The Role of Outreach: Responding to Primary Homelessness

The Role of Outreach: Responding to Primary Homelessness Homelessness Research Collaboration National Homelessness Research Agenda 2009-2013 Anne Coleman, David MacKenzie and Brendan Churchill School of Social Sciences, University of Tasmania Swinburne Institute for Social Research, Swinburne University 1 Dr Anne Coleman: School of Social Sciences University of Tasmania Contact details: 03 6226 7598 or anne.coleman@utas.edu.au Associate Professor David Mackenzie Swinburne Institute for Social Research Swinburne University Contact details: 03 9214 5462 or dmackenzie@swin.edu.au This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and enquiries concerning reproduction and rights should be addressed to Commonwealth Copyright Administration Attorney General’s Department Robert Garran Offices, National Circuit, CANBERRA ACT 2600 or posted at www.ag.gov.au/cca Commonwealth of Australia 2013 ISBN (ISSN): 978-0-9775259-6-6 This project is supported by the Australian Government through the National Homelessness Research Agenda of the Department for Families, Housing, Community Services and Indigenous Affairs. The opinions, comments and/or analysis expressed in this document are those of the author or authors and do not necessarily represent the views of the Minister for Housing and Homelessness and cannot be taken in any way as expressions of government policy. 2 TABLE OF CONTENTS LIST OF FIGURES.................................................................................................... 4 1 INTRODUCTION............................................................................................... 8 2 ROUGH SLEEPING IN AUSTRALIA ....................................................................12 3 4 5 1.1 Statistics on primary homelessness ................................................................... 14 1.2 ABS statistics on Primary Homelessness (2011) .................................................. 16 1.3 International data on rough sleeping ................................................................. 18 OUTREACH CONCEPTS AND MODELS ..............................................................21 3.1 Context ............................................................................................................ 22 2.2 Definition of outreach ....................................................................................... 24 2.3 Outreach as a practice concept ......................................................................... 24 2.4 Outreach models .............................................................................................. 26 2.5 Housing First..................................................................................................... 30 2.6 Outreach programs ........................................................................................... 33 2.7 Outreach practice ............................................................................................. 35 METHODOLOGY .............................................................................................38 4.1 Aim and research questions .............................................................................. 38 4.2 Sampling and recruitment ................................................................................. 38 4.3 Method ............................................................................................................ 39 4.4 Strengths and limitations .................................................................................. 41 FIELD WORK FINDINGS ...................................................................................43 5.1 Outreach as a concept .......................................................................................... 43 5.2 Outreach as a practice .......................................................................................... 47 5.3 Qualities of outreach workers ............................................................................... 53 5.4 Ethical issues ........................................................................................................ 55 5.5 Context and the practice of outreach .................................................................... 57 6 DISCUSSION ...................................................................................................61 6.1 Questions and Answers..................................................................................... 61 6.2 Policy ............................................................................................................... 66 REFERENCES.........................................................................................................73 3 LIST OF TABLES Table 1: Primary homelessness by state ................................................................. 16 Table 2: Number of rough sleepers, Australian capital city CBDs, 2001- 2011 ........ 17 LIST OF FIGURES Figure 1: Typology of ‘rough sleepers’ .................................................................... 12 Figure 2: The three core levels of good outreach practice ...................................... 47 Figure 3: Scoping and negotiating context, practice activities and purposes ........... 48 Figure 4: Building social capital, practice activities and purposes ............................ 48 Figure 5: Working with individuals, practice activities and purposes ........................ 49 4 Year: 2013 Project title: The Role of Outreach: Responding to rough sleeping PRINCIPAL INVESTIGATOR: Dr Anne Coleman ADDRESS: School of Social Sciences, University of Tasmania, Private Bag 17, Hobart TAS 7001, PH: 03 6226 7598 or anne.coleman@utas.edu.au EXAMPLE OF KEYWORDS: homelessness, primary homelessness, outreach, practice. OBJECTIVES: 1) How do outreach workers conceptualise and practice outreach work? 2) How do people sleeping out experience street based outreach? 3) What benefits do agencies using outreach models see in outreach? 4) What are the elements of good practice outreach to people sleeping out? 5) What outcomes does good practice outreach produce for people sleeping out; for agencies providing outreach; and for funders? NON-TECHNICAL SUMMARY: The White Paper, The Road Home, brought a renewed interest in outreach with its explicit objective ‘‘to offer supported accommodation to all rough sleepers who need it’. Outreach came as part of the Housing First approach along with some influence on the UK Rough Sleepers Initiative that has had a demonstrable impact on street homelessness. The research was conceived to investigate outreach practice in Australia, but also to include a field visit to New York, where a major outreach program has been in place for some years. Following a review of the literature on outreach fieldwork was undertaken with five agencies in three states, and interviews were conducted with 18 workers: 14 current outreach workers and four formerly experienced outreach workers. During the fieldwork, outreach workers were accompanied and observed during their street work. In New York, discussions were held with several of the New York leaders in the homelessness sector. Some eight observational excursions in the field at night were done together with on-site visits to five New York Shelters for the Homeless. 5 Outreach can be described as ‘… a contact-making and resource-mediating social activity performed in surroundings and situations that the outreach worker does not control or organise, and targeted at individuals and groups who otherwise are hard to reach and who need easy access linkage to support’ (Andersson 2012). An underpinning rationale is that people sleeping in public spaces for long periods of time are often estranged from the homelessness service system or experiencing severe mental health issues. On their own volition they tend not to seek help. Outreach practice from the accounts of outreach workers is composed of practices some of which were explicitly named while others were tacit and taken for granted. Outreach is sometimes described as performative and the metaphor of ‘dance’ is used. It draws as much from social work as it does from anthropological field methods. Good practice outreach is a meld of organisational factors, worker’s orientation to their work, outreach styles and the attitudes of the communities where they work. We identify and discuss three key concepts of outreach practice – negotiating the context, building social capital and working with individuals. Although we did not formally interview, public space dwellers, they generally appear to appreciate contact with outreach workers. The agencies that support outreach are positive about its value although in most, outreach is only one element of what they do. In one agency there was a negative perception about outreach. The recent Australian literature distinguishes ‘assertive outreach’ from what is described as ‘traditional’ outreach. Our finding after reviewing the literature on outreach and doing fieldwork is that the use of the descriptor ‘assertive’ is at best redundant but at worst misleading. A key policy parameter is linking systematic good practice in outreach with planned pathways into an appropriate for of supportive housing. In terms of policy, there is evidence that street homelessness in the inner city has decreased substantially in some places but not others. The rebuilding of outreach linked to pathways into supportive housing seems to have been a sound policy setting, although it is not clear how much impact it has had. If it is to be embedded in the ongoing response to street homeless in Australian cities, some reorganisation and strengthening of the generic model should be considered. What we don’t have in place is a planned and systematic approach to inner city street homelessness, where we have well-resourced specialised outreach teams that have access to a small steady stream of supportive housing units. One suggestion is that inner-city outreach be more amply supported as part of a planned response and specialist agencies 6 funded to work on a whole of the city mandate with linked to housing providers whose role would be to make a sufficient stream of supportive housing available. What is clear is that good outreach practice in Australia is connecting with the most marginalised and stigmatised group among the homeless. Outreach services are continuing to contribute to the reduction in public space dwelling and should be retained and enhanced as a valuable practice in addressing street-based homelessness. 7 1 INTRODUCTION Homelessness has received unparalleled attention since the release of the Australian Government’s Green and White Papers addressing homelessness. This attention has been directed to strengthening prevention and early intervention responses; enhancing and improving existing homeless services; involving agencies whose core business is not homelessness; and rebadging homelessness as everybody’s business. Among the many groups experiencing homelessness, particular attention has been given to people who sleep out, and whose everyday lives are lived on the streets, in public spaces and in squats. Throughout the report, we have tried to avoid using the term ‘rough sleepers’ as a universal descriptor. This research project is about outreach practice with people experiencing homelessness, who live in, or are largely reliant on public spaces. In Australia, this group is defined as experiencing ‘primary homelessness’ and its members are referred to in the literature as ‘rough sleepers’, the ‘chronically homeless’ or ‘public space dwellers’. Primary homelessness includes a range of situations where people don’t have access to conventional dwellings. These situations include sleeping in cars, vans or in railway carriages. Sheltering in derelict buildings is also included under this category. Of course, some people do sleep on footpaths or in public parks. Wherever possible, we have used other terms such as ‘sleeping out’; ‘street homelessness’ or ‘public space dwelling’ because these terms are less value laden than the most common term ‘rough sleepers’. One problem with using the term ‘rough sleepers’ is that it evokes a stereotype and belies the sometimes orderly nature and amenity of some street dweller’s abodes. Also, we acknowledge the point made by Paul Memmott and his colleagues (2003), that referring to sleeping out, public space dwelling and other less value laden language avoids labelling as ‘homelessness’ the traditional ways that Aboriginal people of make use of public space. The majority of State and Territory homelessness responses have included a policy setting directed to public space dwellers, and there have been a range of initiatives to address ‘rough sleeping’ and reducing the visibility and number of people who do sleep out. These commitments help to explain governments’ interest in, and readiness to fund, models that promise to contribute to this reduction. Our research is an exploration of outreach as a way of responding to street homelessness, which is timely, given there is considerable interest and investment in ‘housing first’ models (such as Street to Home and Common Ground) as a way of addressing primary homelessness. These models rely on ‘assertive outreach’ as the first (and sometimes 8 sufficient) step in housing people and supporting transitions from public space dwelling into stable housing. The research employs a multi-method approach to increase understanding of the practice of outreach involving a review of the literature on outreach practice, and field visits to agencies and workers engaged in outreach in both Australia and the United States. Because of the prominence in Australia being given to promoting ‘assertive outreach’ in contrast to what is described as ‘traditional outreach’, we have examined this distinction conceptually but also on the basis of field data on various outreach programs. In terms of broader policy thinking, we have benefited from discussions with some of leading practitioners in Australia as well as several leaders in the homeless sector in New York. Contemporary policy on homelessness has been framed by the release of the Federal Government White Paper in 2008, which foreshadowed national action to reduce homelessness. For the first time, the Australian Government set two specific goals to be achieved by 2020: to halve homelessness; and to offer supported accommodation to all rough sleepers who needed it. The announcement was an unprecedented commitment by a national government that moved homelessness from being a residual and marginal policy issue to a national issue of significance. Homelessness policy is aimed at ending homelessness by strengthening prevention and early intervention responses, reducing cycling through the system, and improving the efficiency and effectiveness of service responses to homelessness. The Road Home nominated three strategies in its response to homelessness: (1) ‘turning off the tap’ or prevention and early intervention; (2) ‘improving and expanding services’ by reforming and enhancing the existing service system; and (3) ‘breaking the cycle’ by implementing measures to ensure that people coming out of homelessness do not become homeless again. Interest in outreach occurs in the context of the framework set by these strategic priorities. Outreach has traditionally been a key component in engaging with people identified as ‘hard to engage’. It is a strategy for reaching people in need of support on their terms and often on their territory, rather than providing a service that they can access if they wish by turning up. In terms of homelessness, outreach workers were active during the 1970s and1980s attempting to engage homeless young people who were described as ‘street kids’ in the media. In the United States, in the 1980s, various outreach programs were created as a response to the rise in street homelessness in American cities. Engagement is seen as the 9 beginning of a process that includes building a purposeful relationship as the precursor for work to address need. In order to meet their objectives in relation to ‘rough sleepers’, Australian governments have adopted and are implementing a Housing First approach to respond to the needs of people living in public spaces. Housing First models are underpinned by the assumption that providing housing to people sleeping out is a critical part of addressing their homelessness. Considerable investment has already been made in Housing First models in South Australia, Queensland, Victoria and Tasmania where Common Ground and Street to Home services are already operating or being developed. Providing housing depends on engaging with people living on the streets. Outreach is a practice that provided the means for engaging with this group, many of whom are reluctant or intermittent users of services. In ‘Housing First’ models, outreach is vital as it is allows outreach workers to identify and contact people sleeping out, assess their ‘vulnerability’ (and thus prioritise their access to housing), and then encourage and facilitate their entry into housing. For example, a critical element in the Common Ground and Street to Home models, both of which have been adopted in Australia, is ‘assertive outreach’. While the outcomes of the Housing First models and of ‘assertive outreach’ have yet to be proved in the Australian context, there is some evidence of outcomes from the US. Several evaluations suggest a reduction in the level of alcohol consumption by people after being housed, and a reduction in the number of people accessing crisis shelters. However, there has been some critique of the methods used and the findings of these evaluations. There has been equally mixed reaction to the ‘assertive outreach’ model, with one researcher describing the model as ‘coercive outreach’. In light of the investment in Housing First models and the key role outreach plays in forming a bridge (or means of transition) for people sleeping out into housing, an understanding of effective outreach practice becomes critical. There is, however, little research documenting the practice of outreach even though outreach has been the basis of work with many groups identified as ‘hard to engage’ and having ‘complex needs’. These groups include young people experiencing homelessness; older people experiencing long term and chronic homelessness; people with a mental illness experiencing homelessness; and difficult to engage Centrelink clients. This study then has relevance in the context of homelessness but also more broadly. 