Sponsored by The California Institute for Mental Health Facilitated by Gary Shaheen Laura Ware

1. “Work as a Priority”Strategies for Employing People with Psychiatric and Co-occurring Disabilities who are Homeless Sponsored by The California Institute for Mental Health Facilitated by Gary Shaheen Laura Ware Advocates for Human Potential, Inc. 518-475-9146, ext. 243 gshaheen@ahpnet.com

2. DAY #1 Learning Objectives • Learn about factors resulting from homelessness that affect people’s ability to obtain and retain employment • Understand how recovery and rehabilitation principles and practices can provide the foundation for employment success. • Understand how to address factors of motivation, self esteem, powerlessness that affect employment success • Apply information through scenario exercises

3. Larry MeredithIn Hooked by Lonny Shavelson 2001 “If we are going to make a difference, then we have to realize that drug abuse & mental health is related to housing is related to health care is related to joblessness is related to poverty. You can’t deal with any one of those without dealing with all of them.”

4. “RJ” • I have been homeless for five years • I have schizophrenia and have been drug addicted since the age of six • I smoked crack • Did some time a few years back on a burglary charge • I don’t know where I’m going to sleep tonight • Shelters are bad places where they rob you and beat you up. The staff looks the other way. • I am an artist. I could be a millionaire if I could get money to make and sell my paintings • If the Mayor can spend millions building a new city hall he should be able to give us money to help us get jobs and a decent place to live.

5. Distrust Focus on immediate needs Co-occurring disabilities Learned helplessness and emotional instability Functional limitations Cognitive limitations Illiteracy Communication deficits Physical/emotional trauma Poor self-esteem Fragmented or inadequate services/supports Mobility Skills mismatch Fear Legal issues: custody convictions, judgements, probation Lack of personal documentation Child care Transportation Earning disincentives Lack of permanent address and phone # Lack of hope Lack of skills regarding how to work towards a sustained goal, not just immediate gratification Disincentives to Employment……

6. Program-Level Challenges • Lack of knowledge, experience • “Paradigm paralysis” • Different providers speak different languages and often can’t share much information • Readiness prerequisites • Ethnic/cultural sensitivity • Different outcome expectations • Different roles and ‘turf issues’ • Not enough $$ or in the wrong places • Lack of coordination, communication • Promising more than can be delivered

7. Service System Challenges • Different systems are not aware of each other, and are resistant to change • Fragmentation-funding sources, priorities, roles, criteria, etc • Political priorities and issues that may prevent effective communication • Stigma • Lack of $$ • Lack of cross-systems training • EBPs not understood

8. “Breaking the Cycle” • Trust-building is fundamental • Recognize/utilize personal strengths • Provide factual information • Teach by example • Recognize and address complex needs • Affirm personal dignity and self-worth • Reinforce personal responsibility, choice and empowerment • Facilitate discussions to help individual see how previous choices and decisions can be done differently • Adapt vocational approaches to meet needs • Provide comprehensive, long-term supports

9. Common Themes • Jobs that people want and can manage well • Linking Housing First/Work First • Entrepreneurial approaches • Clear & reasonable expectations for all parties • Flexible outcomes • Redefining failure • Provide personal service supports • No arbitrary time limits • Hire consumers as staff • Cultural competence/relevance • Link to treatment, rehabilitation, recovery services

10. Guiding Principles #1 • Treat people on the basis of facts and inherent capabilities, not generalizations and stereotypes • Provide genuine, effective, and meaningful opportunity (provide reasonable accommodations and modifications) in integrated mainstream environments

11. Guiding Principles #2:Social Justice and Equity • XXX% of all people who are homeless are persons of color • Stigma, discrimination is a “triple whammy”- • 1) homelessness + mental illness + substance abuse + criminal justice issues • 2) poverty and disenfranchisement • 3) racial stereotyping, prejudice and discrimination You should consider the impacts of these factors on employment as well!

