Eliot CHS Homeless Services in Lexington, MA is a recipient of a Projects for Assistance in Transition from Homelessness (PATH) grant from the Center for Mental Health Services. The PATH program serves people with serious mental illnesses and those with co-occurring substance use disorders who are experiencing homelessness or who are at risk of becoming homeless.
For Jay S. Levy, stories are not just a result of doing outreach. Rather, understanding the narratives of people experiencing homelessness is the starting point for his way of doing outreach.
This is the philosophy behind the “pretreatment” model of outreach that he developed. At its core, the model takes an approach that meets people where they are at and gives them whatever type of support they are willing and able to welcome at that time.
Jay is Regional Manager for the Projects for Assistance in Transition from Homelessness (PATH) program at Eliot CHS Homeless Services in Lexington, MA, serving central and western Massachusetts. He has spent over twenty years working directly with people experiencing homelessness and supporting outreach workers. He has been instrumental in developing several innovative Housing First models. He has also written two books and several journal articles on effective outreach, focusing on a pretreatment approach to engagement.
Jay says pretreatment is a critical piece of outreach for people on the streets and newly housed individuals alike. He tells the story of one of his former clients, Andrew*, to illustrate the five principles behind this approach. In reaching out to Andrew, Jay spent months slowly gaining his trust and forging a connection. He showed up consistently and reflected back Andrew’s own concerns about being approached. He slowly, painstakingly built up a relationship with him. And in doing so, Jay fulfilled the first principle of pretreatment: promoting trust through stages of engagement.
“We’re there to listen and learn, not to tell them what to do or how to do things,” Jay says. “We’re there to piece together their perspective and story, and to understand why they are in the situation they’re in.”
Jay came to understand that Andrew believed he had been “mentally murdered,” and that part of why he was resisting outreach was because he felt it would take away from the time he spent doing his research. Learning this was critical, Jay says, because understanding the language that clients speak is the same as understanding their ideas and culture. And from there, realizing the second principle of pre-treatment—developing common language for effective communication—is possible.
Jay says that reflecting and using the same language that the client uses is key. But “bridging language,” as he calls it, is just as important. This is based on the idea that clients will encounter many different “houses of language” as outreach workers connect them to various services. For instance, social security’s house of language includes the word “disability,” and a mental health clinic’s house of language might involve the words “therapist” or “psychotropic medication”—all of which might have very negative connotations for the client.
“So we are always thinking about what house of language the client is in and how to bridge their language to what we’re trying to connect them to,” explains Jay. “In other words, what language do we need to prepare them for?”
In Andrew’s case, Jay began to connect the way that he understood his situation—that of being “mentally murdered”—with the idea of trauma. He helped Andrew understand that both “mental murder” and trauma can lead to some of the same difficulties, and he connected Andrew’s trauma to that of war survivors, which seemed to help preserve his dignity. Jay also helped Andrew see that if he had a quiet place to study—such as his own house—he would be in a better position to conduct the research he was so passionate about.
“Often, people don’t take the time to appreciate how people have adapted to their homelessness,” says Jay, “but in outreach, it is so important to understand how they have found meaning in the experience.”
Developing a common language makes it possible to achieve the third principle of pretreatment, that of supporting transitions. “The people we work with are constantly transitioning to new things every day, whether it’s an outreach worker approaching them, a new idea being presented to them, or transitioning in or out of homelessness,” Jay says. He cites examples of newly housed clients who preferred to sleep on the floor or to keep the windows open much of the time. Some clients aren’t ready to be housed at all. And that’s okay, he says—outreach continues to be centered around meeting the client where he or she is at that point in time.
The pretreatment approach is not about getting clients to a pre-defined place. A lot of the work focuses on maintaining safety, which is the fourth principle of pretreatment. For homeless outreach workers, this could include helping someone find emergency housing, giving them a blanket on a cold night, or providing crisis intervention services.
But even though the direction of change is not predetermined, change is indeed at the core of this model, says Jay. Change, the fifth principle of pretreatment, is founded on a Stages of Change model of behavior change and relies heavily on Motivational Interviewing so that outreach workers can help people move in the direction of change they determine to be the right one for them.
“But no matter what happens with that individual—whether they stay in housing or not—the key is to keep that relationship solid,” Jay says, “and to place such an emphasis on building trust that the person knows we are true allies and that we respect their autonomy. With that, we’re able to have enduring relationships. And we don’t give up on them just because housing didn’t work out.”
You can access a list of Jay’s publications on homelessness and pretreatment on Google Scholar or at Jay’s website.
*Not his real name. His name has been changed to protect his identity.
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