10 The research explores outreach as a core element in the outcomes achieved by Housing First models; documents the elements of good practice outreach; and gathers evidence about the effectiveness of good practice outreach. 11 2 ROUGH SLEEPING IN AUSTRALIA What is called ‘rough sleeping’ (or sleeping in a public space with no other usual address) is what members of the public typically think of when they think of ‘homelessness’. Rough sleepers are the visible section of the homeless population. In Australia, during the 1980s and the 1990s, there was considerable media coverage of youth homelessness with stories about ‘street kids’ and scores of images of young people bedding down in derelict buildings or without shelter. When statistics are released on the extent of homelessness (105,000 in 2011), including primary homelessness (that includes rough sleeping), secondary homelessness (i.e. temporary or emergency shelter only or supported accommodation) and tertiary homelessness (i.e. long-term residents in rooming houses and many people living in caravan parks), it was not uncommon for the media to refer to 100,000 ‘rough sleepers.’ In fact, only a small minority of the total homeless population were sleeping out on the night of the 2011 Census. On the basis of fieldwork with outreach workers and extensive contact with a Victorian 24/7 outreach program and field experience in Queensland and Western Australia, there are some comments that can be made about sleeping out in the city. Although we know that people sleep out in rural and regional areas, public space dwelling is concentrated in the inner cities. The CBDs are relative small geographical areas and the visibility of rough sleeping is high if there are one to two hundred homeless people sleeping rough as is the case in Melbourne or Sydney. Figure 1 sets out a typology of rough sleeping. Like all typologies, its purpose is to highlight the distinguishing characteristics of the phenomenon, which in this case is public space dwelling. Figure 1: Typology of ‘rough sleepers’ Categories of ‘rough sleepers’ Duration of ‘rough sleeping’ Duration of homelessness Appropriate response Recently homeless rough sleepers Short-term Short-term Early Intervention Long-term homeless recent rough sleeper Long-term Short-term Rapid return to supported accommodation Intermittent rough sleepers Long-term Relatively short-term (maybe many episodes) Homeless crisis service and social housing Chronic rough sleepers’ Long-term Long-term even if across several episodes Long-term supported housing for high needs residents 12 In terms of homelessness, sleeping out is a form of homelessness where a person has no usual home elsewhere. However, duration is a key variable (Chamberlain & Mackenzie, 1992; 2005). People sleep out for varying periods of time. Based on interviews with outreach workers and field experience, four groups of rough sleepers can be identified in the primary homeless population. First, there is a group that can be described as chronic rough sleepers (Figure 1). These are people, predominantly men, who sleep out for extended periods of time – months or even years. They may not be in regular contact with services and they often have serious mental health issues and/or substance abuse problems. Outreach is justified when there are chronic rough sleepers who do not approach services for assistance. There are reports of people sleeping rough for extended periods of time in rural and regional areas and occasionally in the suburbs, but outreach workers in the cities are most familiar with this group. Census figures on ‘primary homelessness’ (which includes sleeping out) report people sleeping rough on the night of the Census but whether they have been sleeping rough for a long time or a short time cannot be determined. A second group in the primary homeless population are people who sleep out intermittently. Many of these people are long-term homeless, but they often stay in boarding houses on a regular basis. These boarding houses are usually residences with 6 to 12 individuals in small rooms or outside sheds, with a shared bathroom and kitchen. Conditions are usually poor and there are reports of standover methods being used to intimidate vulnerable tenants. If someone cannot pay their rent or is in dispute with other tenants, then they might quickly find themselves living on the streets. There has been considerable media attention given to boarding houses, particularly in Melbourne but the same issue exists in New South Wales and Queensland. In 2009, the Victorian Government established a team of 12 inspectors to identify boarding houses and ensure that regulations were enforced. The Taskforce’s report stated there were 497 registered boarding houses but estimated that there were between 500 and 1000 unregistered properties. The Taskforce report described poor conditions in many properties (Rooming House Standards Taskforce 2009). Several jurisdictions have introduced legislation and regulations for rooming houses and caravan parks. According to service use data, this group in the homeless population appears to be a ‘feeder pool’ for many of the intermittent rough sleepers in the city. In regional centres and country towns, people ejected from caravan parks might also become intermittent rough sleepers. 13 A third group are people who may have been homeless for long periods but only recently slept out. They might have not been able to pay their rent in a rooming house or been staying with an acquaintance and been forced to leave after an argument. They have been homeless for a long period but not slept rough or not slept rough often. Finally, there is a fourth group in the primary homeless population: people sleeping out who are newly homeless. These are people sleeping rough but who have only become homeless recently. In some cases, these will be adults (or families) sleeping in a car. The interviews with service providers in regional and rural Victoria has suggested that many people were in the recently homeless rough sleeper category. An appropriate response for this group would be reconnection with their family or community of origin and an effort to provide ‘early intervention’ support rather than channelling them into homeless accommodation services. There are no reliable data to provide a comprehensive statistical profile of this group but outreach programs in Melbourne have found that over a year a large number of people are in this category. The Melbourne City Mission’s Reconnect service at Frontyard on King Street was set up to respond to cases where recently homeless young people come in seeking assistance. The 24/7 Melbourne’s Road Home team, which works with a broader and generally older cohort, reports that over a year about 40 to 50 per cent of the rough sleepers they encounter are people who have become homeless only recently. Outreach is relevant to all of the above groups from those who do not engage with services to people who have turned up homeless in the city, but whose homelessness is relatively recent. Apart from the need to undertake good outreach practice, the typology serves to sensitise outreach programs in the inner cities that their responses range from a form of ‘early intervention’ to rapid return to supported accommodation to a long-term engagement and support for people with high and complex needs to secure supported housing of some kind for them. 1.1 Statistics on primary homelessness Australia has been compiling statistics on its homeless population since 1999, when the first report on Counting The Homeless was produced using data from the 1996 Census of Population and Housing (Chamberlain, 1999). Further reports followed (Chamberlain & Mackenzie, 2003, 2009). For the analysis of the 2011 Census, the Australian Bureau of Statistics produced its own statistical definition of homelessness and various figures (see section 1.2 for details). The operational category for primary homelessness is the census category ‘improvised homes, tents and sleepers out’. This category includes people in: 14 Sheds, tents, humpies and other improvised dwellings … it also includes people sleeping on park benches or in other ‘rough accommodation (ABS 2006, p.182) These data have been interpreted as the number of rough sleepers. In the White Paper, The Road Home (2008), Table 1 on page 4 presented figures on the above category under the title ‘Rough sleepers by state and region’). The total number of rough sleepers in Australia was given as 16,375 using Counting The Homeless data. However, the category ‘improvised homes, tents and sleepers out’ actually includes a wide range of situations from someone sleeping rough, sleeping in their car, sheltering in a derelict building, or in an improvised dwelling of some kind. Improvised dwellings can vary from humpies, caravans with a lean-to attached, derelict buildings, to assembled colour-bond farm or garden sheds that can be fitted out as habitable dwellings. Rough sleeping is generally interpreted as sleeping in the open, but also in a car or a train carriage or a derelict building. People living in sub-standard but habitual sheds are in a different situation. Unfortunately, it has not been possible to disaggregate the census data on the number of people in improvised dwellings (sheds, garages and cabins) from the number of people rough sleeping. Mackenzie and Chamberlain (2009) cautioned about the interpretation of this data because there was evidence that in some localities people were living in sheds (ie. improvised dwellings) on rural properties. But, there was no simple way of disaggregating the data in this category. In 2006, as part of Counting The Homeless project, the issue was further investigated to try to clarify the count of ‘rough sleepers’. This was done by investigating various crosstabulations between the ABS ‘primary homeless’ category and other census variables combined with a large number of fieldwork interviews in communities throughout Australia. This field inquiry gathered information on ‘improvised dwellings’ to find out about the nature of such dwellings. In terms of the analysis available in the census data, ‘dwelling tenure’ distinguished between owners and renters. When the responses of people in the ‘improvised dwellings’ category to the census question about ‘dwelling tenure’ were examined, 39 per cent of households were in dwellings that they report as owned or being purchased and another 10 per cent were in rented improvised dwellings. Field information building inspectors and town planners, supported an interpretive judgment that the ‘owner, purchaser,’ reply indicated that these households were usually living in improvised dwellings such as sheds, garages and shacks on land that they owned or were purchasing. Individuals and families in these situations were not transient nor ‘homeless’ under the definition of ‘primary homelessness’ – i.e. people with no access to conventional dwellings. It was less clear whether the rented improvised dwellings were similar to the habitable farm sheds. Half of the ‘primary homelessness’ households (51%) did not answer the question 15 about dwelling tenure, so an assumption was made that they provided no information on dwelling tenure because they were not living in a dwelling, but were sleeping rough, squatting in derelict buildings, or sleeping in their car (Chamberlain & Mackenzie 2009) The statistical implications of this reanalysis was clarification that in the inner city areas nearly all the individuals in the category ‘improvised homes, tents and sleepers out’ were living in public spaces, whereas in rural and regional areas most people in this category were living in sheds. Probably only about 14 per cent were rough sleepers. Rough sleepers in rural areas tend to be small numbers spread over large areas. Mackenzie and Chamberlain proposed that the number of rough sleepers was not 16,000 but closer to 6,600. 1.2 ABS statistics on Primary Homelessness (2011) The ABS produced new statistics on homelessness in Australia for the 2011 Census using a revised statistical definition of homelessness. Table 1 shows the figures for rough sleeping by state and territory produced by the ABS. Table 1: Primary homelessness by state 2001 2006 2011 New South Wales 1698 1596 1920 Victoria 1018 786 1092 Queensland 2322 2026 1584 South Australia 512 436 258 Western Australia 1410 1016 925 Tasmania 125 122 158 Northern Territory 1798 1213 848 61 51 29 8946 7247 6813 ACT Australia (Total) The statistical definition used by the Australian Bureau of Statistics is derived from the cultural definition of homelessness, although the ABS definition includes new exclusions and some new enumeration guidelines. In terms of rough sleeping, the derivation of rough sleepers follows the logic used for Counting The Homeless (2009) with several minor changes. Beginning with all persons in the category ‘improvised homes, tents and sleepers out’, people with a usual address elsewhere in Australia (campers), people on overseas 16 visits, imputed records, people who indicate that they own or rent an improvised dwelling and other renters who are in this category, are removed. This leaves people sleeping out without shelter, people sleeping in their cars or in public spaces somewhere and some people bedded down in derelict buildings. Over the decade to 2011, there has been a decrease in primary homelessness in Australia. In 2001, there were 8,943 persons classified as rough sleepers; by 2011 this number has decreased by over 23 percent. The greatest change was apparent in the Northern Territory, Australian Capital Territory and South Australia where there was a decrease of around 50 percent in the number of persons classified as rough sleeping. There was a smaller, but still significant, decrease in both Tasmania (26 percent) and Queensland (31 percent). Over the same period, the number of persons classified as rough sleeping in New South Wales bucked the national trend and increased by over 13 percent. Public space dwelling is prevalent in the capital cities, Melbourne (60%), Greater Sydney (62%) and Adelaide (67%), however, in Queensland, most rough sleeping is in regional areas (90%) and in Western Australia only 40 per cent of the rough sleeping is in Perth. Queensland, Western Australia and the Northern Territory all have significant populations of Indigenous people who camp out in public spaces. While outreach is sometimes undertaken in regional centres, the major commitment to outreach is in the centre of the capital cities. For the 2011 Census, the ABS introduced a new geographical classification. The new Australian Statistical Geography Standard (ASGS) replaces the long-standing Australian Standard Geographical Classification (ASGC). The ASGS has been used for the release of data from the 2011 Census of Population and Housing, Most ABS data will be released in the new geographical classification. This has changed the boundaries for the inner city areas throughout Australia, so comparing the trend from 2001 to 2011 needs to be undertaken with care to ensure that the geographical areas being compared are the same. On this basis, Table 2 compares the number of rough sleepers for Sydney, Melbourne, Brisbane, Adelaide and Perth CBDs. Table 2: Number of rough sleepers, Australian capital city CBDs, 2001- 2011 2001 2006 2011 % Change 2001-11 Sydney 299 344 490 +64% Melbourne 107 105 133 +24% Brisbane 294 145 67 -77% Adelaide 104 134 103 no change 17 Perth 195 221 188 no change These figures provide data on the number of rough sleepers in these Australian capitals on Census night in August. The persons enumerated on census night are more likely to be those who have spent long periods as public space dwellers, and people whose period of rough sleeping is relatively short are less likely to be found rough sleeping when the census count is done. The research into outreach for this project is not in a position to draw evaluative conclusions about the effectiveness or impact of outreach in the capital cities of Australia. Streets to Home projects were funded throughout Australia with the aim of responding to rough sleepers and assisting them into stable supportive housing. It is reasonable to expect a measurable impact on the inner street sleeping population, but changes or no change can also reflect the effect of other extraneous factor in a particular city and state. The ABS statistics on rough sleeping are one available indicator of the effect of all the activity directed to rough sleeping in these locations where rough sleeping is concentrated. 