12. Guiding Principles #3 FULL PARTICIPATION • Involve people in decision-making at the individual, managementand systems levels • Ensure informed choice and share information using various mediums • Provide support for self-determination, empowerment and self-advocacy

13. UPENN RESEARCH-MAJOR FINDINGS • Homelessness is a “Revolving Door” Phenomenon • Point in Time vs. Longer Time Frame • Identified 3 Subgroups * Transient * Episodic * Chronic

14. CULHANE’ S SUBPOPULATIONS • Transient: 80% of overall population, single, economically caused episode, low rates of illness • Episodic: 10 % of overall population, multiple episodes of homelessness over time • Chronic: 10% of overall population, multiple, complex problems, long term homelessness

15. Resources • “Changing for Good”-Prochaska, Norcross & DiClemente, 1994 • “Motivational Interviewing: Preparing People to Change Addictive Behavior”-Miller & Rollnick, 2002 • PATHPROGRAM.COM-Click on “Technical Assistance” • “Implementing Interventions for Homeless Individuals with Co-Occurring Mental Health and Substance Abuse Disorders”-Winarski, 1998

16. FOUR PHASES OF TREATMENT • Engagement • Persuasion • Active Treatment • Relapse Prevention Source: Osher and Kofoed (1989)

17. STAGES OF TREATMENT ENGAGEMENT ACTIVE TREATMENT RELAPSE PREVENTION PERSUASION • Develop • Relationship • - Outreach Skills • - Interpersonal Skills • Provide Basic Supports • Peer Intervention • Develop • Relationship • - Outreach Skills • - Interpersonal Skills • Provide Basic Supports • Develop Readiness • - Enhance Motivation • Peer Intervention • Hospitalization • Outpatient Treatment • Residential Treatment • - Medication • - Individual Therapy • - Group Therapy • - Peer Support • Psycho-education • Drug-education • Rehabilitation Skills for • Supported - • Housing • Education • Employment • Peer Interventions • Community/Peer Support • Individual/Group Therapy • Psycho-education • Identify Signs/Triggers • for Relapse • Rehabilitation Skills for: • Supported - • Housing • Education • Employment • Peer Interventions Case Management - Planning - Linking - Advocating

18. RECOVERY: A UNIFYING CONCEPT

19. Consumer Self-Report of Items Important to Recovery (Ralph,R) • Ability to have hope • Trusting my own thoughts • Enjoying my environment • Feeling alert and alive • Increased self-esteem, spirituality • Knowing I have a tomorrow • Having a job

20. How MH Professionals Help (Ralph,R) • Encourage my independent thinking • Treat me like an equal in planning my services • Give me freedom to make my own mistakes • Listen to me and believes what I say • Recognize my abilities • Work with me to find the resources/services that I need

21. UNDERSTANDING RECOVERY • Recovery Occurs for All People • Recovery Occurs at Multiple Levels • and at Variable Rates: The Centrality of Loss • Recovery Follows a Non-Linear Course Source: Winarski and Dubus (1995)

22. FACILITATING RECOVERY • Create Environments that are Conducive to Recovery. • Attend to Motivational States. • Respond to Mental Health & Substance Use Disorders Simultaneously. • Create Community. • Define Expectations. Source: Winarski and Dubus (1995)

23. Role Recovery is…. • Obtaining and sustaining a valued role as a: • Worker • Family-member • Friend • Homeowner/tenant • Partner, etc • By overcoming personal losses, setbacks, obstacles, and limitations • Obtaining the skills and trust from others needed to perform that role • Educating others re: personal abilities • Using natural and professional supports as needed

24. INSIGHT DEVELOPMENT Identify values preferences, choices Prepare for change – personal and environmental Honest self-assessment Trust in self and others Hope for the future SKILL DEVELOPMENT Setting work goals Testing work preferences Evaluating skills, personal strengths and supports against goals Skills Teaching: tasks and work habits, as well as pursuing, obtaining and managing success Support Service planning Worker Role Recovery-Two Dimensions

25. ASSESSMENT

26. ASSESSMENT IS ON-GOING • Longitudinal approach: collect and interpret • information during each contact. • Focus on signs and symptoms rather than • making diagnosis. • Comprehensive assessments may take many • weeks and/or months.

