Voices from the Field Blog: Matching Housing Options to People’s Stages of Change

by Darby Penney
December 31, 2015

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Homeless and Housing writer Darby Penney interviewed Dr. Ken Minkoff, a leading national expert on integrated treatment of individuals with co-occurring psychiatric and substance use disorders, on the range of housing options that need to be available to help people who have experienced homelessness find housing that reflects their self-identified preferences at the stage they are in in their lives.

In order to successfully house people who are experiencing homelessness and have substance use disorders, a “one-size-fits-all approach” must give way to “person-centered, trauma-informed, recovery-oriented, and integrated approaches,” said Ken Minkoff, M.D., Assistant Professor at Harvard, a Senior Systems Consultant for ZiaPartners in San Rafael, CA (www.ziapartners.com), and a leading national expert on integrated treatment of individuals with co-occurring psychiatric and substance use disorders.

“People [experiencing homelessness] commonly have a whole array of co-occurring mental health conditions and substance use disorders; one or more of their mental health or substance use conditions may be significantly out of control, and one of these conditions may be a more significant problem for them than the other. People may also have serious physical health conditions and disabilities, including cognitive issues as a result of substance use or traumatic brain injury, as well as developmental disorders. They may be responsible for children, they may be survivors of domestic violence, and there is a high prevalence of trauma,” he said. “So individuals have different preferences about what their most important goals are at a particular moment, which includes their desired living situations, the kinds of services they want, and how important housing is on their list of needs.”

Dr. Minkoff believes that communities must, therefore, make a range of housing options available so that people experiencing homelessness who also have substance use conditions can choose the type of housing that best fits their vision for a happy life, their preferences about what is their most important next step for help (e.g., housing, employment, medical care, mental health care, or substance use treatment), and their current “stage of change” for each issue in their recovery.

Stage of change is issue specific, not person specific, and best practice interventions, including housing, need to be “stage-matched,” according to Dr. Minkoff. “We need to be respectful of people’s choices,” he said. “We must get much better at acknowledging that people need to have meaningful choices that offer them the kind of support they currently want. For people with substance use conditions, one approach to stage-matched (for substance use) housing is to think of housing options in terms of whether they are ‘wet,’ ‘dry,’ or ‘damp.’ This is not about whether we will ‘let’ you drink or drug—it means that we reach out to you where you are, provide housing that matches where you are in your approach to using substances, and then help you get where you want to go by being successful in that housing,” he said.

“Dry” housing refers to housing—usually group housing—where abstinence from alcohol and drugs is an expectation. “When we invite someone to live in dry housing, we [should not] demand that people follow an inflexible rule in order to keep their housing, because [it may be] the only housing option they are offered,” Dr. Minkoff explained. Ideally, people living in dry housing will have “a genuine desire to live in a setting where everyone will be abstinent … People with substance use issues who choose this housing are usually in a ‘late action’ or ‘maintenance’ stage of change regarding their substance use. They are committed to sobriety.”

Minkoff said that, in dry housing, there should never be a “one-strike, you’re out” policy. “If and when people slip, it is taken seriously, and people in the house wrap around the person with helpfulness. They ask, ‘How can we help you achieve your goal of sobriety?’ But if people revert to using and no longer want to be sober, then we help them find a living situation that fits them better at this point in their life,” he said. “Knowing how to work with people properly is so important,” he said. “You have to be non-punitive and respectful; you need to have the right attitude. There is a big need throughout the entire system to shift to this way of thinking and working with people.”

“Wet” housing refers to housing in which people may drink or use substances in the privacy of their home, unless this leads to behavior that will cause them to lose their housing. Most of us live in “wet housing,” Dr. Minkoff observed. The scattered site housing first approach used by Pathways to Housing (https://pathwaystohousing.org/) and the supportive housing developed in Seattle by DESC (http://www.desc.org/) are two examples. Wet housing is often an apartment in which a person lives independently, with wraparound support focused on maintaining housing.

“You must be very purposeful about developing wet housing,” Minkoff cautioned. “You need to build relationships with people based on where they are currently and help them move from a ‘pre-contemplative’ stage of change regarding their substance use to a ‘contemplative’ stage, in which they are open to discussing their substance use with housing support staff, even though they may not want to change. We need to understand that it is the person’s life and they get to make their own choices. We can help them learn skills that will enable them to keep their housing if they agree to let us help them. So, for example, people don’t need to be sober or take psychiatric medications to stay in wet housing, but what they can’t do is urinate in the hallway. So we talk to them about that, or about the fact that they can’t invite dealers into the building and keep their housing, not whether they drink or drug.” If wet housing is done right, Minkoff noted, people’s drug and alcohol use usually goes down and their mental health improves, because they are in safe housing and have supportive relationships with staff.