1.3 International data on rough sleeping In more recent years, the United States has been seen as a source of responses to homelessness. Homelessness is more visible in US cities, in particular large metropolitan cities, such as New York, Los Angeles and Chicago, where street homelessness is more prevalent and present. The social security systems are different. In New York, there has been a major effort by the city to respond to homelessness, in particular rough sleeping. It was because of the Australian interest in New York outreach programs that a fieldwork visit was undertaken to New York in 2012. The purposes were to learn more about homelessness in the US context, and to consider similarities and differences between what happens in the US compared with Australia. In New York some $14m altogether is invested in outreach program and this was the main focus of this research project. One of the issues often overlooked is that in the United States, homelessness is defined more narrowly than in Australia. The Department of Housing and Urban Development (HUD) defines a homeless person as someone ‘sleeping in a place not meant for human habitation (e.g. living on the streets) OR living in an emergency shelter for the homeless. When official statistics are compiled in the United States, people are counted as homeless who are in shelters or sleeping on the street on the night when the count is done. Using this definition, in 2012, the official figure for homeless individuals in the US was 633,782 made up of 390,155 people in shelters (sheltered homeless) and another 243,627 counted on the 18 streets (unsheltered homeless). Translated into an Australian context, this would comprise the national figure for rough sleepers according to the ABS (6,813 on census night) and the number of individuals accommodated in Specialist Homeless Services (21,258 on census night), or a total homeless population of 28,071 by applying the HUD definition to Australian data. In New York, where people experiencing homelessness have a legal right to be accommodated in a city shelter, there were 46,344 homeless persons in the shelter system in 2012 compared to 35,445 in 2006. Shelters in the US, unlike Australian Specialist Homelessness Services, usually consist of dormitories and many shelters accommodate hundreds of people in the one building. Street counts are done towards the end of January, which is winter in New York. Advocates continually complain that street counts involve a considerable under-estimation. According to these critics, young people are undercounted because they cannot readily be identified in the streets count because they move out of the way and so many are part of the large couch-surfing population. The New York City Administration has tended to focus on claims that street homelessness has decreased from a high of 4395 in 2005. However, the number of homeless persons counted on the streets of New York has increased between 2010 and 2012 from 2,648 to 3,262. The extent to which the City has funded street outreach and the way its press releases are written suggests that getting people off the streets is a policy priority. The City’s media messages are that street homelessness is decreasing in New York. That might be the case for ‘chronic rough sleepers’ but overall homelessness is on the increase as organisations such as the Coalition for the Homeless point out. There is a major focus on reducing the sub-population of chronically homeless. This group is defined by HUD as ‘either (1) an unaccompanied homeless individual with a disabling condition who has been continuously homeless for a year or more, OR (2) an unaccompanied individual with a disabling condition who has had at least four episodes of homelessness in the past three years.’ Homelessness in the US context means sleeping on the streets or in homeless shelters. The HUD definition of ‘chronic homelessness’ was constructed as collective decision by several Federal agencies including HUD, the U.S. Department of Labor, the U.S. Department of Health and Human Services, the U.S. Department of Veterans Affairs, and the U.S. Interagency Council on Homelessness. A person must meet only one of the ‘timeframed criteria’ to qualify under the definition. 19 All the outreach programs in New York are funded to respond to ‘chronic homelessness’ as defined above. In the United States, using this definition, there were 107,148 chronically homeless individuals in 2011 and 99,894 in 2012. In the United Kingdom, there has been a major push to respond to rough sleepers and encourage people on the streets to take up a bed in one of the shelters. As in the US, figures for rough sleeping are contested (Cebulla, 2009), but there does appear to have been a steady decline in the past decade in particular. The policy on rough sleeping in the UK was probably influential in shaping thinking in the Australian White Paper. This above discussion serves to highlight the considerable differences between countries such as Australia and the United States. Context matters. The extent of rough sleeping in the cities is hugely different. We are not able to enumerate the extent of chronic homelessness in Australia, but it must be orders of magnitude less than in the United States. There are people sleeping out who are ‘chronic rough sleepers’ and there are people who fit the category of ‘intermittent rough sleeper’. By the very nature of cities, people will tend to gravitate to the inner city and street homelessness will be a continuing phenomenon. Major outreach programs can be justified in situations where there are large concentrations of people estranged from the service system and living in public spaces. The capital cities are the main sites where this approach is necessary. The rediscovery of outreach in the White Paper was linked to the adoption of Housing First and reflected the influence of the Rough Sleepers Initiative in the UK and some of the outreach being done in US cities such as New York. A more planned and systematic response and a systematic evidence-based implementation of best practice outreach is clearly an important component of the homelessness response. There is an argument for supporting outreach specialists who take a whole of the city approach and who link in with specialist supportive housing. Should the various supportive housing providers be also doing outreach? These agencies currently do outreach to many of their housed clients, however, a community-focused homelessness outreach is a different proposition. These are questions for policy-making directed to assisting rough sleepers. 20 3 OUTREACH CONCEPTS AND MODELS Outreach is a critical tool used by workers to engage with, and assist, ‘hard to reach groups’ (Andersson 2011; Black and Gronda 2011; Erickson and Page 1998; Lam and Rosenheck 1999; Levy 2004:372; Memmott, Chambers, Pitts, Green and Ingram 2005; Ng and McQuistion 2004; and Rowe, Fisk, Frey and Davidson 2002). These hard to reach groups are characterised by avoidance of services and include people with mental health issues; people engaged in illegal activities such as street prostitution; young people disengaged from family and/or school; and people experiencing homelessness. Outreach services also provide the only, or primary, contact with support services and an entry point to other, specialist services for people who live in public spaces. People experiencing street homelessness are specifically identified and targeted by all homelessness strategies and responses developed by the Australian, state and territory governments. They are also most likely of all the groups experiencing homelessness to attract the attention of local governments because of their visibility and use of public spaces. This group is constructed in policy documents and service agreements (and in a proportion of the academic and grey literature) as vulnerable and at-risk – while simultaneously being framed as unproductive, homeless by choice, and troubling as well as troubled. Many public space dwellers have been homeless for considerable periods of time, and some identify strongly with a local area or community. (Coleman 2001). Some may have adopted homelessness as a ‘lifestyle choice’ but the majority have chosen to live on the streets as their best option (from among limited choices), and the majority would prefer to have a ‘home’ (Phillips, Parsel, Seage & Memmott 2011). The majority are facing a combination of challenges and on-going issues that mean that their perceived need for services and supports is high, but their access and engagement with services (particularly mainstream services) tends to be sporadic, often crisis driven and frequently unproductive (Andersson, 2011; Erickson & Page 1998; Hollows & Middendorp 2007; Ng & McQuisition 2004). This literature review considers outreach – its conceptual and methodological background and its practice. Firstly, the review begins by outlining and considering literature that addresses the context in which outreach is practised, and the implications of the context for the development of policy and practices responding to public space dwelling. Secondly, the literature that defines and conceptualises homelessness outreach is examined. Moving from concept towards an examination of outreach practice, there is a discussion of outreach models (including traditional/assertive outreach, outreach in continuum of care models and 21 Housing First, and outreach targeting particular groups within homeless population). Finally, we conclude with a discussion on the focus of this report – the practice of outreach. 3.1 Context There has been particular interest in public space dwellers, with specific reference made to this group in The Road Home. This is despite the fact that this group represents a relatively small percentage of the homeless population in Australia (6.5 per cent of the total number of homeless people or 6813 individuals as enumerated in the ABS Census of 2011). The primary objectives of the Australian Government’s response to homelessness (2008) were to ‘…halve homelessness by 2020’, and ‘to offer supported accommodation to all rough sleepers who need it’ (p.17). The first objective was both historic and strategic because for the first time, Government committed to a measurable reduction in homelessness. The second objective was ‘to offer supported accommodation to all rough sleepers who need it by 2020’1 and this objective has influenced policy directions and been supported by a major expenditure of funding between 2008-2013. The majority of state and territory governments (including Queensland, Victoria, South Australia, Western Australia and Tasmania) have included responses to public space dwelling in their homelessness strategies. Outreach activities noted in the literature include: providing material goods; providing advice and information; networking; establishing working partnerships; diverting people from involvement with police and custody; referring people to specialist services; and advocacy (Memmott et al. 2005; Phillips et al. 2011). The literature reveals tensions between governments’ preoccupation with visible homelessness and the resources devoted to addressing ‘rough sleeping’, and the scale of the problem. Following the release of The Road Home, the Government committed funds, reconfigured former SAAP services as the specialist homeless services, encouraged service innovation and signed off on its commitment, together with the states and territories, to improve and enhance existing responses to homelessness and increase the availability of affordable housing through the National Affordable Housing Agreements (NAHA). The policy literature 1 In 2012, this objective was modified to offering supported accommodation to all ‘rough sleepers who seek it’. This shift in language from ‘who need it’ to ‘who seek it’ was prompted by a concern that, given the difficulties associated with establishing the level of need and with measuring response to need, quantifying and tracking requests for need would provide a more robust and measure of outcomes. 22 clearly signals an acceptance of the idea that access to housing is a significant step towards ending individual street homelessness. Consistent with their present commitment to offer supported accommodation to ‘all rough sleepers who seek it by 2020’, the Australian Government and the majority of state and territory governments have focussed considerable attention on this group. Among the responses to public space dwelling, governments have been quick to identify the potential of models such as assertive outreach and Housing First. Assertive outreach and Housing First models have been viewed as an answer to street homelessness because together they promise a way of engaging with people sleeping out and then facilitating their rapid transition into stable accommodation, which serves as a base from which other issues can be addressed. Much of the Australian literature has focussed on this policy shift with its interest in taking people directly from the streets and into stable accommodation. In the context of its public commitments to address homelessness and the desire for evidence-based and cost-effective approaches, Housing First models have become particularly attractive. Housing First promotes ‘…residential stability, cost savings and consumer choice’, but the approach has been criticised for failing to address broader issues, such as substance abuse amongst homeless people. In response, advocates have maintained that a Housing First approach prioritises ending homelessness, not substance abuse. Critics of Housing First have argued that ending homelessness will not be achieved by the provision of housing alone, but must include consideration of the housing market more broadly, the labour market, and income security (Levy 2012). Standhope and Dunn (2011) and categorise Housing First as an outcome of ‘reductionist…positivist research’, which seeks to provide a simple solution to a simple problem. Del Casino and Jocoy (2008) have argued that in the context of neo-liberalism in the US, outreach is at risk of being co-opted for the purpose of identifying and clearing public space dwellers from the streets. In the homelessness literature, outreach is seen as a key component of Housing First approaches. More positively, assertive outreach In Housing First models emphasises rapid access to housing as its first priority. Moreover, Housing First can be understood in terms of a broader assertive outreach program with a distinctive philosophy that argues that housing is a human right and that access to housing and support should be independent of one another (Phillips et al. 2011). 