Beruflich Dokumente
Kultur Dokumente
and consistent staff contact through assertive outreach (Cohen & Tsemberis,
1991; Rife, First, Greenlee, MiLler, & Feichter), "meeting the client where he is"
both geographically and existentially
(Cohen & Marcus, 1992; Lamb, Bachrach,
Goldfinger, & Kass, 1992); help with immediate subsistence needs such as food,
emergency shelter, and clothing (Interagency Council on the Homeless, 1991);
gradual engagement and persuasion to accept treatment through the d e v e l o p m e n t
of trust (Brickner, 1992; Susser, Goldfinger, & White, 1990; Swayze, 1992); an emphasis on client strengths (Chafetz, 1992;
Martin, 1990; Ridgway, 1988; Vaccaro,
Liberman, Friedlob, & Dempsay, 1992),
client choice of services a n d the right to
refuse treatment (If,ass, Kahn, & Felix,
1992); and the delivery o f comprehensive
services including mental health and substance abuse treatment, medical care,
housing, social and vocational services,
and help in obtaining entitlements (Lamb,
Bachrach, & Kass, 1992). In addition to
these components, the use o f formerly
homeless a n d / o r mentally ill individuals
as outreach workers and case managers is
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gaining recognition as a method of reaching and serving homeless mentally ill persons (Dixon, Krauss, & Lehman, 1993;
Van Tosh, 1993).
While additional empirical research is
needed to establish the efficacy of this new
treatment approach, the challenge for
managers is to respond to the pressing
needs of mentally ill homeless persons by
fostering innovation and improvement in
services for this population. In practice,
this means implementing the consensusdriven treatment approach described
above in the face of some uncertainty
about its specific strengths and limitations. Innovation should be attempted
within the context of the larger treatment
system so that services for homeless persons are positioned as one critical link in
the web of a comprehensive continuum of
care. Integrating this treatment approach
within a traditional service system, however, is difficult, since there is virtually no
literature on implementation and since
the core assumptions of this approach
about where and how the work is done differ substantially from the way in which
care is routinely delivered in most treatment settings.
Drawing on our work with a comparison site for the federal ACCESS (Access to
Community Care and Effective Services
and Support) initiative, a nine state research demonstration designed to test the
importance of systems integration strategies in providing services to people who
are homeless and mentally ill (Randolph,
1995), we identify six critical issues that
mental health administrators are likely to
confront in developing outreach, treatment, and rehabilitation programs for this
population. They are 1) confronting, at
federal, state, and local levels, the political
question of whether to serve homeless
mentally ill people; 2) identifying the target population by attempting to define
"homelessness" and "mental illness"; 3) putting the guiding principles of non-traditional treatment into operation; 4) facilitating interdisciplinary and interagency
CRITICAL ISSUES
Why Serve People Who Are Homeless
and MentallyIll?
With few exceptions, public mental
health systems have devoted scant resources to serving people who are homeless and mentally ill, due to several factors.
First, while these individuals have multiple
needs they appear to make few demands
for traditional services. Second, the public
sector agencies that could provide treatment and supports are overburdened with
demand from individuals who actively seek
help for their psychiatric symptoms (Lipsky, 1980). Thus, there is little motivation
to engage in case finding outside of agencies, particularly to locate individuals
whose needs for basic life supports such as
food, clothing, and shelter are so pressing
that it is easy to regard them as having predominantly social rather than psychiatric
"
problems (Cohen, 1990; Goldman & Morrissey, 1985). Third, the guiding principles
of outreach state that caring for homeless
mentally ill persons is a long-term, labor intensive process which, when successful,
produces slow, incremental changes in the
quality of individuals' lives (Rife et al.,
1991). Managers and policymakers often
judge the cost-benefit ratio of such activities to be high compared with the potential
benefits of helping a greater number of
less impaired and more "motivated" clients.
(Chafetz, 1992), particularly when empirical support for the cosily outreach work is
limited. Managers, already operating with
scant resources, may legitimately fear taking on the fimancial burden of working
with such "hard to serve" individuals.
Since service demand and cost-benefit
considerations can discourage mental
health providers from allocating resources
to treat homeless people with mental illness, other forces may be required to catalyze the decision to reach out to them.
One such force is public reaction, such as
outrage against homeless people for intruding into personal space or public
places, or advocacy from those who support the needs of this disenfranchised population. Another force stems from the
philosophical or moral commitment of
mental health administrators, or policymakers who decide that serving homeless
people with mental illness must take precedence over pure service demand and costbenefit.considerations. Their actions may
be driven by the evolving "populationbased practice" paradigm in community
psychiatry (Sabin, 1993), which emphasizes
our professional responsibility to meet the
needs o f all clients suffering from mental
illness and thus expands the targeted population for public mental health services.
Finally, grant support from government
agencies and private foundations, perhaps
arising from public outcry or philosophical
commitment, provides a practical incentive to administrators to serve the homeless population without reducing services
to other individuals.
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558
Strategies. Service providers must attempt to clearly define the target population for the new homeless p r o g r a m at the
p r o g r a m ' s inception. This definition must
address clinical needs in the local service
area and a c c o m m o d a t e the d e m a n d s o f
the funding source. The definition will
then be challenged by both staff and
homeless persons as outreach workers locate individuals who could benefit from
comprehensive services but who fail to
meet formal criteria. Managers must walk
a fine line between satisfying their funding
source, addressing the stated mission o f
the program, and helping the host mental
health system to r e s p o n d to the needs o f
individuals who do not fit neatly into bureaucratic categories. They must also monitor the congruence between the defined
target population and the characteristics
of patients actually served to ensure that
the pressure to increase their census,
which is easily satisfied by enrolling the
most accessible and easily identified patients, does not result in excluding those
most impaired and most in need. In o r d e r
to do this they must maintain close contact with their funding source regarding
"grey areas" in the admissions criteria, and
continue to develop new outreach strategies to find "hard to reach" homeless mentally ill persons.