“Damp” housing is a variation of the Housing First concept, according to Minkoff, in which people are choosing to live in a group setting because they want social support, but they are not yet interested in being abstinent. The focus is on helping the person be successful in this housing environment, as well as being a successful member of the community. In damp housing, each person has his or her own space, but there are also common areas, shared activities, and a sense of community. It does not come with expectations of sobriety, like dry housing, but offers additional layers of support and expectations, compared to wet housing. Minkoff explained, “The most important message in damp housing is: ‘Although we recommend that you don’t use, it is your decision. However, if you are going to use, the most important requirement is that you are able to talk to us about it and share your experiences with the community, so we can all pull together to help you figure out the right amount of use that will allow you to be successful in this program.’”

“The approach is to let people know we are there for them if they want to come in off the street, and that we realize this can be hard. We welcome people into our community and let them know our job is to help them be successful here. It is their choice whether or not they accept mental health or substance use services. While there aren’t expectations of sobriety, it is expected that any substance use is done in a way that doesn’t hurt the community. And the program must be designed without hidden expectations of sobriety, despite rules to the contrary. That just sets people up to fail,” Minkoff said. “It is important that the expectations in damp housing are transparent to everyone.”

To be responsive to people who are experiencing homelessness and who have substance use conditions, we need to build programs and housing resources that are respectful of people’s choices and reflect their self-identified preferences at the stage they are in in their lives, Minkoff believes. “Unless we understand that different people want different things from their housing, including how they choose to approach using substances, and unless we realize that we are talking about a continuum of housing to match those choices, we will fail people in the housing we provide, as well as waste resources trying to force people into mismatched housing programs,” he said.

Interested in being an HRC Guest Blogger? Email us at HomelessPrograms@samhsa.hhs.gov.

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Voices from the Field Blog: Winter Weather Preparations for Those Living Unsheltered

by Darby Penney
November 14, 2014

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Homelessness and Housing contributing writer Darby Penney discusses the onset of winter weather and what many cities have instituted in response to tragic deaths from hypothermia and other cold-related conditions to temporarily enhance access to shelter when the temperature falls.

Living on the street can be daunting and dangerous at any time of the year, but in many parts of the country, the onset of winter weather can quickly make this a potentially lethal circumstance. In response to tragic deaths from hypothermia and other cold-related conditions, many cities have instituted Code Blue programs to temporarily enhance access to shelter when the temperature falls.

In New York City, for instance, the Department of Homeless Services initiates Code Blue when the temperature falls to 32 degrees or lower, or if there are sustained winds or periods of intense snowfall. While a Code Blue is in effect, twice the usual number of street outreach vans are deployed to help locate people in need and offer them rides to shelter, assess them for medical needs, and provide warm clothing and food. In addition, people may access any of the agency's shelters and drop-in centers without going through the usual intake process. Many cities have similar programs, although the instigating weather conditions, rules, and available services vary from place to place.

But some people do not live in places with Code Blue programs, or, for a variety of reasons, may choose not to come into shelter. In some localities, people who are under the influence are not welcome to enter shelters, even during emergency weather conditions. But across the country, homelessness service providers, volunteers, and generous citizens have come up with ways to help unsheltered people survive frigid temperatures.

In Buffalo, New York, volunteers Jesse and Kristen Dixon recently founded the Code Blue Relief Mission in October 2014 to collect and distribute blankets, coats, sleeping bags, and other winter gear to people living outside. The Dixons formerly volunteered with an organization that served a similar mission but closed down last year. Realizing that people experiencing homelessness in Buffalo would otherwise go without this service this winter, the couple rallied friends, family members, and community volunteers to make sure these needed supplies are collected and distributed. Inspired by his father, a Vietnam veteran, Jesse Dixon started volunteering in order to help veterans experiencing homelessness and felt that direct outreach to individuals living on the streets of Buffalo was the best way he and his family could help. Code Blue Relief Mission has a drop-off point at a parking garage near the stadium during every Buffalo Bills home game, which brings in much-needed clothing and gear. They also solicit donations from citizens, churches, and other organizations. The group collaborates with local homeless service providers, as well as volunteers, to locate people experiencing homelessness who could benefit from their services, and they distribute the donated supplies to people living on the streets, underpasses, and other outdoor locations during evenings and weekends. Kristen Dixon said, "For me, it's very personal; it warms my heart to be able to help somebody. Basically, you hand somebody a blanket and you might be changing their lives. You don't know their story or what they've been through, but you know at that moment you were able to help them."

Chris Krager, Executive Director of Samaritan House, a homeless shelter and transitional housing program in Kalispell, Montana, also believes in encouraging local people to reach out and offer to help their neighbors who are homeless during the winter. Samaritan House, located in Montana’s remote Flathead Valley, hosts a blog, Homeless in the Flathead, which mixes inspirational reflections, the stories of people who have experienced homelessness, and requests for specific items to be donated. “Every year around this time, I post an article on the blog asking people to be neighborly, to look out for their neighbors who are homeless and cold and to help them out,” said Krager. “If people feel uncomfortable approaching a homeless person, I ask them to let me know where I can find the person, and I’ll go talk to them myself.” He also knows from experience where many of the established camps are, and drops by to offer people access to Samaritan House. It helps to bring presents, he said, noting that he always brings a blanket, a coat, some socks, or similar items when trying to establish a rapport with an individual.

