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Administration and Policy in Mental Health

Vol. 23, No. 6,July 1996

CRITICAL ISSUES IN SERVING PEOPLE WHO ARE


HOMELESS AND MENTALLYILL
Michael Rowe, Ph.D., Michael A. Hoge, Ph.D., and
Debbie Fisk, M.S.W.

Mental health professionals and researchers have b e g u n to explore the use of


a new a p p r o a c h to providing treatment,
rehabilitation services, and housing to
homeless mentally ill persons who often
avoid contact with traditional mental
health p r o g r a m s because o f past difficulty
in gaining access to care (Koegel, 1992),
d e m a n d s f r o m clinicians for treatment
compliance, o r having been hospitalized
against their will. Key c o m p o n e n t s of this
new t r e a t m e n t a p p r o a c h have been identified in the research literature: frequent

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

Michael Rowe is Project Director, New Haven


ACCESS of the Connecticut Mental Health
Center. Michael Hoge is Associate Professor of
Psychology, Department of Psychiatry, Yale
University, Debbie Fisk is Clinical Coordinator,
New Haven ACCESS.
The authors are grateful to their colleagues
who provided comments on an earlier draft of
this paper.
This work was supported in part by a grant
to the State of Connecticut from the federal
Center for Mental Health Services.
Address for correspondence: Michael Rowe,
Ph.D., ACCESS/CMHC, 566 Whalley Ave., #6,
New Haven, CT 06511.
555

9 1996 Human Sciences Press, Inc.

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Administration and Policy in Mental Health

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

collaboration to care for homeless people;


5) assessing and responding to racialethnic differences a m o n g staff and between clients and staff; and 6) addressing
the role of formerly homeless a n d / o r
mentally ill individuals ("consumers") as
staff.
These issues are not unique to homeless outreach a n d / o r mental health programs. In addition, the importance, interaction, timing, or even presence of some
of these issues will vary from program to
program. Still, we believe that these six
factors will be present in most programs,
sometimes as critical issues requiring specific decisions but often as .recurring
themes that wax and wane as sources of
debate and controversy. They are simultaneously barriers to service implementation and developmental marker points
around which the Work is done. In this
paper, we describe these critical issues
and offer ideas on strategies to manage
them effectively.

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

Michael Rowe, Michael A. Hoge, and Debbie Fisk

"

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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For homeless programs to emerge,


then, some form of crisis or opportunity
may be needed to circumvent the forces
that discourage us from working with
homeless mentaUy ill persons. In the case
of New Haven, a philosophical commitment on the part of several administrators
intersected with the availability of substantial grant support for the ACCESS
program through the federal Center for
Mental Health Services, and resulted in a
major homeless outreach initiative. Securing initial funding and institutional support was a major accomplishment, but it
did not erase concerns about service demand and the cost-benefit ratio. Caring
for this population remains relatively new
to the mental health center which hosts
the homeless program, and doubts about
this new mission wax when d e m a n d by
those who come in for office-based treatment increases, when state and federal
governments threaten to reduce service
funding, or when homeless people who
have been successfully engaged through
outreach are referred for continued care,
adding to the caseloads of overburdened
service providers.

Strategies. In addition to caring for


clients, program administrators need to
pursue ~trategies to influence the culture
of the host institution so that the needs of
homeless people are not only understood
but become a source of concern for clinicians, managers and policy-makers. As this
occurs, the needs of homeless people will
be recognized as a legitimate element of
the institution's mission and support for
homeless programs will be less vulnerable
to erosion. Specific strategies for accomplishing these goals include highlighting
homeless mentally ill patients and successful outreach activities in case conferences
and grand rounds presentations. Convening conferences on the care of these
clients and adopting a lead role in local
homeless planning efforts may also foster
the legitimacy of the homeless agenda
within the host institution.

