11.1 Introduction

In general, the longer a person experiences homelessness, the more likely they are to experience substance abuse, victimization, mortality, and the harder it becomes to change their life. This highlights the importance of engaging the homeless people with services at the earliest. However, sometimes it is difficult for them to engage. In this unit we will learn about the most recurrent reasons of non- or low engagement with the services and will consider approaches and attitudes of the service providers as well as characteristics of the services that will improve the chances for a successful engagement.

11.2 Learning objectives

In this unit the learners will

• Understand the reasons of low engagement of homeless populations with health and social services
• Familiarize themselves with the role the experts by experience and peer supporters can play in adapting services to the needs of the users and facilitating their engagement
• Learn the criteria for positive engagement
• Familiarize themselves with the strengths-based outreach approach

11.3 Engaging clients in the services

People who are homeless have multiple needs, including housing, financial assistance, physical and mental health assistance, and social support. They are vulnerable to the so called ‘tri-morbidity’, the co-occurrence of poor mental health, poor physical health, and substance abuse. These challenges may often cause or contribute to breakdowns in relationships with family, friends, as well as breakdowns in contact with support services (Miler et. al., 2020).

The term engagement can have different meanings; therefore, it is precise to clarify that by engagement in services we mean linking individuals to services or, more precisely: “a person that has been contacted through outreach participates in an intake process and is assigned a case manager, psychiatrist, counselor, or medical provider” (Olivet et. al., 2010). If the person responds positively, accepts the help and interacts with the staff/service providers, we may say that she has effectively engaged in the services. On the contrary, if the person refuses the help, doesn’t get involved with the services or interrupts the involvement, it means that the engagement has failed.

Lack of engagement with services is frequently seen by the public structures and service providers as a problem with the individual. However, often the problem lies with the way the service is offered or designed, for instance, with the requirements for the users to access the service, the incompatibilities between different services or responsibilities, or the way the service providers interact with the users. Low level of service engagement can also be due to the fact that the user and the service provider have different perceptions of service needs and, as a result, the services offered don’t correspond with the users’ needs.

On the other hand, we shouldn’t forget the likelihood that the people experiencing homelessness will prioritize satisfying their immediate day-to-day needs over seeking other services that might not seem so necessary to them at a given moment, such as primary health care or education, which would help them in the long term.

Yet another reason for none or low engagement with the services is the perceived stigma in the service providers. This is especially true for homeless people that experience mental health issues or substance abuse. To give one example, in a research study with young homeless people with mental health issues in Australia, the participants’ give accounts of generally negative experiences of health and social services providers, which made them feel stigmatized, patronized and generally made to feel unwelcome and unworthy (Darbyshire et.al., 2006).

In another study, based on interviews conducted in New York City with twenty-four individuals who had been homeless for longer than one year, the researchers found out that many homeless lacked confidence in the care and the caregivers. The interviewees believed their attention was not genuine and that it was “just a job” for the workers, which was the main declared reason why these individuals refused services. The researchers concluded that, in order to improve the engagement response, there was a need for an approach to outreach incorporating individualized attention from outreach workers, using an empathetic listening approach, adopting a non-judgmental attitude, providing greater choices, and employing formerly homeless people as outreach workers (Kryda & Compton, 2009).

Complexities of Multi-agency provision

Those who do not have access to stable housing cannot be categorized only in terms of their homeless status. In fact, it is improbable for the lack of housing to be the sole cause of the person’s problems. There are multiple disadvantages that add to their homelessness such as mental health issues, addiction problems, physical health issues, illegal status or criminal history. Some of the issues might have contributed to the individual becoming homeless, while others may have developed in response to their homeless situation. Related to these, each person might fall into different “categories” and might be a potential user of services and agencies from different areas of intervention. In some cases, different providers will successfully collaborate to provide the person with a complete range of services (multi-agency partnerships) but it is likely that the person might “fall out of the system” if each service assumes his needs are being addressed by someone else (Reisenberger et. al. 2010).

The role of a Peer Supporter in engaging clients

The involvement of experts by experience in the process of designing and providing services can be particularly valuable. For instance, at the first stage of designing the service, they can incorporate the point of view of a service user at the core of the service design.  At the stage of service evaluation, they can also help analyze the outcomes and understand which aspects of the service are likely to cause drop out or prevent people from accessing it.

Another option for an expert by experience is to take the role of a Peer Support Agent and become part of the service provision system by acting as a bridge to a service user’s successful engagement with the services. At the stage of the “first contact” and “recruitment” of the users, their involvement can be particularly helpful since they might know where and how to reach people. It is also likely that it will be easier for them to build trust than it will be for staff without lived experience.