27. THE ASSESSMENT PROCESS IS INTEGRATED WITH THE HELPING RELATIONSHIP • Assessment takes place concurrently with activities • that facilitate connection to the program. • Information is most effectively gathered in the • context of a trusting relationship. • Gather information in an environment free from • distractions.

28.    ASSESSMENT PROCESS Observe/Listen  Ask Critical Questions Collect and Interpret Information Source: Bassuk (1994)

29. Tips for Effective Interviewing • Choose between open-ended and closed-ended questions. • Avoid leading questions. • Structure chronological answers. • Divide the experience into parts. • Share experiences by generalized feelings. • Be aware of ‘non-verbal communication • Conclude the interview.

30. Common Errors in Interviewing • Imposing values. • Offering false reassurance. • Asking double questions. • Interrupting answers. • Discouraging or forbidding the expression of real feelings. • Saying “I understand” inappropriately.

31. Techniques for Identifying Dual Disorders • Screen-expectation not an exception. Increase the “Index of suspicion”. • Self-report • Signs and Symptoms • Chemical testing • Collateral information • Correlates or predictors of substance use disorders • Indirect measures (e.g. Family history -Car accidents). Assess 1 Source: Drake (1993)

32. At Outreach/Engagement Information about work Conversations about work “Standing offer of Work” Purpose: Develop Trust, Awareness & Motivation Brief Intake/Assessment Interviews Situational Assessments Purpose: Develop Initial Goal/Plan Discovery Options Part-time/Transitional Work Social Enterprises Person-centered planning Education Volunteer Work Purpose: Further Define Choices Develop Confidence/Skills/Trust Supported Employment EBP Options Rapid Job Placement in Open Market Jobs Employer-sponsored Training and Credentialing Time-Unlimited Support Ongoing Assessment Purpose: Get, Keep, Advance Ongoing Contact with Employment Specialist Ongoing Support as Needed for Re-Placement, Job Acquisition, Advancement

33. Employment-Centered Outreach • Make work part of the conversation about engaging in services • Prompt and listen to people’s stories about jobs they had and jobs they may want • Encourage stories that help the individual to see unidentified yet transferable skills • Provide information • Assess the value of an offer of work as a ‘hook’ to influence positive change • Understand the ‘stages of change’

34. Challenges People may not be interested in services once they are in the housing unit They are not sure what they want to do and avoid staff They are engaged in behavior they are trying to hide from staff Staff try to “over –engage” or overstep boundaries and push participants away Staff may not maintain proper boundaries with participants, especially if he/she can relate to a particular challenge or situation Lack of cultural sensitivity to the background, needs, challenges and goals of a specific participant Suggested Responses Offer incentives in order to develop their interest Keep the conversation focused on what the participant is thinking or feeling, and what he/she wants to do about it Be aware of how your body language or other non-verbal communication Remember that the staff role is to guide and support, not direct, over-invest, “mother “ a participant, or become emotionally involved Suggest meeting in an open space such as outdoors or in a private space such as a counseling room Try to never force an interaction unless absolutely necessary, or unless someone’s safety is at risk “Vocationalize” the housing environment by having a variety of available activities that offer opportunities for engagement around work Principles/Practices #1:Linking Employment and Housing

35. Vocationalizing • Creating a culture that expects work - verbally, mentally, environmentally and literally. • Arranging things, activities and resources to include and/or support employment. • Assign accountability for employment outcomes to all staff. • Develop and maintain organizational policies and practices that support client employment • Begin tracking employment outcomes.

36. “Mary” • Mary accepts housing but refuses to consider employment. Even though the Personal Services Coordinator reminds her that the program is offered only to those who want to work as well as get a place to live, she says she is “not ready” and won’t discuss it any further. What are some ways you might help Mary address motivation to work?