23 2.2 Definition of outreach There are few broad definitions of outreach. The existing definitions are generally embedded in specific contexts. Andersson (2010: 68) defines outreach work as: … a contact-making and resource-mediating social activity performed in surroundings and situations that the outreach worker does not control or organise, and targeted at individuals and groups who otherwise are hard to reach and who need easy access linkage to support. In the context of homelessness specifically, outreach is, according to Levy (2012:1) ‘…an essential toward meeting people experiencing long-term or episodic (multiple episodes) homelessness and developing the critical trusting relations necessary for supporting transitions to housing or further treatment’. Communication and relationship building are critical elements of outreach to ‘hard to reach’ groups, including people who live in public spaces (Andersson 2012). Erickson and Page (1998: 2) define homeless outreach as ‘…the initial and most critical step in connecting, or reconnecting a homeless individual to needed health, mental health, recovery, social welfare, and housing services.’ Their definition explains recent policy interest in outreach, as well as its methods and purposes. Outreach is also described as a process (Erickson & Page 1998; Ng & McQuisition 2004). The acknowledgement of ‘process’ as a defining characteristic of outreach suggests that without good process, outcomes for this group may be difficult to effect; and that, in terms of good outreach practice, the process is as important as a focus on a desired housing outcome. Whilst some literature defines outreach work with people experiencing homelessness in the specific context of medical care, homelessness outreach is broader in scope (Elissen, Van Raak, Derckx & Vrijhoef 2011) and the delivery of in situ medical care to public space dwellers is a relatively recent addition to the existing services provided through outreach. There is no broad definition of outreach that can be applied in all contexts, and the majority of the literature exploring or collating definitions shows the most useful definitions to be those that are context specific. In the following section, we consider the concepts and ideas that underpin outreach practice. 2.3 Outreach as a practice concept The conceptualisation of outreach (and of outreach work) is problematic because of a ‘lack of methodological discussion’ surrounding these terms. Andersson (2011:2) notes that there 24 is ‘…something uninvestigated in the concept of outreach work.’ Morse, even more pessimistically, laments the ‘conceptual void’ that surrounds outreach, and Kirkpartrick (2000: 39) comments on the dearth of literature ‘regarding theoretical models of outreach’. In part, this lack of conceptual investigation and rigour in the literature can be attributed to the fact that outreach is seen primarily as a method and a practice that has developed organically, and because the conceptual underpinnings of outreach work are often invisible to the non-practitioner. On the surface, outreach appears to be ‘…easy to understand and define’ (Andersson 2011). As a practice, outreach consists of activities that may be linked to the context of the work, and much of the research and resultant literature is context specific. This adds to the difficulty of teasing out the ‘universal’ concepts that can be applied across contexts and specific fields of outreach practice. Researchers in the area reserve for outreach (amongst all the homelessness practices and responses) language that reflects the tentative, relational qualities of outreach work. Erikson and Page (1998:1) refer to the dance-like quality of outreach where: The process of outreach and engagement is an art, best described as a dance. Outreach workers will take one step towards a potential client, not knowing what their response will be – will the client join in or walk away? Do they like to lead or follow? Every outreach worker has a different style and is better at some steps than other. To dance with grace, when the stakes are high, is a challenge for us all. Quoting from guidelines developed by outreach workers, Andersson (2011) observes that ‘…outreach work is primarily an attitude and only after that a method’ and refers to the ‘…almost performative character’ of outreach. The tendency of outreach workers to define what they do in terms of moral commitment lends itself to the conceptualisation of outreach as a ‘romantic ethic’ (p.5). Rowe and colleagues (2002) argue that the complex nature of outreach requires outreach workers ‘…to become artists of sorts’. Fisk and her colleagues (1999: 232) see outreach as ‘…the practice of creatively engaging…’ with people sleeping out. The most recent development in the Australian literature is the identification of assertive outreach as a distinctive form of outreach practice, and an improvement on traditional outreach. Given the conceptual gaps identified in the literature relating to outreach generally, it is clear that considerable work remains to be done to specify the fundamental concepts underpinning homeless outreach. The following section moves from considering the models and frameworks that support, contain or constrain outreach practice in this country. 25 2.4 Outreach models Australian homelessness literature since the release of the White Paper on homelessness has been dominated by interest in ‘assertive outreach’, and in establishing its credentials particularly in relation to ‘traditional’ outreach models (which are those that existed before the adoption of assertive outreach as a term and the response of choice). Literature addressing assertive and traditional models of outreach is considered first. in this section of the literature review. These two putative approaches are compared in order to explore the idea argument presented in the literature that they are indeed distinctively different forms of outreach practice. Attention is also given to literature that looks at the models of outreach associated with Housing First programs; the Continuum of Care model; and finally to models of outreach developed in response to particular groups and/or issues within the homeless population in Australia, namely Aboriginal and Torres Strait Islander people; people with a diagnosed mental illness or a mental health issue, and young people. Assertive or traditional outreach? The questionable status of assertive outreach has been compounded by the apparent rush to adopt the language of assertive outreach to the extent that earlier experience of outreach has been obscured and excluded in the literature, other than as a lesser, less effective forerunner to assertive outreach. Thus, when reference is made to ‘traditional outreach’ the reference is to is any type of outreach that is not ‘assertive’, and highlights not what traditional outreach is, but what it is not. The previous section touched on the literature critical of the poor conceptualisation outreach (either traditional or assertive) and what might be its salient principles, operational or practice guidelines, and achievable outcomes (Andersson 2011; Morse 1994). With no overarching definition of outreach that encompasses the context of the work, specific target groups and fields of practice, it is hardly surprising that there is no clear definition of either assertive or traditional outreach. Broadly defined, traditional outreach can be considered as ‘street-based outreach’– the provision of services to homeless people in public places (Phillips & Parsell 2012). Traditional outreach may encompass different types of services and support, including the provision of food and drink, clothing, accommodation and support from welfare services. Services provided under traditional outreach may also extend to counselling and advice on legal issues, support for drug and alcohol abuse and transport (Phillips et al. 2011). Traditional models of outreach locate outreach workers in a variety of practice settings, including boarding houses, public places and caravan parks (Black and Gronda 2011: 9). 26 What predates assertive outreach is differentiated by its ‘bottom up’ approach that is outside human service organisations and that can directly assist with housing homeless people. Phillips & Parsell (2012:13) note that there are many ‘overlaps’ and differences between the two approaches to outreach. Assertive outreach is envisioned as a ‘part of a broader, integrated and intentional policy response’ to homelessness/rough sleeping (Phillips et al. 2011: 16). Generally, assertive outreach is integrated with some form of Housing First response. The most significant difference between traditional forms of outreach and assertive outreach identified in the literature is that it has not been the ‘primary objective’ of traditional outreach approaches to seek more permanent forms of housing for homeless clients. Phillips et al. (2011: 16) argue that while there is ‘… no doubt that [traditional outreach] provides important services that contribute towards people’s health and well-being, these services rarely elevated to ending service users’ homelessness’. They conclude, however, that the inability of traditional outreach to provide housing for homeless clients it is not for lack of interest or effort in housing people. Rather, Some traditional outreach approaches to homelessness in Australia have focused on permanently ending homelessness, it has been their limited resources and absence of supporting policies in areas such as access to long-term housing and health care that has made this realisation (stated or otherwise) goal difficult to achieve. On this basis, the differences between the two main approaches can be largely distinguished by access (or lack of) to resources that are beyond the control of the outreach practitioners: Assertive outreach is new in that it is meant to include the housing resources otherwise not easily accessible to rough sleepers through traditional providers (Phillips et al. 2011: 17-8). However, they note that the availability of housing cannot be assumed, even in ‘assertive’ outreach models: …availability of permanent housing may turn out to be of an espoused ideal than an empirical reality. Thus, the actual differences between assertive outreach and other forms of outreach will not be known until the assertive outreach approach has matured, and been implemented and evaluated in practical settings (Phillips et al. 2011: 17). Despite efforts to establish the argument that there are two distinct forms of outreach, this has not necessarily been taken the field, perhaps, in part, because outreach practice is shaped as much by location, target group, duration, process and context as it is by model type. 27 Yet there are some major inconsistencies within this discourse. For example, Phillips and her colleagues argue that one of the reasons traditional outreach never achieved the outcomes being attributed to assertive outreach was the lack of affordable housing, rather than any inherent flaw in the model or practice of the outreach work in itself. Also, the renewed attention being paid to assertive outreach is described as a policy shift, rather than the emergence of a new and distinctive form of outreach (Johnson, Parkinson & Parsell 2012). This body of literature tends to present assertive outreach in Australia in a decontextualised way and fails to link the adoption of assertive outreach with the political imperative imposed by public nature of the White Paper commitment to reduce rough sleeping. Outreach is presented as a neutral activity devoid of political influence. In the international literature, outreach, and often this is referred to as assertive outreach without too much argument, is discussed in a highly contextualised way. Articles specifically referring to England, Scotland, the United States, and the Netherlands all question how innovative the approach is outside the US (Atherton & Nicholls 2008; Johnsen & Teixeira 2010). It is acknowledged that assertive outreach was innovative when it was first applied broadly to homelessness and in the specific context of responses to people dwelling in public spaces with a mental illness in the US, but there are few references to outreach prior to the development of Housing First to which assertive outreach to street sleepers was conjoined. Assertive outreach is presented in the literature as ‘an effective way of engaging “hard to reach” communities within the homeless population, predominantly those sleeping rough and who have been chronically homeless’ (Black & Gronda 2011: 51). Phillips and her colleagues (2012: 13) nominate three distinctive facets of assertive outreach: (1) its aim to permanently end homelessness for clients through sustainable resources; (2) its use of an integrated approach drawing upon multi-disciplinary teams to work with clients; and (3) its persistent, long-term engagement with clients to ensure transition between rough sleeping to stable housing. None of these conceptualisations of assertive outreach illustrate or describe practices that are unique to assertive outreach In the United Kingdom, outreach services derive largely from the Rough Sleepers initiatives in England and Scotland, and the evaluations and research into that initiative. Assertive outreach has also been introduced into various mental health policy frameworks and guidelines during the late 1990s; however, homeless programs using assertive outreach principles were in existence prior to this. According to Black & Gronda (2011: 51), the Rough Sleepers Initiative (RSI) developed in England in the early 1990s was one of the earliest examples of a successful program using assertive outreach principles. An evaluation 28 of the RSI found that the use of ‘contact and assessment teams’ (CATs) saw over 1600 homeless persons (out of a total of 3000) assisted into accommodation. The effectiveness of the program is largely attributed to a stronger ‘interventionist approach that disengages with the “social work” approach’, instead favouring ‘a focus on intensive street work’ and ‘persistence by outreach staff’ by not leaving those who initially refuse assistance from outreach workers’ (Black and Gronda 2011). The Rough Sleepers Unit (RSU) – established in the wake of the RSI - further promoted the assertive outreach model (see Randall & Brown 2002 for further details). Critical to the RSU and the more general approach to rough sleepers was ‘a style of outreach that would ‘persuade’, ‘encourage’ or ‘help’ rough sleepers to move into accommodation and ‘…”discourage” them from sleeping rough’ (Phillips et al. 2011: 25; Randall & Brown 2002). Phillips and her co-authors (2011) refer to critical commentary about the success of the RSU, instead attributing the decline in the number of rough sleepers to the fact that the number of temporary accommodation units doubled after the RSU was established (see Sale 2005 in Phillips et al. 2011). They add that ‘it has been suggested that the program’s success was at the expense of providing appropriate accommodation and meeting the longer-term housing needs of people sleeping rough’ (Phillips et al. 2011: 25). Randall & Brown (2002) observe that the reductions in homeless people on the street have resulted in an increase in public space dwellers who have a greater incidence of mental illness and/or drug and alcohol substance abuse issues. Phillips, Parsell, Seage & Memmott (2011) observe that outreach responding to homelessness has been used in Australia since the early 1800s. Although some describe traditional outreach services to be ‘emergency-based services’ offering food, blankets and clothing together with counselling, social support and access to housing (Christian & Abrams 2004: 169), this is a somewhat narrow view of traditional outreach that fails to capture the nuances of these outreach services, or their meaning from the perspective of people experiencing homelessness. Fine grained, local studies reveal the meanings that daily contact with these ‘emergency based services’ have for the people who access them, including providing a sense of acceptance and identity (for example, Coleman 1998) and structure to their days (see, for example, Quine, Kendig, Russell & Touchard 2004). An early use of the term assertive outreach appears in the Australian literature in 2007 (Middendrop & Hollows 2007). The principles of assertive outreach (as defined by Phillips and her colleagues and discussed above), in some form or another, have been used in a number of organisations across Australia for a number of years prior to the release of the Australian Government’s (2008) White Paper on Homelessness. Since then, assertive outreach has become de rigueur in Australia in all facets of homelessness –practice, policy 29 and research. In some cases, assertive outreach principles are being adopted by services and organisations that are not housing or homelessness focused, such as health service especially mental health services. The sections below provide a brief overview of the literature regarding the contexts in which outreach reviewed in the literature, namely Housing First; Continuum of Care; and outreach to particular groups. 