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Notes by Summer D Clemenson
Facilitated by: Cowlitz-Wahkiakum Council of Governments
Speaker: Ken Kraybill w/t3 think • teach • transform 617-467-6014 www.thinkt3.com
- >>>Download Best Practices in Case Management Presentation by Ken Kraybill May 23, 2013 (pdf)
- >>>Download Creating Resiliency Presentation by Ken Kraybill May 23, 2013 (pdf)
- >>>Download Critical Time Intervention Presentation by Ken Kraybill May 23, 2013 (pdf)
Best Practices:
Housing First, Motivational Interviewing, Self-Direction, etc.
“The rush and pressure of modern life are a form, perhaps the most common from, of it’s innate violence.” Thomas Merton
It is important to be able to quiet ourselves to better serve people.
The manner or spirit in which we provide care has a significant impact on people’s receptivity to accepting the help being offered.
The spirit of Motivational Interviewing
- Partnership – demonstrating profound respect for the other; both parties have expertise; dancing rather than wrestling
- Acceptance – prizing the other’s inherent worth and potential; providing accurate empathy; supporting autonomy; affirming strengths
- Compassion – coming alongside in a person’s suffering; actively promoting the other’s welfare; giving priority to the other’s needs
- Evocation – eliciting the person’s own knowledge, wisdom, strengths and motivation; “you have what you need and together we will find it”
Adapted from Motivational Interviewing, 3rd edition by Miller & Rollnick, 2013
Core Values Listed by Group Needed with Caring for People
- Forgiveness
- Empathy
- Openness
- Reliability
- Integrity
Listed Strengths by the Group
- Good listening skills
- Determination
- Creativity
- Stewardship
- Accountability
Hospitality comes with no strings attached. It does not pass judgement or make demands. Hospitality provides space where a person can freely explore their situation, needs, concerns, strengths & hopes. It allows for self-reflection and restoration.
Hospitality can be offered in many ways:
- Gesture of acknowledgement
- Smile
- Cup of coffee
- Listening patiently
To care means to be present to someone.
Homelessness has always been about:
- Race
- Class
- Gender
- Disability
- War, Natural Disasters & Poverty has been a constant cause of homelessness.
- People who are homeless are not one people – they are all individuals.
- Lack of finances & housing are the cause of homelessness.
- DESC.org – to find information re: housing in Seattle 1811 Eastlake Project
Transitional Housing may cause another barrier to people because the fear of being forced to leave may cause anxiety & failure.
New Ideas to Help Homeless People
Coordinated Systems/Sharing
- Data Sharing
- Treating mental and substance abuse together
Continuum of Care
Shelters, Mental Health Providers and all Services working together to help end homelessness.
Emergence of Evidence Based Practices instead of Traditional Methods
- Rapid Rehousing
- Motivational Interviewing
- Critical Time Intervention (timely case management)
Case Management That Works
- Person-Centered Care: prioritizes the self-identified needs and preferences of the individual. The helping relationship is collaborative and invitational. Support, information and options are offered. Services are tailored to the individual.
- Housing Focused Care: Housing itself is a form of treatment. Emphasis is placed on putting people into permanent housing as soon as possible.
- Trauma Informed Care: Homeless people experience a high level of trauma. Viewing the lives of people through a “trauma lens” helps to understand their behaviors, responses, attitudes and emotions as a collection of survival skills developed in response to traumatic experiences.
- Recovery Oriented Care: People can and do recover from substance abuse, mental illness and homelessness. People experience recovery of hope, self-worth and participation in meaningful relationships and activities.
- Outreach and Engagement: involves going into the community and meeting homeless people where they are – on the streets, under bridges, in shelters and drop-in centers. Workers seek to develop trust with individuals and to provide or connect them with needed services.
- Flexible, low-demand services: Services are provided in a individualized manner, varying in frequency, duration and scope depending on one’s changing needs and wishes. Participation is not required as a condition for continuing to receive services such as accessing entitlements or housing.
- Interdisciplinary Care Teams: Teams are composed of various health, behavioral health and social service providers who work together to ensure that a homeless person’s needs are being addressed in an appropriate and coordinated manner.
- Integrated Care for Co-Occurring Mental Illness and Substance Use Disorders: Refers to concurrent, coordinated clinical treatment of both mental illnesses and substance use disorders provided by the same clinician or treatment team. Integrated treatement has been shown to be more effective than a parallel or sequential treatment approach.