Additionally, involving experts by experience in planning and provision of services can be beneficial for the other staff employed at an organization in question. In particular, their presence seems to reinforce the understanding that homeless people are individuals with diverse needs. The frontline workers recognizing this can be particularly effective in changing the way they engage with service users (Community Fund, 2020).

Peer Supporter as an outreach worker

Studies often define outreach as contacting or engaging individuals within non-office settings to services. In other words— going to where people are rather than waiting for them to seek services at a specific place. As alternative to traditional approaches to site-based social services, outreach is considered an effective strategy for identifying and engaging hidden populations- such as the homeless people- with services.

A key factor to success of outreach is the relationship between the outreach worker and the client which is an important focus itself. Building new relationships and traversing various systems of care can be difficult and stressful for a person experiencing homelessness, and one consistent helper can facilitate service engagement and continued service use. Engagement with such person can help overcome past negative experiences with others, and can plant the seed for hope, self-efficacy, and future orientation. (Slesnick & Van Hest, 2018)

While some people require many contacts with the social support worker before they are willing to engage, others may engage with them even on the first meeting, requesting help and detailing their needs. Patience in the engagement process is essential, as is the expression of unconditional positive regard.

The success of an outreach program depends greatly on the quality of the outreach worker, whose role requires high levels of social and emotional skills and intuition. They should show empathy and understanding. The workers often have a paraprofessional status and the lived experience can be an added value to the position, which makes it an interesting possibility for Peer Supporters to adopt this role.

It is recommended that outreach workers travel in pairs. Staff shall be well informed about any potential risks associated with the intervention and shall be offered specific training to identify and reduce risk.

What can service providers do to make engagement easier?

Some of the most important aspects in the engagement of members of the most vulnerable groups in any service are:

·       Good atmosphere and a safe context

The main concern for the homeless people- especially those who are not connected with services- is survival, and this means that they are in a constant state of alert and facing difficult situations associated with street life which can include physical attack, robbery, illness or arrest. To forestall these threats to engagement, it is essential to provide emotional support to the person in order to build a good atmosphere and a safe context for them to perceive that they can focus on their recovery and engage in social, educational and/or employment programs.

·       Genuine empathy, respect and acceptance

When interviewed, homeless people make reference to feigned sympathy or pity of those who approach them but fail to actually listen to their problems or to respect and accept their wishes.

·       Non-judgmental approach 

The experience of feeling looked down at, scrutinized and judged by others, including the service providers, is often brought up in interviews with homeless persons as reasons that restrain them from engaging with services.

·       Control over the helping process

The intervention process shall acknowledge and respect their needs as individuals, maximizing the beneficiary’s control over the helping process. Involving clients in program planning will further promote their self-determination and autonomy.

Criteria for positive engagement

Here are some specific recommendations that will help service providers facilitate engagement:

• Developing trust takes time and repeated contact. Be patient.
• Adopt a person-centered approach, where the individual is at the center of the support they receive. At the stage of engagement, this means that we actually ask the person what their perceived needs are and what they want to achieve. Support the clients around setting and pursuing their own goals and do not insist on goals they do not share. When service providers force their goals onto the client rather than helping them set their own goals, the client is likely to disengage from the service.
• Show the client acceptance no matter what he says or does. Do not expect the client to mirror your beliefs, feelings or experience.
• Be open and honest with the client. Inform him about what happens (or is likely to happen) in the services in order to create realistic expectations.
• Offer your client accessible, clear and comprehensive information. Avoid technicalities, acronyms and jargon.
• Respect the boundaries of your clients. Respect their personal space. Be careful about inquiring personal information and make the person see that they are free to share their personal story on their own terms and respond—or not respond—to your questions.
• Adapt the types of support available to different needs. Keep in mind that the needs differ not only from one person to another, but also depending on contextual circumstances that may also change overtime.
• Adapt the practical aspects of the support to the individual needs of the person. For instance, being flexible about the location where the support takes place, adapting the frequency and the duration of the appointments to the individual needs or supporting the clients to get to a given place can facilitate the engagement process.
• Assist the clients in overcoming whatever obstacles prevent them from following the recovery program rather than punishing them when they don’t fulfil their obligations (e.g. missed appointment).
• Recovery is a process with obstacles along the road. In order to foster acceptance and prevent frustration, work with the person towards reframing perceived failure.

11.4 Further reading

• Darbyshire et. al.,   Engagement with health and social care services: Perceptions of homeless young people with mental health problems, 2006.

Slesnick & Van Hest., Canadian Observatory on Homelessness. Mental health & addiction interventions for youth experiencing homelessness: Practical strategies for front-line providers., 2018.