to explore and resolve ambivalence in the context of a variety of health-related behaviors.

Principles of motivational interviewing

Motivational interviewing follows four principles.

• Express empathy: Empathy means acknowledging someone’s experience, feelings, and reactions to their environment. In motivational interviewing, it’s important to let clients describe their experiences while using reflective listening. Successfully resolving ambivalence is more likely when a client feels heard
• Support self-efficacy: The individual takes the lead in motivational interviewing and should be encouraged to make plans for change and then carry them out. The counselor supports that work by listening, motivating, and offering support as needed.
• Roll with resistance: In motivational interviewing, ambivalence and resistance are expected elements in the change process. To move past them, the counselor and the individual together explore the source of the resistance. Rather than provide direction, the counselor helps the individual explore any concerns and guides them to consider new perspectives and solutions. For example, when there is a substance use disorder, the professional might ask, “Why would you want to cut back on your use of alcohol?” or “What’s the downside of your continuing to use heroin?”
• Develop discrepancy: Through motivational interviewing, individuals can find and assess how current behaviors keep them from meeting future goals. The counselor’s role is to help the individual see that the disconnect is getting in the way of successful change.

Consider these questions when implementing motivational interviewing

• Did staff complete any training in preparation for implementing motivational interviewing? If so, what kind?
• Is fidelity to motivational interviewing being assessed? If so, how?
• Is clinical supervision offered to provide constructive feedback?

Person-centered planning

Planning is something that all people do. People set goals. People dream of things they want in order to live their best life. Over time, with individual effort and outside supports, goals can be achieved.

In human services work, best practice is to use person-centered planning methods. Person-centered planning has a constructive focus verses a focus on problems, tending to symptoms, and treating a diagnosis. Services exist to benefit the people served (and not vice versa). Person-centered planning is done with the people served, for the people served. When practitioners and recovery-oriented systems embrace person-centered planning, they see each person as an essential partner in making decisions about services.

Person-centered planning involves ongoing conversations about action, as well as the creation of a written document about action. Planning is not something done once and then finished. Written plans change and evolve as the person does. No two plans are identical. Natural supports and the strengths and resources they offer are encouraged and engaged. Services and action steps are collaboratively identified, and balance what is important to the person and what is important for the person.

Peer support

People with serious mental illness or in recovery from co-occurring disorders who have experienced homelessness or housing insecurity have first-hand insight into how to survive and thrive. In a judgment-free and supportive way, peers share this knowledge with others in similar situations. The credibility inherent to peer support fosters hope and honest communication. Individuals receiving peer support have living proof that recovery is possible, a mentor for the steps to take, and a sounding board for when things don’t go according to plan.

Critical Time Intervention

Critical Time Intervention is a limited-time intervention that uses a phased approach of community-based case management.

Critical Time Intervention is a practice to prevent homelessness at a time when an individual is particularly vulnerable, such as after being discharged from a hospital. It can be used with many populations, including people who have already experienced homelessness, people who have been incarcerated, people with mental illness, and veterans. This short-term approach helps ensure that an individual has necessary community supports and can use that network independently.

The Critical Time Intervention model emphasizes small caseloads and regular supervision and case review sessions. The phases of Critical Time Intervention are as follows:

• Pre-Critical Time Intervention—Develop a trusting relationship with the client prior to phase 1 (transition).
• Phase 1 (Transition)—Support client and establish service/support connections (about three months), during which home visits are conducted, needs are identified, and supportive connections are forged.
• Phase 2 (Try out)—Monitor support network and support client (about three months), during which modifications are made and conflicts are mediated. Clients are encouraged to take on more responsibility.
• Phase 3 (Transfer of care)—Withdraw Critical Time Intervention case management (about three months), ensuring that supports function without Critical Time Intervention case management. Clients develop long-term goals and review progress.

Consider these questions when implementing Critical Time Intervention

• Did staff complete any training in preparation for implementing Critical Time Intervention? If so, what kind?
• At what point are clients typically engaged in Critical Time Intervention services?
• For a typical client, where do client meetings most commonly happen?
• On average, how long are clients engaged in Critical Time Intervention services?
• What is the average caseload size for Critical Time Intervention case managers?
• Is fidelity to the Critical Time Intervention model being assessed? If so, how?

Trauma-informed care

Life on the streets or in a shelter is often marked by exposure to violence or victimization, generating fear, helplessness, and a sense of disconnection from family and community. Furthermore, research from the American Journal of Public Health indicates a high prevalence of adverse childhood experiences among individuals experiencing homelessness—scars that can reopen during times of vulnerability.

The Substance Abuse and Mental Health Services Administration describes individual trauma as an event or circumstance resulting in physical harm, emotional harm, and/or life-threatening harm. Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.