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Administration and Policy in Mental Health

Defining the Target Population


With funding secured, the task o f defining the target population o f individuals
who are both "homeless" and "mentally ill"
would a p p e a r to be straightforward, but it
is not. The d i l e m m a o f scarce resources
a n d overwhelming d e m a n d simply moves
from the institutional to the p r o g r a m level
as administrators o f homeless outreach
services d e t e r m i n e where to direct staff efforts. Public sector mental health systems
typically rank o r d e r different forms o f
mental illness, dedicating considerable resources to those with "severe" disorders
and giving less attention to those with
non-chronic psychiatric conditions. In
states where mental health and substance
abuse treatment are administratively separated, some mental health services are
dedicated to the "dually d i a g n o s e d " - t h o s e
with co-occurring mental illness and substance use disorders--while those with "primary substance use" disorders typically are
considered the responsibility o f the substance abuse treatment system. Service
providers a n d funding sources also categorize and create service priorities for different "types" of homeless people such as
street dwellers without shelter, sheltered
individuals with no access to temporary
housing, and "houseless" individuals with
access to a t e m p o r a r y residence but without a p e r m a n e n t home.
Most outreach programs "target" a subset o f those who are considered homeless
and mentally ill, and selection is determ i n e d largely by the forces which led to
the program's creation. The ACCESS initiative, for example, funds outreach to
"street" and "sheltered" homeless persons
who suffer from severe psychiatric disorders and co-occurring substance abuse, but
excludes those who are "houseless," whose
pr/mary clinical p r o b l e m is substance use,
or who have a non-chronic psychiatric condition. In contrast, traditional mental
health providers are likely to press homeless programs to accept the "houseless"
who find their way into inpatient services,

where policy often prohibits discharge


until housing is arranged. Beyond these
more apparent forces that shape the definition o f the target population, there are
explicit or subtle pressures to enroll a large
n u m b e r o f homeless individuals in outreach programs in o r d e r to justify the cost
o f these services. Ironically, this can divert
attention from the most impaired and socially withdrawn individuals since they take
considerable time to find and engage.

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

Michael Rowe, Michael A. Hoge, and Debbie Fisk

population, implementation can begin.


While the treatment a p p r o a c h we summar i z e d in the introduction--assertive outreach, help with immediate subsistence
needs, gradual engagement, respect for
client choice, and integrated services-has
b e e n articulated in the professional literature a n d by funding agencies, it runs
c o u n t e r to established service practice
with r e g a r d to 1) location a n d scheduling
o f the work; 2) client choice versus clinical
control; a n d 3) adherence to bureaucratic
norms in providing treatment. We consider each o f these below.

Location and Scheduling of the Work.


Outreach workers must adjust to a service
style in which at least one aspect o f the
usual client-worker relationship is reversed: the clinician or case manager must
go to the d i e n t and sell services on the
client's turf rather than wait for h i m / h e r
to come to the office (Interagency Council
on the Homeless, 1991). Reversing one's
professional approach, though, neither
happens n o r remains in effect automatically. Powerful institutional and professional norms must he confronted in the
early stages o f p r o g r a m development and
at later points. F o r example, in the New
Haven project staff gradually became accustomed to working outside of the office,
b u t the authors observed staff isolating
themselves in the back r o o m of one soup
kitchen and "setting up office" with a card
table at another, waiting for clients to approach them rather than seeking them out.
Thus, the pioneering spirit that many staff
carry into the outreach work can be temp e r e d by insecurity and timidity in negotiating the alien culture o f homelessness. In
addition, the case manager may become
discouraged when a homeless person does
not show up for a p r e a r r a n g e d "appointment" at the soup kitchen (Breakey, 1987),
although consistent efforts to contact this
individual may eventually pay off in a negotiated routine that satisfies both parties.
Staff may b e committed to the work and
wear its difference as a badge o f honor, but

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still retreat to office-based habits when


confronted with the unfamiliar culture or
a lack of direction from leaders.