- Motivational Interventions: Person-centered clinical strategies that seek to help people resolve ambivalence and move in the direction of change. Make ample use of open questions, affirmations, reflective listening and eliciting change talk.
- Self-Help Programs: Programs are typically based on the AA 12-step method. Focus is on developing personal responsibility within the context of peer support. Participation has been shown to decrease substance use and inpatient treatment, and improve self-esteem and community adjustment.
- Involvement of Recovering Persons: Individuals in recovery play a critical role providing outreach, direct services, supporting peers in recovery, contributing as active members of planning councils, advisory boards, and community advocacy groups.
- Long-Term Follow Up Support: The recovery process from homelessness, mental illness, addictions, etc. is neither a linear or short-term process from most people. Individuals require long term follow up support from interdisciplinary team of care providers.
- Prevention Services: Examples include appropriate discharge planning from institutions/hospitals/treatment programs, short-term intensive support upon re-entry into the community, and provision of subsidized housing and adequate income support.
Adapted from Blueprint for Change: Ending Chronic Homelessness for Person with Serious Mental Illnesses and/or Co-Occurring Substance Use Disorders, DHHS Pub. No. SMA-04-3870. Printed 2003.
Case Management Models:
- Assertive outreach and engagement
- Flexible, Low Demand Services
- Housing First
- Rapid Rehousing
- Permanent Supportive Housing
High Expectation is not a Best Practice because it does not work.
Mindset of Case Management:
- Interdisciplinary Teams
- Integrated treatment for co-occurring disorders
- Care Navigation (aka case management)
- Involvement of recovering persons – many organizations hire peers (formerly homeless) to lead
Four Processes of a Conversation about Change: Engaging, Focusing, Evoking, Planning
The Method
Consists of four relational processes that are somewhat linear
- Engaging necessarily comes first
- Focusing is a prerequisite for evoking
- Planning is logically a later step
The four processes are also self-repeating
- Engaging skills continue throughout
- Focusing is not a one-time event; refocusing often needed; focus may change
- Evoking can begin very early on
- “Testing the water” for planning may require more engaging, focusing, evoking
The spirit and core skills of Motivational Interviewing are used throughout
- Spirit: partnership, acceptance, compassion, evocation
- Core skills: open questions, affirmations, reflective listening, summaries
Engaging – the process of establishing a mutually trusting and respectful helping relationship
- Goes beyond informal chat
- Includes being welcoming, offering a cup of coffee, showing genuine interest, offering hope
- Important to avoid traps that promote disengagement
Focusing – clarifying a particular goal or direction for change
- Focus can arise from the individual, the external context, or the practitioner
- Three basic scenarios: 1) focus is already clear 2) several options exist from which to choose 3) focus is unclear and there’s a need to explore
- Three styles of focusing: directing, following, guiding
Evoking – eliciting the person’s own motivation for a particular change
- Intended to help to resolve ambivalence in the direction of change
- Emphasis on recognizing and evoking change talk
- Goal is to elicit preparatory and mobilizing change talk
Planning – developing a specific change plan that the person is willing to implement
- Includes looking for signals of readiness from the indivdual
- Developing a plan is not a final but a beginning step
- Implementation requires a specific plan and intention or commitment o carry it out
Adapted from Motivational Interview, 3rd edition by Miller & Rollnick, 2013
Basics of Case Management
- Motivational Interviewing to evoke from people what they already have.
- People are already an expert on themselves
- When people are using drugs, not using condoms or making other decisions that seem destructive they are still filling a needs.
- We can’t change anyone but ourselves but we can make a difference
Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options.
- Defined as integration and allocation of individualized care within limited resources.
- Primarily office-based
Critical Time Intervention Basics
Critical Time Intervention (CTI) is a specialized, time-limited case management intervention designed to help people transition from homelessness or institutional settings to live more independently in the community. CTI helps individuals and families to be as successful as possible during this critical period of transition.
CTI is designed to bridge the gap between homeless-specific services and other services and resources in the community. CTI prevents recurrent homelessness, residential instability and fragmented care by connecting the person to informal networks (e.g., family, shopkeeper at the corner store, friends) and to informal caregivers (e.g., case manager, psychiatrist). The goal is to help the various caregivers and other support people in the community connect with each other to form a network of care.