2.5 Housing First The key elements of Housing First models identified in the literature are: choice and options for clients (both about housing and about when/how to address other issues); a mix of scattered and single site housing; and intensive and assertive support beginning with what is termed ‘assertive outreach’ (Tsemberis, Gulcur, & Nakae, 2004;Levy 2004). The original Housing irst models have spawned hybrids, such as Common Ground and Street to Home (S2H), imported from the US and Canada. Assertive outreach engages persistently with its target groups in order to encourage them into stable housing. Continuum of care Some researchers (for example, Wasmer 1998; Erikson & Page 1998; Phillips et al. 2011; Parsell 2011) argue that models of outreach can be understood as distinctive, but related models along a continuum, with ‘traditional’ models at one end, and the more contemporary, ‘assertive’ outreach models on the other. As noted above, however, this is not a satisfactory or sustainable argument as there is little evidence presented in the literature to support this argument. Erickson & Page (1998: 6 - 7) and Wasmer (1998) describe a continuum with ‘find and link’ responses at one end, and ‘find and serve’ approaches at the other. This presentation of outreach as a continuum of care is a more productive one that avoids the sometimes circular debates around assertive versus traditional outreach, and focuses instead on the actual methods of work. Aboriginal and Torres Strait Islander peoples living in public spaces In a body of research (including a number reports for FaHCSIA), Paul Memmott and his colleagues have raised challenges to the understanding of Aboriginal homelessness and public space dwelling– and the difference between the two – and what might be appropriate responses. These reports are replete with references to the multiple ways and contexts in which outreach services are being used in Aboriginal communities. How to theorise Indigenous ‘homelessness’ and the nuances of the Indigenous experience of homelessness remains an issue in the broader field of homelessness research. 30 The role of outreach in responding to Aboriginal and Torres Strait Islander homelessness is addressed. This literature also documents initiatives, including homeless specific initiatives, targeting Aboriginal and Torres Strait Islander peoples who are public space dwellers. Phillips, Parsell, Seage & Memmott 2011; Memmott 2005; Memmott, Long & Chamber 2003; Memmott, Chambers, Pitt, Green and Ingram 2005). In their report on the Inner City Aboriginal Homeless Research Project (Vol. 1) Memmott and his co-researchers classify ‘patrols and outreach services’ as one of fourteen practice responses to Indigenous public space dwelling and homelessness. They also note the importance of making linkages to ‘…relevant service agencies…’ in good outreach practice. Mental illness People living in public spaces are presented in the policy literature as vulnerable and at risk. Vulnerability is operationalised as having chronic health conditions likely to result in early death; high and complex needs requiring intensive support and access to services; and a higher incidence of mental illness. Together, these factors impact negatively on people’s access to the support services they need (Lam & Rosenheck 1999). The ‘Vulnerability Index Tool’ assesses the vulnerability of public space dwellers to immanent death on the street (Parsell & Jones 2012). This tool is being used in Australian models of ‘Street to Home’. Parsell and Jones (2012: 35) comment on a Queensland service provider’s use of the Vulnerability Index: The service provider believes that the Vulnerability Index Tool has increased their capacity to individually tailor responses according to need, by providing more detail and a clearer picture of client need. The tool allows a more comprehensive documentation of individual client locations and mobility patterns, and assists to isolate the homeless population into sections of need, which promotes a more structured and individualised response Adding to poor engagement with services is that fact that many people living in public spaces have had negative previous experiences of engaging with services that are not flexible enough; not trusted enough; and not responsive enough (Coleman 2001; Coleman 2007). Such circumstances underscore the need for street outreach programs. There is a considerable body of literature from the United States and the UK that has a specific focus on outreach to people who are homeless or who have a mental health issue (see Page, Meaden & Amphlett 2009; Farrell, Huff, MacDonald, Middlebro & Walsh 2005; Tischler, Voastanis, Bellerby & Cumella 2002; Rowe, Kloos, Chinman, Davidson & Boyle Cross 2001; Lam & Rosenheck 1999; Morse, Calsyn, Miller, Rosenberg, West & Gilliland 1996). 31 In some recent literature on assertive outreach, it is claimed that homeless outreach programs have their beginnings in assertive outreach programs designed for those with mental illnesses. However, the concepts and principles of ‘assertive outreach’ used in the mental health sector were introduced into that sector from the homeless sector where outreach was already an important element of early service provision (Fisk et al. 1999: 232). Assertive outreach is also known as Assertive Community Treatment (ACT), ‘active community treatment’ and ‘intensive support’ (Cupitt 2010). Assertive outreach began in the United States in the late 1970s following the deinstitutionalisation that had been taking place over some two decades. This opened up the development of community-based mental health support rather than a reliance on an institutional-only treatment model (Cupitt 2010). Some aspects of the assertive outreach approach have become foundations of homelessness policy in the United States, particularly with the Housing First approach and the emergence of supportive housing (Phillips et al. 2011). Indeed, under the Bush administration, local communities adopting a Housing First approach (including ‘assertive outreach’ as a key component) were considered eligible for bonus funds through the US Department of Housing and Urban Development (Del Casino & Jocoy 2008: 197). There is some criticism in the literature of assertive outreach approaches to people experiencing homelessness and a mental illness because it is claimed this can lead to worse outcomes for the homeless individuals with complex mental health needs. Drawing upon a social citizenship framework, Rowe and colleagues (2001: 16) note that ‘program citizenship’ or the participation of homeless individuals with mental illnesses in continuing treatment programs and substandard housing as an outcome of assertive outreach is just as costly as the ‘non-citizenship of homelessness’ because it ‘discourage[s] individuals from reconnecting with family and friends and their own lost of unused mainstream skills’. Assertive outreach workers in this context ignore the ‘consideration of how or whether their clients can attain full membership and citizenship of their communities’ distinct from their health or housing status. Moreover, homeless people, including those with mental illness are not only resilient but are able to adapt to homeless ways of being (Coleman 2001; Rowe et al. 2001). Young people Outreach has been recognised by youth workers as an essential element of their practice for decades. The term outreach was commonly used, along with the term detached work, when outreach practice was introduced in Australia, either as a response to local need in an organic, ground up process, or as an idea imported from England. 32 While young people constitute a small percentage of the total number of people sleeping out, providing outreach services to young people accords with policies emphasising early intervention, particularly when young people experience street homeless for the first time. Outreach approaches have previously proved to be highly effective in linking and providing services, such as health screening and treatment (through some of the Innovative Youth Health Services), to highly mobile group of young people, including those experiencing street homelessness. 2.6 Outreach programs The promotion of assertive outreach in Australia has largely been via the Housing First philosophy, and the Common Ground and Street to Home (S2H) programs, funded under the National Partnership Agreements on Homelessness (NPAHs) between the Commonwealth and the states and territories. Street to Home (S2H) is the most prominent program said to be engaged in assertive outreach in Australia. It has been introduced in a number of states and territories since 2008: New South Wales, Victoria, South Australia and Queensland as well as the Australian Capital Territory. The S2H program targets rough sleepers with ‘persistent and long-term engagement’ (Phillips et al. 2011). S2H attempts to aggressively end homelessness with ‘persistent and purposeful’ street-based outreach through the provision of housing and access to services and programs upon being housed. This approach is interventionist and integrated (Parsell & Jones 2012: vii). Parsell & Jones (2012: 21) describe the S2H program as a ‘collective of ideas and responses to homelessness’. Street to Home was first developed in New York City and is based on Housing First and Common Ground programs from the United States and the Rough Sleepers Initative in England and Scotland (HomeGround 2012; Phillips et al. 2011). There are four guidelines for the Common Ground/New York City ‘Street to Home’ program: (1) identify and record people who are permanently homeless; (2) establish a priority list of those who are most vulnerable using the ‘vulnerability index tool’; (3) ‘simplify the process’ for people needing services; and (4) organise services for clients (Parsell & Jones 2012: 20). Assertive outreach is a critical element in all the Street2Home programs. In New South Wales, the ‘Way2Home’ service, based on the S2H model, was developed under the Homelessness Action Plan (NSW Government 2009) and the NSW National Partnership Agreement on Homelessness (NPAH). Under this partnership agreement, assertive outreach services were established in Sydney and Newcastle. The approach used in Sydney, according to Phillips et al. (2011) is ‘strongly influenced’ by Common Ground and 33 Housing First initiatives developed in the United States. The guiding principle underlying these services in Sydney is the notion that homeless people ‘do not choose to be homeless’ and that any ‘reject offers of support [are] not taken as the final answer’ (Phillips et al. 2011: 10). Once housed, the program aims to stabilise people exiting street homelessness in their housing, and make links with other support services. Victoria’s ‘Street to Home’ was established in June 2010 under the Victorian NPAH. The service is led by HomeGround, but involves a consortium of organisations, including the Salvation Army and the Royal District Nursing Service (Philips et al. 2011). Initially, the program was forecast to provide support for 300 ‘rough sleepers’ over 3 years, but this was halved to 150 ‘rough sleepers’ (Wylie & Johnson 2012). Street to Home (S2H) has adopted a Housing First approach; ‘prioritising access to housing according to vulnerability (scored using a Vulnerability Index) and then using stable housing as a base to deliver support and health services’ (Wylie & Johnson 2012). In Queensland, ‘Street to Home’ began in mid-2010. As Parsell & Jones (2012: 35) note that while ‘street outreach theoretically covers all these suburbs [189 in the area covered by the Brisbane City Council], the majority of people sleeping rough in public places are concentrated in relatively small inner-city suburban areas’. One of the key principles of the Brisbane S2H model is Housing First. From a service delivery perspective this means engaging with public space dwellers, and then supporting people to make the transition from the street into stable, long-term housing (Queensland Government 2008: 3). The provision of social/community housing is a critical component of the S2H model in Brisbane. However, the success of S2H has been impaired by Queensland’s housing policy and a lack of appropriate and affordable housing stock (Parsell & Jones 2012). In the Australian Capital Territory, the Street to Home program began in 2010. The program’s mission is to ‘assertively engage chronically homeless rough sleepers and assist them to re-engage with support services to gain and sustain a successful tenancy’ (Wylie & Johnson 2012: 24). Like previous S2H programs described above, the ability to effectively carry out this program is dependent on housing supply. There is, however, an absence in the current literature on innovation and effectiveness of assertive outreach models regarding the role agency plays in the uptake of outreach services. What literature there is reduces the challenge of engaging with people sleeping out to a simple one of sufficient and sustained assertiveness on the part of outreach workers. Christian and Abrams (2003) challenge this view of outreach by exploring the factors that influence engagement by people experiencing homelessness with outreach services. Their 34 research indicates that the beliefs and attitudes of people sleeping out to ‘institutional authority’ (Christian & Abrams 2003: 153), and whether or not people identify as ‘homeless’ and identify with homelessness services determine whether and how people engage with outreach services. Johnson and Parsell (Date) also note that people sleeping out are likely to disengage when there is no housing on offer, and no prospect of it. Homeless people are not passive recipients of any service that is offered to them; and engaging with people sleeping out requires not only assertiveness on the part of outreach workers but a willingness on the part of public space dwellers to engage, and a belief that engagement will lead to better options. 2.7 Outreach practice The practice of outreach is guided by the overarching principle of improving people’s lives and according to Andersson, there are three core areas of outreach work (Andersson 2012). The first area is described as ‘contact making’, where outreach workers make contact with people (in need) and refer people to specialised services. The second aspect of outreach is initiating (social) change, which is in part achieved through the first step of contact (making). Outreach workers, might equally choose to ‘carry through the effort themselves’ by negotiating with clients about the problem(s) they are challenged with, their causes and what solutions can carried out. This categorisation is similar to Erickson and Page (1998) and Wasmer’s (1998) where they identify ‘find and link’ and ‘find and serve’ approaches as the extreme points on a continuum of care offered by outreach services. In reality, this choice lies beyond individual inclination or decision, and is clearly dependent on an agency having a mandate and the resources to undertake outreach and support their frontline outreach workers to make on the spot decisions. The third aspect of outreach is the establishment and maintenance of the initial engagement, in order to facilitate the change process. On this point, Andersson notes that ‘… because outreach work is performed in environments and situations that can be rather turbulent, a need for immediate intervention does occur’ (p.6) but that some outreach workers prefer to work on long-term solutions. Erickson & Page (1998) list a number of guiding values and principles of outreach work. These principles – which include recognition of, and respect for, the individuality of clients, their contexts and abilities; client driven goals; hope; kindness and advocacy - are based on a philosophy that emphasises the restoration/maintenance of the ‘dignity of homeless persons, [by] dealing with clients as people’. They operationalised these principles into a set of standards, which can be considered as the standards for good practice outreach work. These standards include: 35  The definition of the target population and location of potential clients: efficient outreach programs have clearly defined programs and objectives, which target small subpopulations or geographical areas, which facilitates follow-up contact. Outreach activities under this standard include ‘scouting’ locations, such as bridges, laneways, parks, squats and vacant allotments, and working with homeless people to develop networks, which can assist in locating clients.  On-going, long-term engagement with clients to build relationships and successful outreach outcomes. Erickson & Page (1998) note that outreach workers in Barrow’s (1998) study of five New York programs took, on average, 3.9 months of engagement with clients before support services were engaged. Meaningful engagement is critical in these relationships as it helps outreach workers establish ‘credibility’.  