During the winter, Samaritan House uses roll-away beds to help accommodate more guests than usual, going from 62 beds to 99 beds, and is still within the fire code occupancy limits. Some people are reluctant to come in during the cold, Krager said, because they currently use drugs and alcohol (Samaritan House cannot accommodate people who are actively using). For people who remain outdoors in the Montana winter, said Krager, “what’s most important are just common sense things: warm gear like boots, coats, socks, hats, and gloves.” Offering these items to people in a spirit of genuine empathy, he believes, is a way anyone can “look out for their neighbor and help them out in a neighborly way.”

Samaritan House’s blog, Homeless in the Flatland, can be found at http://homelessintheflathead.blogspot.com/

Code Blue Relief Mission has a Facebook page: https://www.facebook.com/pages/Code-Blue-Relief-Mission/801651253229259

Information about the New York City Department of Homeless Services’ Code Blue program is at http://www.nyc.gov/html/dhs/html/communications/code-blue2014.shtml

Interested in being an HRC Guest Blogger? Email us at HomelessPrograms@samhsa.hhs.gov.

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Voices From the Field: Bearing Witness to Self-Sufficiency

by Kevin Lilly
September 24, 2013

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Youth homelessness is a major problem. There are many young people on the street on a given night with nowhere to go and no access to adequate shelter. That being said, with every social injustice in the world today, you have people who work tirelessly to fight for change. These activists don’t do this for any attention or reward, but because they want to see a difference and see an eventual end to a perpetual problem.  Bridge over Troubled Water (BOTW) is an organization that since its inception in the 1970’s has helped over 80,000 homeless and runaway youth out of the grips of poverty and into self-sufficiency. This shelter may look like an ordinary cozy house like its neighbors on the street, but the power within is something that you just need to visit for yourself to experience.

One of the case managers, Theresa Heisler known by everyone as “Terri”, a 23-year veteran, was gracious enough to give me a tour of the shelter. At this particular location, they deal with four primary groups of young adults: males, females, runaways, and young mothers with children. Each group has their own housing area, but they come together for community dinners and social events. When I arrived, I spent most of my time in the young mothers building. During the tour, I noticed the housing itself is well kept. Fridges are filled with healthy choices, and the mothers have a monthly trip to BJ’s, a wholesale warehouse grocery and retail store. The bedrooms are tidy and the young people are encouraged to keep the house clean and organized. I could go on about the housing itself, but the power of this shelter isn’t so much in the housing as much as it is the people in it.

These mothers are nothing short of amazing young women. As a young man I can’t imagine all the work that goes into raising a child. These young women also work (some working multiple jobs) and complete assigned house tasks and attend classes. It’s inspiring to hear their stories of survival to make it to where they are today. A few stories Terri told me were tough to hear. One mother shared that she had become homeless after an unfortunate incident forced her out of her family’s house. Then she lost custody of her son. She ended up coming to the BOTW shelter where she worked hard to get her son back. She continues to work 40+ hours a week at popular restaurant chain while enrolled in a BOTW GED program as well. This is one of many powerful stories that I came across in that shelter. These young people have been through a lot. As Terri put it, “It’s like they are carrying the weight of the world on their shoulder”. What I admire about all these young people is that although life has them on the ropes and is hitting them with everything it got, they continue to fight and endure.

What BOTW hopes to do is not only to offer these young people in need safe and adequate shelter, but to teach skills so that they could one day successfully make the transition from shelter to permanent housing. Young people staying in the shelter are encouraged to make preparations for independent living. They are assigned house tasks specifically to ensure they have a good foundation once they move out and will need to perform household duties in their own apartment. The shelter also provides the young people with resources to not only get on their feet, but have fun as well. Throughout the buildings, there are bulletin boards filled with information about free events, job postings, employment opportunities, as well as healthcare resources.

The staff members are incredible men and women. I didn’t get a chance to meet all of them but Terri, Cynthia, and Steve are three people who genuinely care and work tirelessly, to help young people. While some people might see these young people’s present circumstances alone, staff members at BOTW see their untapped potential. Shelter staff members are present 24 hours a day, and are really invested in these young people’s lives. As Terri put it, “We try to find out who they are, what they like, help them with their self esteem, and meet their goals so that one day these kids could have the life they dream about.”

While on the tour I came across an image that I feel does a great job in summing the program, the people, and the shelter. This image was a photo taken during a recent graduation. In the picture it shows one young mother smiling proudly in her cap and gown with her handsome son dressed up right by her side. The picture is just one of many successful stories that come out of this house. It shows that although the odds appear to be stacked, one can always overcome. This whole experience has made me even more grateful for the support system and opportunities I have in my life. It also energizes me to do more as far as being an advocate for unaccompanied homeless youth. As a young person I know I would not be where I am today had it not been for the great support system around me.

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Category: General | Guest Entry