37. Typical Challenges Sense of hopelessness about vocational goals based on experience to date Numerous setbacks in general or negative work or other vocational experiences Many think of jobs or tasks that have historically been available without a great deal of creativity Some may be struggling with depression or other clinical/medical issues that make it difficult to get motivated Current stresses in life that make feeling motivated difficult Negative consequences of work such as child support payments, credit debts, SSI/DI disincentives, etc Suggested Responses Motivation as a State not a Trait: it can change over time and be influenced Ambivalence is Good: Tease out both sides, help tip balance towards change “Resistance” is not a Force to be Overcome-Roll with it Focus on Person as Ally, not Adversary Recovery, Change and Growth are intrinsic to being Human Remember that People who have suffered many losses may relinquish hope to survive Paint a picture of immediate incentives that can trigger motivational thinking Principles and Practices #4Helping “Mary” Develop Motivation for Work

38. STAGES OF BEHAVIOR CHANGE • Pre-contemplation: No awareness of problem or need to change • Contemplation: Emerging Awareness, ambivalence • Preparation: Identify, anticipate “hot spots”, planning, rehearsal, identify skills, supports • Action: Plan implementation with feedback loop • Maintenance: Reinforce what works • Relapse Prevention: Anticipate and plan for relapse, viewed as learning opportunity

39. FACTORS THAT INLUENCE CHANGE READINESS • Perception of Need: Person’s experience of discrepancy between the pain of the present and the potential for future improvement • Belief that Change is Possible: Positive outcome is achievable in reasonable time period • Sense of Self Efficacy: Believes they can succeed • Makes Stated Intention to Change

40. MOTIVATIONAL TASKS • Pre-contemplation: educate, raise doubt re: perception of risk, identify other areas of high motivation • Contemplation: Tip the Balance- evoke reasons to change and risk of not changing • Preparation: Choose best strategies, anticipate difficulties, plan, rehearse • Action: Frequent monitoring of progress and ongoing lessons • Relapse: Help reframe as learning opportunity, not failure, plan Describe a time in your life you attempted change-how difficult? Who helped? Outcome?

41. Typical Challenges Developing effective relationships with staff of other partners, especially when they are located elsewhere Creating a “project culture” that encourages joint decision making Effectively documenting services for overall reporting, informational and evaluation purposes Seeing regular , consistent meetings as crucial, useful and a priority Developing centralized systems and procedures for intake, assessment, r intervention, communication processes, follow-up, referral, contacts with outside community Avoiding “turf” issues Suggested Responses Clarify for all staff and organizational partners, in writing, who is responsible for each role and component of the project Sponsor a series of “shadowing” or “job switching” opportunities Include discussion of partner and staff roles in regular staff meetings Facilitate regular “case meetings”, at which all staff working with a specific participant are present and asked to share information as well as next steps Create opportunities for staff to talk about successes and challenges, and for other staff to assist in problem-solving Designate a team leader Principles and Practices #2Integrated Team Planning

42. “John” • John says that there is no use in trying to find a job, because all he will do is fail at it anyway. He used to be a good carpenter but that was many years ago. Years of living on the street has eroded those skills and reduced his stamina. He says he feels hopeless of ever finding anything better than dishwashing or carrying out garbage. How would you help John develop an employment goal?

43. Typical Challenges Many people have not thought about having vocational or employment goals, since their first goal on the streets has been survival Many are focused on immediate gratification, such as earning a bit of money or paying off a debt They may have had negative vocational or employment experiences because of the barriers they face They have trouble thinking about small steps that will lead to achieving a vocational or employment goal Some may not be currently motivated to pursue vocational or employment activities, and are content to maintain current status or activities Some may need help to identify how current interests, activities or desired participation can be seen as vocationally-oriented Suggested Responses Create opportunities in which they can have a sense of immediate success or achievement Focus on a person’s perceived or inherent strengths, gifts, skills and interests Work with them to acknowledge all achievements (including survival on the streets) and make them visible to them as sources of strengths and knowledge that may have a job application, Focus on immediate goals first, and how these can lead to a larger goal. Give timeframes to specific goals as a way of motivating participant and yourself as a staff Make sure all goals are developed or agreed-to by the participant Make sure goals of any type are clearly defined and fleshed out by the participant and staff so that they are real and true Principles and Practices #3Helping “John” Create Employment Goals