Trauma-informed care is a strengths-based delivery approach that understands and responds to the impact of trauma across settings, services, and populations. Programs can minimize the potential for retraumatizing individuals by infusing trauma-informed care throughout its operations: governance and leadership; policy; physical environment; engagement and involvement; cross-sector collaboration; screening, assessment, and treatment services; training and workforce development; progress monitoring and quality assurance; financing; and evaluation.

Principles of trauma-informed care

Trauma-informed care follows six principles.

• Safety: Physical settings and interpersonal dynamics are physically and psychologically safe for all individuals, including staff and program participants of all ages.
• Trustworthiness: Organizational operations, processes, and procedures are conducted with transparency.
• Peer support: Connecting individuals with lived experience of trauma to each other builds safety, hope, trust, and mutual aid.
• Collaboration and mutuality: Everyone involved in service consumption and organizational functioning plays a role in supporting trauma-informed care. Healing is supported through relationships and meaningful sharing of power and decision-making.
• Empowerment, voice, and choice: Consumer and staff strengths are recognized and built upon. The belief that people are resilient and can recover from trauma is a core component of the organization. Empowerment is fostered through a balance of power, shared decision making, choice, and personal goal setting.
• Bias-free thinking: The organization works to move past cultural stereotypes (examples: gender, race/ethnicity, sexual orientation). It provides gender-responsive services, uses a culturally sensitive approach, and recognizes historical trauma.

Consider these questions when implementing trauma-informed care

• In what ways are trauma survivors involved in your program?
• In what ways is the physical, psychological, and emotional safety of individuals maintained?
• Is fidelity to trauma-informed care assessed? If yes, how?

Retention

Trusting relationships are key to retaining someone in services and housing. Engaging an individual in PATH is a significant step, but it is not uncommon for people coming out of homelessness to struggle to stay in housing. Eviction can happen for a variety of reasons, many of which are tied to inability to abide by the terms of the lease. Many people leaving homelessness have been living with chronic crises, health problems, histories that include criminal justice, lack of income and resources, and active mental health and/or substance use disorders. This can make it even more difficult to achieve stability in services. The time immediately after enrollment should be structured to allow PATH staff to help clients access needed services and resources, while still allowing them to make their own decisions. Looking at and addressing root causes leading to crisis equates to better retention.

It is essential PATH participants become engaged in the supports needed. Typical supports include mental health services, substance use disorder treatment, social services, job placement, life-skills training, 12-step or other support meetings, housing, financial resources, and insurance.

Steps to promoting retention

1. Identifying and mitigating barriers to housing.
2. Identifying and leaning into client strengths.
3. Identifying and accessing resources.
4. Documenting steps toward housing.
5. Building in flexibility to respond to changing circumstances.

Specific strategies to improve retention may help, such as rewards for achieving and maintaining drug abstinence or for consistent participation in prevention or treatment activities. A written plan is required and is a good strategy for retention. It provides a road map for the client and the case manager, breaks goals down into attainable steps, clarifies goals and responsibilities, and provides a benchmark for identifying progress.

Transitions in care

PATH staff may continue to work with PATH-enrolled individuals who have and are residing in permanent housing or who have been referred to mainstream resources for a period set by the state PATH contact. In Wisconsin, this period is 90 days.

Transition in care from PATH-funded to mainstream services can be a critical time for PATH clients. PATH is an intervention model that is intensive and time-limited. After spending a great deal of time building a relationship with a PATH provider, it may feel like a loss to clients when they move into permanent housing and start receiving services from mainstream community providers. Failure to properly transition clients can have dire consequences, including a return to homelessness.

Homelessness is complex and often includes feelings of shame and guilt, backgrounds of significant trauma, economic and employment barriers, inadequate health care, and more—all of which can be exacerbated by separation from intense services. PATH workers must help meet the psychological, physical, and emotional needs of their clients.

After-care is integral to the continued housing and wellness success of individuals with serious mental illness or co-occurring disorders who have experienced or are at risk for homelessness. The needs of the individual will determine the specific elements of after-care, which may include assistance with the following:

Resources that can help in after-care include 211 and the 988 Suicide & Crisis Lifeline. These resources can help people connect with community services and counselors trained to support people experiencing a variety of challenges.

Success story: meeting John where he is at

The PATH team met John while conducting street outreach along the river where people experiencing homelessness congregate. Although friendly, he did not want to disclose much information to the PATH team. The team’s daily visits generated John’s trust to such a degree that he felt comfortable reaching out to his case worker during challenges with his mental health. The PATH case worker validated John’s feelings, talked with him about his struggles, and helped John secure treatment for his dual diagnosis. The PATH team helped John secure a job, which allowed him to move out of an emergency shelter into an apartment. PATH was able to connect John to an agency with rental assistance for five weeks, so John could use extra money on food, furniture, and other necessities. John’s hard work, combined with the dedication of the PATH street outreach team, led to John’s gainful employment, a place to call his own, and renewed relationships with his family.

Go back - Section 2: Overview of PATH
Next - Section 4: About Housing