Assessing individual needs in a holistic manner before services are offered  Providing ‘basic support’ through the provision of (temporary) housing, shelter, clothing, access to showers and other amenities, and medical care.  Linking clients to services, organisations or agencies where possible and advocating where possible on the behalf of clients ‘who are disenfranchised and discriminated against’  Following-up to ensure support is being provided to clients. While there are similarities between Erickson and Page’s and Andersson’s guidelines and standards, Erickson and Page’s standards are more detailed and seem to better capture the stages and nuances of outreach practice. There is a dearth of literature that documents and explores the practice of outreach, although outreach raises particular issues for workers (Fisk et al. 1999: 234) and outreach workers are said to be interested in practising, and explaining, their work in theoretical and conceptual terms. In describing the experiences of outreach workers, Fisk and her colleagues (1999) explore the issues that arise for these workers in the homeless sector under three themes: boundaries, ethics and staff safety. The practice of outreach in public locations (such as in parks and on the streets) and quasipublic spaces (such as abandoned buildings and soup kitchens) raises unique issues for outreach workers. In traditional ‘office based’ work (Fisk et al. p. 234), boundaries are easy to establish and maintain. This is done by being able to control the environment by strategies such as set appointment times; clear reasons for access; structured space and hierarchical access to these spaces; and access to resources. In contrast, outreach workers operate in spaces over which they have little or no control (Coleman 2001; Wasserman & Clair 2010), and in which their roles are never clear, but always negotiable and changing according to the context. These practical issues also have ethical resonances for outreach workers. 36 Boundaries between public and private activities are blurred for both workers and the people they work with when outreach work takes place. The purpose of outreach workers is often unclear, both for workers and clients. It is easy for workers confronting the day to day reality of life on the streets to feel shocked by this reality, and compelled to go beyond their identified roles to render assistance. It is equally easy for those to whom they provide outreach to misunderstand professional interest for friendship. This confusion also has the potential to extend to sexual boundaries and to result in what Fisk (1999) and her colleagues describe as ‘intrusive sexual behavior’ (p.235). Other ethical issues flow from the location of outreach, such as the ethical dilemma presented to outreach workers concerned about the right of people living in public spaces to privacy (Fisk et al., 1999:232).); and ‘coercive tactics used by outreach workers’ (Fisk et al., 1999:232). Some literature suggests that outreach workers need particular personal qualities, fo example flexibility and creativity. Lipsky (2010) argues that the challenges posed by outreach practice require that outreach workers exhibit the qualities of street level bureaucrats, as well as ‘…the practice of creatively engaging…’ with people sleeping out (Fisk et al., 1999:232). But, as others argue the setting and nature of outreach work causes the development of particular approaches, and is not dependent on workers’ personal qualities (Andersson 2010) In their role as frontline workers, outreach workers also act as valuable conduits of information for the agencies they work in. They bring from the streets first hand and often confronting experiences that illustrate what street homelessness means to the people they work with. They also raise issues which have unique dimensions for outreach workers, and in this way contribute to the development of agency policies and procedures that respond (Fisk et al. 1999: 243-44). Overall, the literature reviewed indicates the organic way that outreach practice has developed, and the significance of context and location in shaping the practice of outreach. For this reason, there is no agreed definition of what constitutes outreach, other than its focus on engaging with hard to reach groups, generally to meet immediate needs and to achieve a change process. Arguments that there is now a distinctive form of outreach known as ‘assertive outreach’ cannot be sustained as, with earlier forms of outreach, the outcomes of assertive outreach rest on housing availability. 37 4 METHODOLOGY 4.1 Aim and research questions The aim of this research is to explore and document good outreach practice, and to identify the outcomes produced by good practice outreach. The research is contextualised in the current policy and service delivery context. The research questions we set out to explore were: 1. How do outreach workers conceptualise and practice outreach work? 2. How do people sleeping out experience street based outreach? 3. What benefits do agencies using outreach models see in outreach? 4. What are the elements of good practice outreach to people sleeping out? 5. What outcomes does good practice outreach produce for people sleeping out; for agencies providing outreach; and for funders? 4.2 Sampling and recruitment The sample frame used in this research consisted of outreach workers and agencies providing outreach services to people living in public spaces. The sample was a purposive one designed to include practitioners and agencies providing outreach recognised in the homeless sector and by their colleagues as providing good practice outreach services. We deliberately did not specify any particular form of outreach (for example, traditional or assertive outreach). Neither did we seek to explore outreach practice within a given timeframe. This allowed us to talk with current outreach workers as well as with workers who were outreach practitioners in the 1960s and the 1970s. We also tried to ensure that the sample (although small) represented a variety of agencies using outreach to connect with people experiencing primary homelessness. Five agencies took part in the research, with the final sample of agencies including:  A mental health outreach service;  Two youth services;  A homeless drop-in centre; and  A homeless agency. 38 We spoke with a total of 18 outreach workers 14 of whom were employed as outreach workers when we met with them. Four had previously been outreach workers, and while they had not been in outreach roles for some time, they were still connected with the field and actively engaged with community services and homelessness issues. 4.3 Method This research is exploratory, qualitative research using multi methods to explore outreach practice and its outcomes. There are three discrete, but interlinked stages in the proposed research. The literature review of published and grey literature was completed before the field work began, and was undertaken to identify current thinking about outreach, models of outreach and the results achieved by various forms of outreach. It also assisted in attuning us to some of the issues we were likely to encounter in the course of our interviews with outreach workers and agency representatives, and while we were observers in the field. The separate but interlinked stages of the research are discussed briefly below. Stage 1 was conducted as two parallel activities. One was the preparation for Australian fieldwork and a review of the literature. The second component was a field visit to New York, internationally known for the high levels of street sleeping and for outreach programs in response. Stage 1a: Grounded investigation and documentation of outreach practice The research team conducted formal interviews of outreach workers in two states to document in detail their practice. In conjunction with these interviews, there were observations of outreach in the field. These observations were used to confirm or challenge the interview data, and as a starting point for interrogating the information provided through the interviews. It was also undertaken as a way of making visible outreach practices that, for some outreach workers, were so embedded as to have become ‘tacit’ knowledge and therefore unlikely to be raised explicitly by them. Stage 1b: Fieldwork in New York There was a field visit to New York between May and June in 2012 for nearly three weeks. Contact was made with the key organisations. One was the Coalition for the Homeless, which acts as a peak organisation on behalf of homeless and affordable housing services but also provides some direct services. By accompanying the Coalition for the Homeless worker on these visits, it was possible to visit a number of New York shelters. Contact was also made with the leaders of the Manhattan Outreach Consortium that is responsible for outreach in the five boroughs of New York, and the Bowery Residents Committee and into 39 the subway system. Altogether, six shelters were visited and field observations done with outreach teams on eight occasions. This fieldwork was undertaken because models and concepts from New York responses to homelessness have so often been used as a source for proposals by some organisations in the homelessness and housing sectors in Australia. Interviews were done with five senior leaders in the homelessness field in New York during the fieldwork. Stage 2: Survey homelessness services employing outreach workers (including a review of service agreements with funders) The second stage of the research contributed to developing a contextualised understanding of outreach models embedded in Housing First approaches to moving people experiencing homelessness from the streets to housing. This included accessing policy documents and agency profiles online, and reviewing agencies’ policy documents where possible. Stage 2 also included field research in the New York where interviews were conducted with outreach workers and organisations working with Common Ground to understand how contextual factors such as legislation and policy influence the practice and outcomes of outreach, particularly ‘assertive outreach’. Stage 3: Follow up and periodic review of the outcomes for people sleeping out While there was data gathered on outcomes from outreach during fieldwork, the original idea of follow-up visits could not be done. There has been some evaluations done on the clients of the Street to Home projects, but follow-up of a cohort of homeless persons who have been contacted by outreach workers is a different cohort and data on this cohort would provide a broader picture of the dynamic of street homelessness as people move in and out of this group. Ethics The University of Tasmania’s Human Research Ethics Committee (HREC) gave approval for this research to proceed (Ethics Reference Number H0012569). Regular reports have been provided to the HREC as required. A final report, together with a copy of this document, will be submitted to the HREC on submission of this report. One of the concerns addressed in the ethics application was that workers, in reflecting on their outreach practice, might be distressed by their inability to end homelessness for everyone they worked with especially in the present context where ‘ending homelessness’ has become a mantra and often an expectation for funders. This proved to be the case, but workers exhibited a somewhat world weary acceptance of this state of affairs and were able to balance what they hadn’t achieved with what they had been able to do with clients who 40 had a history of no or poor access to services before they were engaged by outreach services. 4.4 Strengths and limitations This is s small-scale study of outreach practice relying on data from field interviews and observation of outreach workers and their agencies. The data was qualitative. The thoughtful nature of the workers interviewed, the chances to observe outreach practice and the researchers’ familiarity with homelessness policy, research and service delivery meant that we were able to engage with participants, who gave us an open and honest assessment of their work and the agencies where they were located. The research has been successful in securing the participation of outreach workers in varied locations, in a variety of agencies, and with differing target groups. All workers were keen to talk about their work and were clearly deeply engrossed in that work. Their interest and reflective approach to their work made them ideal participants. One of the original research questions was designed to capture the perspective and experience of people sleeping rough who are in contact with outreach workers. However, only limited direct contact was possible and although some conversations took place, this has not been reported as a body of data. The observations and fieldwork, though limited in number and duration, are another of this study’s strengths. Seeing outreach workers in the environment where they work, and with the people that work with was a rare privilege and one we were honoured to be offered. Being present with the workers provided another dimension to this research and highlighted their commitment, dexterity and skills. Outreach workers were our window into outreach practice. A major limitation of the research is that the findings are not widely generalisable. The selection of good practice outreach services and workers means that outreach practice as discussed in the findings chapter may not equate with outreach practice in the majority of homeless services, or in locations other than the ones we visited. The use of observations and interviews (together with the literature review) has, however, made it possible to triangulate many of the findings of the research. A significant omission in this study is that of the Aboriginal outreach services operating in inner city locations (such as Redfern) and in regional and remote areas (such as Townsville and Alice Springs). Memmott and his colleagues have written extensively about good 41 practice responses and we have drawn on this literature. Our decision, ultimately, was that establishing community connections to ensure that the research was carried out in a respectful and ethical way and was mutually beneficial to researcher and community was beyond the scope of this project. Limitations of the study are related mainly to time limits. Time limits meant that it was not possible to answer one of our research questions – that of how public space dwellers experienced outreach services. While the observations gave very limited insight into their experiences, more systematic data gathering (by, for example, interviewing people sleeping out and in contact with outreach workers) would clearly answer this question more satisfactorily than observations only have allowed us to. A longer timeframe would also allow the collection of data about the potential longer term benefits of outreach. Extended time in the field may also have meant that we were able to gain a more balanced picture of outreach practice over time. The data we have gathered are essentially ‘snapshots’ at a single moment in time and do not necessarily reflect the ebbs ad flows of outreach work. 42 5 FIELD WORK FINDINGS The findings of the fieldwork component of the research are presented in this chapter. While many of our findings confirm those in the literature reviewed, there are also some discoveries about good practice outreach that can be applied to understanding and supporting outreach as a practice, and that have the potential to influence the practice outreach and the development of homelessness policy, including policies addressing public space dwelling. The key findings of this research are that:  Outreach is composed of three core concepts: scoping and negotiating the context; building social capital; and working with individuals.  The activities undertaken as part of outreach fall within one of these three concepts.  Context shapes outreach practice and the actions and interactions of outreach workers and those with whom they work. This chapter describes in greater detail the findings of the fieldwork (above). First, we return to outreach as a concept to find out how outreach workers think and talk about what they do, and to gauge the fit between how workers conceptualise what they do what the actually do. We then consider outreach practice as a series of inter-related activities, and consider the purpose and meaning of these activities. The unresolved issue of how worker characteristics and the setting of outreach work shape good practice is then briefly considered, although still not resolved, and some of the ethical dilemmas identified by outreach practitioners are also briefly considered. The chapter concludes with a consideration of the context of outreach practice, and the interplay between context and practice. 