Implementing a Non-Traditional
Treatment Approach
Once local projects secure funding and
adopt a working definition of the target
559
560
Strategies. We have found two strategies particularly helpful in managing interagency and interdisciplinary work. One is
participatory management, a decisionmaking process that engages all agencies
and staff in managing services and partly
diffuses turf and power issues. In New
Haven, joint day-to-day management of
outreach and case management activities
was provided by. a clinician from the lead
agency and a case management supervisor
from an emergency shelter. Interagency
and interdisciplinary outreach and case
management work teams were established
to cut across agency boundaries, to create
opportunities for staff to share functional
responsibilities and to educate staff in the
value of all aspects of the work. In addition, a monthly meeting involving all collaborating agency supervisors provided a
forum for anticipating and addressing
sources of interagency tension or conflict.
A second management strategy is to create opportunities for staff to educate and
inform each other of their independent
responsibilities. This has the potential to
reduce fantasies and misconceptions
about the work that others do. Staff can be
assigned the responsibility of becoming
the expert in a designated area such as entitlement-seeking or personal safety in
outreach, thus heightening their sense of
making a unique contribution to a shared
endeavor. They can draw on this expertise
or their professional experience to do
"cross-training" of other clinical, case management, and rehabilitation staff.
561
562
Consumer Participation
The contribution that consumers--formerly homeless, mentally ill, or recovering
substance using individuals-can make to
homeless outreach programs has been recognized by various programs and researchers (Dixon, Krauss & Lehman,
1993; Mullins et al., 1994). Consumers
often show great skill in entering the physical a n d psychological worlds o f homeless
persons, locating them in out-of-the-way
street sites, developing trusting relationships with them, and, by their own example, showing them a path out o f homelessness. Much o f the success of consumer
staff seems to flow from their ability to
draw on their personal experience of
homelessness, mental illness, or addiction.
O u r experience has been that when managers are aware o f the potential difficulties
that can come with their integration into
the homeless outreach program, consumers can a d d an i m p o r t a n t element to
the team. W e will briefly note a few o f
these difficulties.
C o n s u m e r staff must make a personal
adjustment from the consumer to provider role. Because consumer staff are
often newly housed, newly stable or in recovery, and newly entering the j o b market,
they are often at a particularly vulnerable
stage in their lives. Their experience of
these "life stressors" may be exacerbated
by feeling they have to prove to supervisors that they can make the transition
from client to staff member, and by fraternizing with staff while voluntarily with-
DISCUSSION
We have attempted to outline critical
developmental issues for programs serving homeless persons with mental illness.
While we have emphasized the dilemmas
these issues pose during the early stages of
implementation, they do not disappear
over time but wax and wane throughout
the life of the program. For example, the
initial question of whether a system
should serve homeless mentally ill people
will re-emerge when funding cutbacks
occur and the homeless outreach program
is now a player in the complicated web of
local services, competing with other agencies for dwindling resources. The definition of the target population may be challe'nged by both homeless persons and
providers as outreach staff make difficult
choices of providing services to duallydiagnosed clients, excluding a very needy
group of homeless persons who "only"
abuse substances and lack a major mental
illness. Consumers employed as staff, having demonstrated their value, may begin
to challenge their pay scales, their minority status, or even their lack of direct control over the program.
Managers, then, must continue to confront these critical issues which first ap-
563
peared early in the program's development. The shape of these recurring issues
and the strategies for confronting them
will vary from site to site. However, the
continuing challenges they pose highlight
the dual imperatives of nurturing and
transforming the initial program culture
into a viable organization, and capturing
institutional support without losing the
distinctive flavor of the project.
564
less outreach programs, but such programs e m b o d y this new treatment approach. By modeling this a p p r o a c h and
teaching its successes through case conferences and day-to-day interactions with
other staff and administrators, p r o g r a m s
for mentally ill homeless persons can foster an increasing acceptance o f these
ideals within the local a n d m o r e traditional service system.
Homeless outreach programs, like
o t h e r innovative clinical a n d social service
programs, operate within an uncertain environment, particularly d u r i n g a time
when cutbacks in social services are being
debated and acted u p o n at the local, state
and national levels. Such programs will always be subject to forces b e y o n d their control, and client d e m a n d for the p r o g r a m ' s
services will probably always outstrip the
supply. Still, careful attention to the critical issues discussed in this p a p e r can help
reduce some o f the barriers to implementation, effectiveness, and long-term survival o f innovative programs for homeless
persons with mental illness.
REFERENCES
Breakey, W. R., treating the homeless. (1987).
Alcohol Health & Research World Spring,
42-47.
Brickner, P. W. Medical concerns of homeless
persons. (1992). In R. H. Lamb, L. L.
Bachrach, & F. I. Kass (Eds.), Treating the
homeless mentally ill: A report of the Task Force
on the Homeless Mentally Ill (pp. 249-261).
Psychiatric Association.
Interagency Council on the Homeless. (1991).
Reaching out: A guide for service providers.
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