Department of Behavioral Health and Intellectual disAbility Services

In Phase 2, we invited members to dream and to set goals for their lives. In this phase, we have a responsibility to help them get the skills and resources they need to pursue their goals. Based on their overall vision for their life and changes that they would like to make, support members in identifying two or three short-term goals (that is, goals that could be accomplished within a matter of days or weeks) and, together, outline a way to achieve the goals. These steps should not be documented or recorded as generic clinical activities such as “attending groups.” Instead, focus on what the member would get out of attending particular groups, such as learning specific skills. Ensure the record reflects the skills the member is improving and the long-term end those skills will serve. In phase 3, the treatment plan should be refined and further individualized to support all of the goals and steps that the person has identified.

Goal 1 strategies:

• Encourage the person to prepare for treatment planning conversations by talking about their goals and priorities with their peer provider or others in the JOH community.
• If the member desires, invite their peer specialist and case manager to be a part of goal-setting discussions.
• After identifying a couple achievable goals, work with the member to identify specific steps they could take to move toward their goals.
• Reinforce planning and implementation skills by working with the member to assess progress toward their goals and, if needed, to adjust their strategies.
• Encourage members to develop skills that support their priorities.
• Know the JOH protocol for new use and develop staff capacity to address substance use without judgment.

Individualizing services means, in part, ensuring that your program offers a range of services that will meet the needs of diverse members. But it also means ensuring that the menu of services is never static, that it changes as individual members themselves change. Stay continually aware of member needs for services, particularly when it comes to enhancing skills related to community integration.

Goal 2 strategies:

• Create a menu of groups or other services that members can choose from, and explore with them how some services or activities could contribute to their goals more than others.
• Ask members what groups they would like to have.
• Host outings based on member needs and interests.
• Increase member’s exposure to a variety of experiences that they may not have had in the past.
• Support peer-run groups.
• Partner with other JOH programs to host groups, outings, and events.
• Develop relationships with community organizations who can be invited to share skills, as needed.

Individuals cope with stress in conscious and unconscious ways, and in ways that are more or less healthy. Members may not have learned strategies for increasing their resilience to stressful situations. Help members get enough experience with a variety of strategies to decide if those strategies could be added to their self-care toolkit.

Goal 3 strategies:

• Support members with identifying strategies to cope with cravings or triggers that they may encounter in the program or community.
• Work with the member to explore self-care strategies such as exercise, yoga, reading, spending time in nature, and other ways to reduce the effect of stressors in their lives in general.

• Support members in identifying their daily self-care rituals. Knowing what helps a person manage stress doesn’t benefit them unless they actually incorporate those strategies into their everyday life.

• Help members identify strategies that they can draw on immediately when they experience stress in the moment.
• Model constructive responses to stress.
• Role-play a variety of responses to stress.
• Work with the member to make analyzing and problem-solving a regular follow-up to their stressful experiences.

Nine of 10 individual receiving publicly funded behavioral health services report a history of trauma, and chronic homelessness is a trauma in itself. Individuals cope with their trauma in different ways, and many won’t feel the need to disclose their traumatic experience to clinicians, peer staff, or anyone else. It’s a given that trauma-informed approaches must be a part of our engagement with JOH members and others. But our core value of healing-centered engagement aims to go further, to acknowledge not only personal trauma, but also collective trauma, and to address trauma at multiple levels to empower individuals and their communities.

Goal 4 strategies:

• Provide personalized therapeutic services; healing looks different for everyone.
• Ensure all staff are trained on how trauma can affect a person’s behavior and expression of emotions.
• Avoid re-traumatizing or tacitly threatening members. It’s not effective to use threatening language, such as, “This might be your last chance,” or “Don’t blow this opportunity.”
• Intentionally help members identify strengths, and work with them to explore their assets and potential.
• Acknowledge the impact of collective trauma and explore healing through activism, volunteerism, education, or other activities.
• Identify relevant community supports for trauma-specific services. Build relationships with these supports and be prepared to introduce members to them.

Clinical care can help launch recovery, but members sustain their recovery in communities. Developing these skills takes time. So don’t wait until the person is preparing to leave the residential portion of the JOH Project to think about the community-based supports that would serve them. Instead, starting as soon as possible, provide opportunities for members to learn or enhance a range of adult living skills and to practice those skills in real-world settings.

Goal 5 strategies:

• Find out what community living skills members would like to work on, such as finding a bus route, learning to read, enhancing parental skills, or applying for a job.
• Encourage peer staff to support people in natural community contexts.
• Work with the individual to identify and apply for volunteer opportunities that will enhance their desired skill sets.
• Assist members in exploring new interests and in participating in activities they may not have had an opportunity to do in the past.

Because it’s impossible to predict when a member may receive a housing match, it’s important to start as soon as possible to assess the member’s natural support system and strategically strengthen it.

Goal 5 strategies:

• Ask members to reflect on how they would like to give and receive support from others.
• Inventory the person’s existing circle of support.
• Help the person identify people that they would like to add to their support system.
• Assist members with developing interpersonal skills that can be helpful in building relationships and expanding their support system (sharing personal information about oneself, taking calculated risks, asking for help, reflective listening, enforcing boundaries, and so on).
• Help members meet new people by hosting events that include members living in other JOH programs and alumni.
• Inventory the places in the community that individuals go to or visit.