Client Choice Versus Clinician Control. Traditional treatment approaches


will clash with the guiding principles of
treating homeless mentally ill persons that
are outlined here, particularly regarding
issues o f client choice versus clinician control. For example, a clinician conducting
outreach is asked to approach the issue o f
mental health treatment slowly, accepting
the homeless person's distrust o f mental
health practitioners and using other services such as housing as a carrot to entice
the client into treatment. T h e same clinician, drawing on m o r e traditional training
a n d previous experience, may feel anxious
a n d even legally liable about the person's
need for treatment and medication. A
classic instance o f the client choice-clinician control dilemma occurs when working with a homeless person who refuses
shelter in severely cold weather and is psychiatrically impaired but n o t legally incompetent. The patient's "decision" to remain on the streets in these severe
conditions, by traditional standards, almost in and of itself establishes him as
gravely disabled. While the choice versus
c o n t r o l question requires case-by-case
team and individual j u d g m e n t and takes
place within a professional, legal, and political context that delimits acceptable
treatment options, the p r o g r a m manager's task is to s u p p o r t staff in shifting
the threshold of acceptable clinical risk in
favor o f fewer unilateral interventions and
m o r e staff-client partnerships in forging a
treatment plan (Cohen, 1989).

Bureaucratic Norms. F u n d i n g agency


requirements, office-based documentation practices, and licensing standards
complicate the implementation o f homeless outreach programs. F o r example, the
principle o f the client's right to consent to
treatment led to the creation o f "permission to treat" forms. However, such forms

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Administration and Policy in Mental Health

are usually designed for institutional use


by "motivated" clients and may arouse suspicion on the homeless person's part,
when a less structured approach might satisfy the principle o f obtaining consent
while not frightening off individuals who
distrust mental health providers. In addition, there is an institutional tendency,
similar to the staff tendency n o t e d above,
to revert to old habits in the face o f uncertainty, d o i n g nothing until all bases are
covered when novel clinical and policy
questions, such as medicating patients on
the street, arise.

Strategies. Each o f these key elem e n t s - l o c a t i o n and scheduling of the


work, client choice versus clinician control, a n d bureaucratic n o r m s - p o s e special
problems for i m p l e m e n t i n g clinical programs for the homeless mentally ill. W e
f o u n d several strategies to be useful.
T h e first is staff selection. This work is
n o t for those who are w e d d e d to traditional clinical practice, who prefer strict
staff-client boundaries, or who d e p e n d on
structure and routine. Staff who thrive in
homeless outreach programs enjoy interdisciplinary work and are m o r e temperamentally suited to "negotiated partnerships" with clients than is the n o r m in
office-based practice. They tend to be
zealous about reaching out to the "underserved" and impatient with rules or bureaucracy that i m p e d e the accomplishm e n t o f that task. Such individuals are
often f o u n d a m o n g those who are new to
the profession or those who are looking
for a new career direction after working
in m o r e traditional clinical settings.
The second strategy is staff training.
Outreach and engagement requires skills
that are specific to the work. Training in
such areas as the initial outreach approach
and outreach safety must be given both
p r i o r to and while working in the field. In
addition, field visits to established homeless programs and exposure to state and
national leaders through retreats, attendance at conferences, and reading the lit-

erature provide guidance a n d inspiration


to staff who practice within a mental
health system that provides few role models for them.
The third strategy is hands-on management. Managers' presence in the field increases their credibility to front line staff
and gives the former a better appreciation
o f the challenges o f this non-traditional
work. Through such a field presence, for
example, we recognized that outreach
workers' retreat to the back r o o m o f the
community soup kitchen resulted in p a r t
from a concern over singling out individuals as having a metal illness. We then
worked with the team to develop less obvious approaches to making initial contact, such as mixing with guests outside
the soup kitchen in o r d e r to negotiate the
delicate balance between outreach a n d
intrusion.