5.1 Outreach as a concept Outreach practice is a complex series of interdependent activities, and the outreach workers in this study sought, and spoke about, concepts that could be used to make a coherent whole of their work. The literature reviewed earlier abounds in metaphors such as dance, art (rather than science), and creative undertaking that are used to describe the concepts that underpin outreach practice, and the activities that constitute outreach practice. 43 The findings of the field research are consistent with descriptions of outreach as amorphous, ephemeral and creative. Outreach practice also has a level of practicality that stands in contrast to what Erikson and Page (1998) describe as ‘a romantic ethic’. This level of practicality is evident in workers’ thinking about what they do; how they respond while on outreach; and their understanding about what is valued by (and valuable to) the people with whom they engage. The literature varies somewhat in the concepts and guiding principles it identifies, but the conceptual elements of outreach identified consistently in the literature are:  Engagement;  Relationship building;  Response to practical and immediate need; and  Addressing complex/underlying issues through linkages. These concepts are consistent with those identified by outreach workers and organisations interviewed in this project. The diverse nature of outreach activities (for example, as outlined in Figures 3,4 and 5 in section 5.2 below) and the sometimes chaotic nature of outreach workers’ ‘workplaces’ make necessary a framework, philosophy or set of values that allows a worker to ‘hold together’ and contain the disparate elements of their work. Their conceptualisations of what they do are drawn from organisational vision statements and aims, professional standards and codes, and disciplinary backgrounds. Some of the workers we spoke with conceptualised outreach as a social justice response because outreach takes services to people who might otherwise not know about or access with them. Others frame their work within psychological and sociological theories about change (for example theories about the stages of change were mentioned by several workers in three agencies as underpinning their work, and guiding the pace of outreach work). Workers explicitly mentioned theories, and were able to reflect on particular cases and justify some of their decisions with reference to these theories. For these workers, the concept of assertive outreach means that workers try repeatedly to engage with people living in public spaces until there was some sign of readiness to engage, and subsequently to make changes. The majority of workers have a professional background, and in addition to disciplinary theories they are guided by their professional codes of conduct. Other workers conceptualised their work as a form of action research, with a focus on 44 outreach as an iterative process (similar to a mutual feedback loop) with constant cycling between conceptualisation, action and reflection and evaluation. For some outreach workers, outreach was a concept defined by the organisations auspicing their work. These were organisations with a history of engaging with marginalised people, often with people sleeping out. They were also often established originally under the auspices of faith-based organisations, and outreach work was often driven by a particular mission or vision. One of our interviewees had been influential in establishing one such outreach service in the 1970s commented on the need for congruence between the vision of the organisation and the mindset of the worker. While the most obvious and visible aspect of outreach work is with individuals living in public spaces, outreach workers are consistent in nominating systems reform as one of the ways they conceptualise the work they do. Conceptualising outreach work in this was makes outreach workers interest and skills in advocacy understandable. Seeing the ‘big picture’ and directing efforts to change at this level may also provide outreach workers with a way to rise above some of the daily frustrations, and thus to make their work sustainable. As well as providing confirmation for our findings, the literature review revealed a significant gap in the way that outreach is conceptualised. In none of the literature reviewed for this project were we able to find a picture of how outreach workers begin to engage with people living on the streets, and how they turn initial engagement into a purposeful working relationship aimed at improving people’s lives. None of the concepts presented in the literature explain this great leap, and the majority of the literature does not mention the gap at all. Below, we present a reconceptualisation of outreach work that explains how workers move from being outsiders to being embedded in a community, location or cultural group; and how work with individuals depends on this embeddedness. This revised conceptualisation pivots on the concept of ‘building social capital’. Our interviews and observations suggest that there are three central concepts that underpin outreach practice. These are:  Scoping and negotiating the context;  Building social capital; and 45  Working with individuals. Under each of these concepts sit distinctive activities. The activities that are characteristic of scoping and negotiating the context include: becoming familiar with the community’s history of homelessness; establishing and maintaining local networks; developing an awareness of the policy context (local, state and national); developing an awareness of various stakeholders; and undertaking what some respondents referred to as ‘unplanned’ outreach. The enactment of ‘building social capital’ includes activities such as working strategically and opportunistically with other well regarded organisations; establishing visibility through branding and/or association; appearing predictably; becoming embedding in and accepted by the sub cultural group; and encouraging harm minimisation. It is this concept that is absent from the literature, and rarely mentioned by workers. Its significance cannot, however, be underestimated. Building social capital is the essential bridge between knowing, and working in, the community and change focussed work with individuals. Working with individuals entails a number of activities that are directed at supporting and sustaining individual change. These activities include: responding to immediate/crisis need; providing information to meet basic needs and provide options; connecting people to services (both the centre based agency where outreach workers are located, and other specialist services through referrals); and carrying out planned outreach. Figure 2 displays the three core concepts of outreach practice identified in the research, together with some of the activities associated with each concept. The idea that brings them all together is that good practice means working through from scoping and negotiating the context, building social capital and then working effectively with individuals to assist them to change their situation for the better. 46 Figure 2: The three core levels of good outreach practice The following section of this chapter provides an account of outreach practice as described by outreach workers and organisations, and observed during fieldwork. 5.2 Outreach as a practice While outreach workers identified common themes and shared approaches to their work, and these themes and approaches replicated what was found in the literature, outreach practice is individualised, idiosyncratic and varied in a way that is not captured in the literature. These individual differences begin to surface in conversations with outreach workers but are most noticeable in the field. The metaphor of the dance has been used in the literature and previously in this report to describe the practice of outreach. Observations of outreach practice confirm the aptness of this metaphor. While there are common themes that run through the interviews conducted (focussed around the concepts of engagement, relationship building, support and referral), each instance of outreach practice observed highlighted the interpretive and interactive nature of outreach. The dance is sometimes tentative but rarely clumsy. Each worker is deeply embedded in the 47 culture of the community where they work and each interaction, while purposeful, had a fluidity to it which was prompted by a nuanced and sensitive understanding of local conditions and the subculture in which they deliver outreach. Each workers performs the dance in a unique way. Figures 3, 4 and 5 below map the three central concepts of outreach, and link these concepts with the activities that make up the practice of outreach. The figures also show the purpose of activities. Observations together with individual and group interviews provided the basis for the conceptual mapping of the key concepts (and associated activities) underpinning good outreach practice. Figure 3: Scoping and negotiating context, practice activities and purposes Key Concept Scoping and negotiating the context Activities Purpose Scoping To locate and estimate the size of the target group Networking To expand options for clients To promote outreach services Reflecting/ evaluating To improve practice by learning from experience Analysing the context (organizational, local & policy) To justify the use of outreach to key stakeholders such as funding bodies, community Figure 4: Building social capital, practice activities and purposes Key Concept Building social capital Activities Purpose Establishing visibility To allow target group to get to know and assess workers Tagging along with other established/ trusted agencies To establish credibility 48 Becoming a regular presence To establish predictability so that target group know where/when to find outreach workers Listening to group concerns To demonstrate willingness to listen and hear issues from the target group’s perspective Managing expectations To maintain credibility with the group and with individuals once established Unplanned outreach To establish visibility; to update knowledge about and location of people sleeping out Figure 5: Working with individuals, practice activities and purposes Key Concept Activities Engaging with individuals in the target group Planned outreach Working with individuals Responding to crises and immediate needs Finding shared interests and points of contact Purpose To start a relationship with the potential to improve people’s situations To look for and make contact with specific individuals To establish and maintain credibility; to improve people’s immediate situations To identify shared interests and perspectives that demonstrate interest in the individual and act as a basis for connection in an on-going relationship Assessing need To develop an understanding of individual needs and the issues and barriers people face and to establish usefulness Assessing readiness for change To pace work in a way that recognises where the individual ‘is at’ Referring To provide people with access to specialist services that address needs Providing housing To stabilise people in accommodation Providing ongoing support To provide the opportunity for clients to address other issues Establishing and maintaining social networks To facilitate social inclusion The activities undertaken by outreach workers were all framed by the goal of purposefully engaging with public space dwellers, and improving their situations by 49 drawing on the strengths that people have and aspirations that they harbour (generally identified by that person). Activities are undertaken, not in a linear progression, but in a sophisticated and almost intuitive movement between activities. Discussion about activities and the practice of outreach are presented below, under headings that mirror and expand on the three key concepts described in the figures above. Scoping and negotiating the context Outreach workers carry street based knowledge about the ebb and flow of life on the streets in their neighbourhood. Community based organisations of all types depend on local knowledge to function strategically. Organisations that have outreach as part of their core business have access to rich, real time data about what is happening in the local community and on the street, who is around or absent, potential conflicts and in-fights, control and use of public spaces, policing, and the availability of drugs. All this information has relevance for the organisation and its work. The majority of organisations’ informal and real time knowledge comes from outreach workers. This information assists organisations (and their centre-based workers) to understand and manage group dynamics within the service; anticipate emerging local issues; and position the organisation to respond to these issues. One of the examples cited by outreach workers was where knowledge about tensions between groups on the street meant agencies’ were prepared to deal with any sign of the problem surfacing in the agency. They’d been kicking on in the park when we turned up….when they turned up later asking us where the others were, we didn’t say a word…you know? We just didn’t know. Other information gleaned from street outreach, for example information about a strong/bad batch of street drugs, can alert agencies to the problem, and allow them to provide information and minimise harm to clients. In addition to the informal knowledge that outreach workers bring, their connections with networks of homelessness service providers and involvement in working partnerships gives them access to formal knowledge about what other services provide; referral protocols; housing; and information about shared clients. Participating in these networks also allows outreach workers to promote the services 50 offered by their own agencies. The credibility workers have means that they are also well placed to challenge some of the assumptions other agencies make about people sleeping out, and to change these assumptions to ensure better treatment for the people with whom they work. One innovative attempt at influencing perceptions in this way was the outreach team who have decided to invite police for the local area to accompany them on outreach. This decision was not taken lightly, given the troubled interactions that sometimes occur between people living on the streets and police (who generally are tasked with removing people’s belongings from public space, taking someone who is unwell for a mental health assessment and a number of other tasks not always appreciated by people sleeping out or the agencies who work with them). Outreach workers believed that police would have an opportunity to meet people sleeping out (as people rather than suspects or public nuisances), to observe the outreach workers modelling appropriate ways of engaging and building relationships, and hopefully to change their opinions about homelessness and their attitudes to people sleeping out. Other outreach teams had strained relationships with police, who they frequently saw as an impediment to their work. On one of the observations, the only tense moments were when the outreach worker with intervened when police appeared to have singled out a group of men who they know to be homeless and were attempting to search. The excerpt below (taken from the field notes) shows that the worker’s purpose in this case was simply to make police aware of her presence as a witness the interaction. Observed a police car parked with lights flashing talking to three men and approached to find out who was involved and what was going on. The worker knows one of the young men, but not the other two, one of whom was being searched by police. The worker observed but did not interfere – and used the time to catch up with the young man she worked with, checked in on his health and where he was staying. The man who had been searched was ticketed under S308 (move on notice and public drinking). The two men not ticketed moved on with their friend. Local outreach workers also use the knowledge they gather in their roles to identify ‘safe’ services that work well with people sleeping out, and will refer to these services. Their position of proximity to those they work with also gave them an excellent insight into how various agencies respond to public space dwellers, and makes them determined advocates when information suggests that people sleeping out are not receiving the respectful treatment workers believe they are entitled to. Good outreach work requires a combination of knowledge about individuals (both housed and homeless) and about the local community and its history and concerns, its services, its public spaces and it’s key stakeholders. It also requires intimate and 51 sometimes real time information about individuals, and this information is gathered over time when workers are embedded in, and trusted by, the group/s they work with. Outreach workers identify strongly with their clients, and this is evident in their non judgemental stance, and their fierce advocacy on behalf of their clients. Our final observation about the significance of knowledge in the outreach role is that the knowledge gathered by outreach workers is always fresh. Because they are out and about most days of the week, outreach workers’ picture of homelessness in their local area is constantly updated. This stands in contrast to centre-based workers who rely on others to tell them about such changes. Thus, outreach workers are not only the eyes and ears of the organisation – they are also contribute to the brain power of homeless services by updating information, and making visible within the service what life on the streets is really like. Building social capital  The worker who gave practical advice aimed at harm minimisation. This approach helped to demonstrate the worker’s non-judgemental stance and genuine concern for the people they engaged with during outreach.  