Principles of CTI
- A two-way street, with the client becoming acclimated to community services and people, agencies, and resources in the community connecting with the client and adapting to meet individual needs for support
- Strives to have the client live in the least restrictive environment possible, and with the maximum amount of support needed
- Addresses client needs along with continuum
- Compliments rather than duplicates existing services
Key Characteristics of CTI
- Time limited (approximately 9 months)
- Three phases with decreasing intensity of services over time
- Focus on only a few areas of intervention at a time
- Community-based model – outreach, assessment, monitoring and intervention – not office-bases
- Small caseloads
- Harm reduction approach to behavioral change
- CTI team supervision by a CTI-trained MSW or Psychiatrist
- Early engagement with client prior to moving into housing
- Early linking to community
- No drop-outs: CTI intervention rarely shorter than 9 months
Phases of CTI
CTI is a nine-month intervention that begins on day of discharge from an institution or other setting. CTI ends approximately nine months later.
PRE-CTI
Prior to client’s actual transition, an assessment is made of community links and client strengths.
PHASE 1: TRANSITION TO COMMUNITY
This phase begins on the day of discharge/transition. It is marked by intensive support and assessment of resources for the transfer of care to community providers.
During this phase:
- CTI worker is there on a day of discharge to help individual get settled and being making community linkages.
- People in the community made aware that the CTI worker will help them with some of the responsibilities in helping the client transition.
- Mediation and negotiation are critical skills for this phase.
- CTI worker and client together develop a plan identifying what areas to focus on initially (This process has already begun in Pre-CTI phase).
- CTI team members identify key providers who will help with services.
- Worker connects client with community members.
- Most of this phase is spent on outreach
- CTI work does in vivo assessment of client’s needs and skills
PHASE 2: TRYOUT
Phase 2 focuses on trying out and adjusting support systems that were initiated in Phase 1. All of the basic support linkages should be in place during this phase.
- CTI worker focuses on strengthening connections between the client and supports in the community.
- CTI worker remains very involved but with decreased intensity of CTI services.
PHASE 3: TRANSITION OF CARE
In Phase 3, the focus is on transferring care from the CTI team to community resources for long-term support. The CTI team steps back to observe, anticipate pending problems, and to ensure the community supports are functioning well. In addition:
- Phase 3 focuses on the final transfer of care and includes a final transfer of care plan.
- Around 2 weeks before the end of CTI, the worker and client have a wrap-up meeting to look back at progress made and look ahead to the future. The two revier the client’s connections in the community with whom to maintain contact.
THROUGHOUT THE PHASES OF CTI:
- Services decrease and responsibility for care is transferred to others. This is made clear all along the way.
- Client and community prepare for life without the CTI worker.
SELF CARE
Providing care for people experiencing homelessness involves working under demanding circumstances, bearing witness to tremendous human suffering and wrestling with a multitude of agonizing and thorny issues on a daily basis.
Healthy self-care is an intentional way of living by which our values, attitudes and actions are integrated into our day to day routines. Self care is not an “emergency response plan” to be activated when stress becomes overwhelming.
Healthy self-care is about being a worthy steward of the self – body, mind, spirit – of which we have been entrusted. It is foolhardy to think we can be providers of care to others without being the recipients of proper nurture and sustenance ourselves.
Heathy self-care is as much about “letting go” as it is about taking action. It has to do with taking time to be a human being as well as a human doing.
ABCs of Self Care
- Awareness – By quieting our busy lives and entering a place of solitude we can develop an awareness of our own true needs and then act accordingly.
- Balance – Balancing action and mindfulness – How much time we spend working, playing and resting
- Connection – Fellowship
Suggested reading: Trauma Stewardship http://traumastewardship.com
“Let us not underestimate how hard it is to listen and to be compassionate.” Nehri Nouwen
This work…
exhilarating
and exhausting
drives me up a wall
and opens doors I never imagined
lays bare a wide range of emotions
yet leaves me feeling numb beyond belief
provides tremendous satisfaction
and leaves me feeling profoundly helpless
evokes genuine empathy
and provokes a fearsome tolerance within me
puts me in touch with deep suffering
and points me toward greater wholeness
brings me face to face with many poverties
and enriches me encounter by encounter
renews my hope
and leaves me grasping for faith
enables me to envision a future
but with no ability to control it
breaks me apart emotionally
and breaks me open spiritually
leaves me wounded
and heals me
Ken Kraybill
Motivational Interviewing with Survivors of Intimate Partner Violence Scenario 1
Motivational Interviewing with Survivors of Intimate Partner Violence Scenario 2
Motivational Interviewing with Survivors of Intimate Partner Violence Scenario 3