Inter-Agency and Inter-Disciplinary


Collaboration
Homeless persons with mental illness
have multiple needs, and thus collaborations that draw on the expertise o f multiple community-based agencies and multiple professional disciplines are a c o m m o n
strategy for addressing these needs. While
such collaborations may reduce certain
"service system" barriers for this population, they can create others. F o r example,
issues o f power may surface between the
lead or coordinating agency and its collaborators. Such conflicts often have historical underpinnings, as when the lead
agency already wields power over local
public mental health resources. In taking
on an interagency homeless project, this
agency exposes itself to "multiple veto
points" and becomes vulnerable to the internal turmoil or failure o f o t h e r agencies
(Johnston, 1991). In addition, mutual lack
o f awareness o f the expertise o f staff from
different agencies and disciplines can lead
staff to under- or over-value the work o f
their peers. In New Haven, clinical staff
from the mental health center t e n d e d to

Michael Rowe, Michael A. Hoge, and Debbie Fisk

under-value the rehabilitation work done


by staff from community-based agencies.
Rehabilitation staff, on the other hand,
tended to mystify the power of clinical intervention, demanding that clinicians
"cure" the patients.

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.

Racial/Ethnic and Cultural Differences


Three facts provide the basis for this
critical issue: most homeless outreach programs are located in urban centers, mi-

561

nority individuals are over-represented in


the urban homeless population, and clinical staff of most publicly-funded mental
health agencies are preponderantly white.
Because of these facts, many mental
health homeless outreach programs show
a racial disparity between staff and clients
or, when efforts are made at minority recruitment, the programs may still be top
heavy with white administrators, psychiatrists, and social workers.
The outcome of these intra-staff and
staff-client disparities vary from program
to program and locality to locality. However, racial-ethnic issues or tensions, if
present, can have a negative affect by
drawing time and energy away from the
work at hand. Regarding intra-staff work,
such tensions may go unstated because
they are difficult for most to discuss
openly. The challenge for program managers is to maintain sensitivity to racial
and cultural differences without losing
sight of the primary task of providing care
to homeless mentally ill persons. Regarding staff-client relations, there were scattered cases in New Haven in which white
or African-American clients seemed more
comfortable with same race staff, sometimes because of perceived experiences of
discrimination f r o m staff in other programs. Once outreach staff had made the
extra effort to follow initial contacts with
a consistent presence and offer of support, though, many of these clients responded warmly to the simple caring attention they were given, seemingly
regardless of race.
We have found a few general principles
to be helpful in dealing with racial-ethnic
issues. First, efforts at creating a racially
and ethnically balanced team are critical.
Cultural diversity is a legitimate 'lob requirement" for homeless outreach projects. Second, it is possible, in part, to
"back into" cultural sensitivity by coming
at it indirectly. Outreach and treatment
team assignments can pair staff across
ethnic and racial lines as one of several
variables in making team assignments.

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Administration and Policy in Mental Health

T e a m discussions about racial or cultural


factors that affect clients' interest o r retention in services can p r o m o t e cultural
sensitivity to other staff as well as to
clients. Third, institutional s u p p o r t for
cultural sensitivity and diversity in racialethnic staff m a k e u p is vital. It may come
either through cultural sensitivity training,
or, perhaps m o r e effectively, through active efforts to recruit minority staff within
the mental health system.

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-

drawing or being excluded from the social


world o f homeless people. C o n s u m e r staff
must also adjust to having access to confidential information and the p o w e r to influence the lives Of their f o r m e r peers.
During the early stages o f this adjustment,
some may vacillate between over-involvem e n t o r over-identification with their
clients and the urge to deny services to
those who have n o t reached their own
stage o f motivation o r recovery. A difficulty for managers in assessing the needs
o f the new c o n s u m e r staff m e m b e r is that
o f finding a balance between the consumer's strength of "having been there"
and his typical lack o f clinical or case management ti'aining. Finally, we should n o t
forget that staff must adjust to working
with consumers who bring a different life
experience a n d different social skills to
the team, and that consumers may have to
adjust to working within a professional
and institutional world that they have seen
as part o f the p r o b l e m rather than p a r t o f
the solution.