44. Typical Challenges Changing attitudes and expectations of all parties Acquiring jobs with built-in flexibility and opportunities for growth and transition Finding effective partners and employers-internal/external Resolving alcohol/substance abuse and mental health issues affecting work Staff and new worker training Providing supervision and support Fulfilling employment services contract/performance requirements Funding the effort “Fit” with SE Evidence based practices Suggested Responses Assume employability All staff supports peoples’ desire to work Look internally as well as externally for $$ Provide direct, tangible workplace-based support to break down barriers Avoid lengthy prerequisites –rapid access to a low-impact job Allow multiple work options-one job does not fit all Understand peoples’ needs, abilities and values Communicate your work expectations Celebrate all degrees of success Weave in conversations and support for the next step Principles and Practices #6Implementing a Standing Offer of Work (In-House Jobs)

45. LAMP Village527 S. Crocker, Los Angeles, CA 90013 (213) 488-0031 • Drop-in Center/Crisis Shelter • Lamp Lodge-50 unit permanent housing VILLAGE INDUSTRIES: - Linen Services - Public Laundromat - Public Showers &Toilets • 1/3 of staff are consumers • Employs 35 people per day

46. Typical Challenges People may not be ready to accept treatment People are fearful of treatment Their friends are not good influences and may disapprove of a person’s decision to enter treatment Stigma Side effects Suggested Responses Establish referral relationships so that the services are accessible to participants when needed Help people understand the implications on goals they chose and commit to achieving Enlist the support of peers to help people understand the positive effects of accepting treatment Be clear about the rules regarding substance abuse on site at HUD housing Principle # - Connecting to MH/SA Treatment Services

47. “Step-Back/Step-Out/Step-Up”A Practical Strategy for Keeping the Door Open for Employment • WHAT IT IS: • a)A strategy for helping people address their treatment issues and impact on work • b) A way of keeping people involved in employment services while they deal with their substance use and/or MH treatment issues • c) A plan for putting together a support plan emphasizing growth • WHEN: At engagement, involvement, continuation • WHO: Implemented by staff, peers • WHERE: Shelters, employment programs, housing sites

48. “Step Back” • Offer alternatives to terminating program involvement for people when substance use interferes with their ability to get or keep employment • Focus on how substance use prevents someone from getting or keeping a job, not the behavior itself. • Provides alternative ‘step-down’ employment-related services that do not risk the safety of the person or others • Step downs still require people to be substance-free while they participate • Examples: employment counseling, presentations by peers or staff, resume writing, low-impact, P/T, time-limited in-house work experience, shadowing, P/T volunteer work Expected Outcomes: Maintain connection, use stages of change strategy to change behaviors, show consequences (eg: person may lose job but staff “never go away”)

49. “Step Out” Some people may not be ready to deal with their treatment issues that affect their jobs and they may need to “step out” of the program. Although you may have to get to the place of reinforcing rules of enrollment-try to maintain contact (through outreach staff, shelter staff, peers, friends, etc) and let them know that the door is open for them to try again.

50. “Step Up” • The job placement is only the first success • Dealing with treatment issues affecting work is an ongoing process ‘owned’ by the individual • Advancement and stepping out of poverty is the goal and is negatively affected by job and housing loss due to treatment issues • Ongoing, follow-along support by an IST to support both treatment and work goals • Support needs to accommodate for success as well as address challenges • Involve peers as counselors or mentors showing how people can overcome fears of change and advancement and maintain balance • Expect relapses and have a plan in place that deals with them Expected Outcomes: Staff realize the job doesn’t end at placement; participants see the benefits of treatment and job retention and advancement; they have access to wrap around supports 24/7