Strategies. Managers must continually


assess the uniqueness o r "sameness" of the
consumer staff role in relation to that of
other staff. These roles may change over
time with the needs and m a t u r a t i o n o f the
project and the evolving skills o f consumer staff. Managers must avoid rigidly
adhering to the principle that c o n s u m e r
staff should routinely disclose their "consumer status" to clients. C o n s u m e r staff
themselves can often provide the lead on
this issue as they learn how to strategically
use self-disclosure for reaching out to particular homeless individuals. Managers
should also avoid a rigid adherence to
"mainstreaming" consumer staff without
acknowledging the unique transition they
have to make. C o n s u m e r staff should be
integrated into the work at a pace that is
comparable with their level o f skill a n d
training, and attempts should be made to
avoid imparting a sense o f second class citizenship by explaining that consumers,
like other staff, will be given m o r e re-

Michael Rowe, Michael A. Hoge, and Debbie Fisk

sponsibility as their familiarity, comfort,


and skills on the j o b increase. Consumers
should have the opportunity to impart to
other staff their unique knowledge of
where homeless mentally ill people sleep
or congregate and how they feel about
being approached by outreach workers.
They should be offered additional supervision as needed and support from other
sources such as peer support groups for
consumer staff. Finally, consumer staff
should be encouraged to participate in
non-routine work activities such as training retreats or in staff social events. These
may help consumer staff to bridge the gap
between doing the work and becoming
comfortable within the staff culture.

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.

The Shift from Culture to Organization


Homeless outreach projects can provoke what French sociologist Emile Durkheim called "creative effervescence," as
staff rally around the urgency of their
client's needs and act on the conviction
that they can cut through the barriers that
confront homeless people. The initial culture of these programs is marked by a relative loosening of boundaries between
staff and clients and a distaste for bureaucratic rules and regulations that slow the
"rescue" operation in which staff perceive
themselves to be engaged. Inevitably,
though, the high energy and communal
passion for the work will recede. It is critical, then, that managers use leadership,
training, and policy development to transform the initial culture into an organization that "encodes" the innovative elements of the work and enables the project
to survive over time. For example, program successes, such as one in which the
unique engagement skills of the staff led
to finding housing for an impaired and reluctant client who was in danger of freezing on the streets, can be enshrined as program myths that embody and teach the
program's ethic. Non-bureaucratic program innovations can be institutionalized
within the project in an attempt to create
a "different kind" of bureaucracy. Managers can emphasize the motto of "not taking 'no' for an answer" when bureaucratic
rules appear to needlessly impede the
work. By doing so, they allow staff to retain the badge of outsider while transforming informal practice into policy. In

564

Administration and Policy in Mental Health

addition, managers, by selectively sharing


their own dilemmas o f working within the
larger institution, can help transform the
spirit o f rebellion against bureaucracy into
one o f a steady c o m m i t m e n t to helping
clients achieve progress against all odds.

Institutional Support for the New


Organization
Transformation o f the emerging culture
into an organization that can survive over
time is inextricably b o u n d up with the
three-tier process o f institutional support.
At the outset, the p r o g r a m must receive at
least minimal institutional s u p p o r t such as
approval to apply for funding and negotiate with the funding source. During the
early stages o f p r o g r a m implementation,
short-term institutional disinterest toward
the new p r o g r a m can work to the latter's
advantage, providing a window for improvising clinical and administrative policies
and refining strategies for working
through internal and external barriers. Finally though, the p r o g r a m must gain
strong institutional s u p p o r t in o r d e r to
survive over the long term, particularly in
the case o f time-limited demonstration
projects. To garner such support managers must generate quantitative and qualitative data that demonstrate g o o d clinical
outcomes, while providing administrators
with a clear sense o f the costs of continued
operation. Program managers and staff
must also meet institutional standards o f
care and accountability while preserving
the p r o g r a m ' s guiding principles.
In emphasizing the homeless outreach
p r o g r a m ' s need to adapt and sell itself to
the larger institution o r mental health system, though, one should not lose sight o f
the fact that the p r o g r a m can influence
the treatment philosophy and approach o f
the institution o r system. The ideals o f
going out of the office to meet the client,
engaging him and developing trust over
time, o f integrating treatment and rehabilitation services, and o f emphasizing
client strengths, are not unique to home-

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.

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