The workers who provided immediate and material assistance to a person sleeping out. Workers provided a swag, and information about food and Centrelink. The outreach workers established themselves at the first meeting as being non-judgemental and useful.  The workers who created a safe space in which they make themselves available to listen to people’s concerns. By doing this, they establish themselves as trustworthy and safe to approach.  They become part of the street scene because they are present there sharing space with potential clients, and with them involved in interactions and events. This accumulated knowledge allows them to read the texture and temper of the streets. Being visible and present provides outreach workers with opportunities to establish their credibility and develop relationships with people sleeping out. Workers use deliberate strategies to gain credibility with their target groups.  In most instances, outreach workers had existing relationships with the people they working with. The meetings and greetings indicated warm relationships between workers and people sleeping out, but also a mutual understanding that these relationships were work-focussed and purposeful in 52 a way that friendships seldom are. Workers were able to respond to requests for assistance, and this seemed to be appreciated. They also responded to needs they identified (such as a sleeping bag) without being asked. In the one instance of this that we witnessed the person, who was given a swag, was clearly touched when workers noticed that he had only one small blanket and was sleeping on uneven, rough ground. The one exception was a client who clearly was not happy about being seen by the outreach workers, but who tolerated their presence and allowed them to administer medication. Working with individuals  The team of workers who provided quick, guaranteed responses to immediate crises. The team was highly effective at responding to medical crises because of their connections with a local hospital. Their capacity to act effectively established their credibility.  The worker who shared some personal interests as a way of connecting with a client. This gave the worker credibility and demonstrated their awareness of the person as a whole individual (rather than a problem). In the literature, there is comment about the tentative and paced nature of outreach work. Whether engaging with the target group generally or with specific individuals, the workers interviewed described similar (or parallel) processes where gauging readiness to engage, negotiating temporary blocks to engagement, and establishing and sustaining rapport were not only a critical first step in purposeful work with individuals, but a time-consuming and continuing activity that was informally but continually evaluated by clients. 5.3 Qualities of outreach workers The literature reviewed for this project varies in its depiction of the importance of workers qualities. Some have argued strongly that outreach work requires and attracts people with particular personal characteristics. Other commentary claims that what appear to be worker characteristics are, in fact, adaptations to the unstructured and essentially non-hierarchical nature of outreach and its location in public spaces. The outreach workers we interviewed did share many common characteristics, and outreach workers in different agencies seemed to have more in common than outreach and centre-based workers in the same services. However, these observations are based on limited time with the outreach workers, and even less with their centre-based work colleagues. The worker qualities noted repeatedly in field 53 notes and in the interview transcripts Include: flexibility; curiosity; openness, reflexivity; a strong professional orientation and clear framework; bravery; and a service orientation. While these ‘characteristics’ could be classified as personal qualities, our research suggests that they are not necessarily core personality traits, but rather a sensible and astute reading of the context and their place in it as outreach workers. The informal nature of the relationships that develop between outreach workers and their clients make it almost impossible for outreach workers to maintain any of the hierarchical divisions between workers and clients that characterise most human service work – and on which much of these organisations’ work is based. Centrebased workers are able to show their professional personas when they meet clients in their offices. Outreach workers, in contrast, need a level of genuineness to operate on the streets where their every action is observed and analysed by a community of people. Outreach workers’ interactions with people on the street are shaped by a complex mix of who they are (their personal characteristics), how they think about their work (their framework), and how they view, and are viewed by people sleeping out (their perceptions and preconceptions). It seems that there are no personal pre-requisites for good outreach practice, no single type. We observed good outreach performed by ostensibly quiet, shy people (whose approach to outreach was often to hang back until they were approached for assistance), through to jokers and clowns who laughed their clients into deep conversations about serious issues. Homeless people’s experiences of outreach (based on our observations) were influenced by how outreach workers engaged and interacted with people on the streets rather than by any personality traits exhibited by workers. People sleeping out who we observed interacting with outreach workers responded to genuine interest and care, to clear, honest messages, and perhaps surprisingly to the process (rather than the outcomes) of these interactions. From what we observed, outreach workers who were welcomed by people sleeping out undertook their work with respect, humour, flexibility and a willingness to see the world through the eyes of the people with whom they work. 54 5.4 Ethical issues Any work with people entails a level of uncertainty, and brings with it ethical dilemmas. Good outreach practice implies ethical practice yet the literature draws attention to the many ethical dilemmas present in the practice of outreach. The literature reviewed earlier refers to the ethical challenges and complications of working on the street and in spaces where the workers have little or no control over what happens. Some of the dilemmas noted in the literature are boundary issues; relationship issues; and the dilemmas raised when workers perceived the ‘public’ spaces where their clients lived as ‘private’ spaces. Workers in this research were all open and reflexive about their work and seemed to value the opportunity to talk about their work with an interested person. They spoke about their feelings of inadequacy as workers (when they could not get the outcome they wanted or believed a client was entitled to) and reflected often on how they might do better. They also spoke about the ethical dilemmas they struggled with in their own work – some of which were raised by the workers themselves; some were mentioned only when a memory was triggered as we talked; and others were observed and raised by us for discussion after observations. The outreach workers we interviewed experienced ethical dilemmas, like all human service workers, and not all their dilemmas related specifically to the indeterminate nature, or the location of outreach work. The most common ethical dilemmas identified by these outreach workers occurred when they:  referred people to the streets for shelter because there are no, more appropriate accommodation options;  struggled to balance advocacy against respect for other ways of working;  were unclear about boundaries and relationships beyond agencies; and  observed criminal activities. Many workers felt that they had let down clients and potentially exposed them to risk when they were asked to find accommodation, but could not do so. All outreach workers were prepared to draw on their networks and to advocate hard to ensure that anyone who wanted a bed for the night (or more permanent housing) was able to access it. In spite of their efforts, there were occasions when workers were unable to find someone a place to stay. One outreach worker in an area where rents were high said that they always had qualms when their best suggestion to someone looking for a safe place to stay was that they could buddy up with someone else (usually 55 someone with more experience on the streets). The worker felt deeply troubled that he claimed to be a homeless outreach worker, yet was often unable to provide the most basic shelter, or even to ensure that people seeking shelter were safe for the night. He saw this as an ethical dilemma. The dilemma existed whether he suggested, or refrained from suggesting, the ‘safety in numbers’ approach. At the core of the dilemma was the idea that he could not meet clients’ most basic needs – a need for shelter that is nominated as one of the basic human rights. It just feels really bad … I’m the worker and they’re coming to me to get some help … housing, whatever. And the one thing they say they want, it’s no go. I worry about whether they’re safe. I always make sure I’m sure about the person I suggest they buddy up with … Other workers struggled with dilemmas that arose because of the treatment they witnessed being meted out to their homeless clients. The workers who raised this dilemma saw the dilemma requiring them to balance good working partnerships with other agencies against their role in advocating for clients and speaking out against the occasionally disrespectful and judgemental treatment they observed in the course of their work. You would not believe the way some of our clients are spoken to, the way [hospital staff] look at them and talk to them…it’s outrageous and I don’t think any human being should be spoken to that way… In this case, the dilemma was resolved with practical assistance from the auspicing agency. Workers in this agency were able to pass such issues (which they framed as discrimination and stereotyping of their clients) on to their agency to deal with, for example by running training and information sessions for agencies not familiar with, or skilled at, working with people experiencing homelessness. This allowed workers to focus on their work without having to engage other services about their understanding of homelessness, and their way of working with people experiencing it. The majority of the workers we spoke with were clear about boundaries, and we observed nothing but ethical practice in terms of boundaries. Workers did, however, mention that challenges of managing relationships that were both professional (when they were at work, and on outreach) and non-professional (for example, when an outreach worker was shopping in the area where they worked on the weekend). It was a bit embarrassing … well, I was embarrassed because I didn’t know what to do. I’m up on confidentiality but now I’m outside work. I thought maybe if I ignored them they’d be pissed off. But maybe they’d be pissed off anyway if I ignored them. 56 More experienced workers seemed to negotiate these shifting boundaries well, but less experienced workers wondered about the appropriateness of acknowledging people in out-of-work hours (a potential confidentiality issue) and how to manage these chance meetings respectfully and sensitively. In these situations, newer workers either sought the advice from more experienced colleagues, or took their lead from the client. As the worker quoted above concluded: She looked at me and half nodded but kept on walking … so I did the same. Outreach work abounds in ethical dilemmas, and workers who remain in outreach work seem to develop ways of managing these dilemmas. Support from team members and from their organisations (in the form of support and supervision) can assist workers to meet these challenges and to develop as outreach workers whose practice framework is solid. 5.5 Context and the practice of outreach A major theme in the literature on outreach is that outreach can only be conceptualised with reference to context, and as a practice is inherently contextualised. In this chapter, the findings of the field research are presented and discussed with a sensitivity for the specific context in which outreach workers carry out their work Based on this research, there are several contextual layers that influenced the way outreach was practised. These layers are:  immediate situational context of the target group or sub-culture;  organisational context;  local/community context; and  policy context. The organisational context determines the purpose and scope of outreach practice. Some organisations included in this research have long experience with outreach, and outreach is viewed unequivocally as an integral part of the agency’s work. These agencies often started as outreach services and evolved into ‘find and serve’ agencies where outreach is a way of bringing people disconnected from services into the auspicing agency where they can access needed services. These services included health and medical services provided on site; showers; clothing; bedding (for example blankets and sleeping bags); meals and food parcels; activities 57 (generally sport or art); referral; and housing. The purpose of outreach in this context is to build bridges between people in need and the agency that can meet those needs. All the outreach services could be described as ‘find and serve’ agencies but the agencies also used a ‘find and refer’ approach when client needs were considered to be too numerous or too complex for the agency alone to deal with. Organisations employing outreach workers see that there is benefit for the organisation’s clients (or potential clients) and for the organisation itself in incorporating outreach with their other services. In addition to access to services, benefits for clients include experiencing genuine concern from outreach workers, being recognised by them as individuals with strengths as well as vulnerabilities, and having a constant, stable presence in their lives. For the organisations, the benefits include having real-time information about potential clients and the situation on the streets, being actively involved in local networks, building working partnerships with other agencies, and high visibility on the streets where their potential clients are. Outreach contact with people sleeping out also positions agencies to meet their service targets and outcome measures. The organisational context impacts to a significant degree on how outreach workers experience their work. Organisations with a history of outreach work and/or a history of working with public space dwellers value outreach work, and generally have a strong organisational commitment to it. Organisations without this history, and/or organisations whose primary focus is not homelessness can find it difficult to understand or value the outreach role. Indeed the literature (Andersson 2011; Erikson & Page 1998; Schneider, Brandon, Wooff, Carpenter & Paxton 2006: 93) notes the tensions that can arise in these organisations between workers managing a standard caseload and outreach workers. Outreach workers in this research working in the health system and co-located with a centre-based mental health service spoke about their concern that the complexity of outreach work was not appreciated by their colleagues, who saw outreach workers as having a lighter caseload and not contributing sufficiently to the outcomes of the organisation. All the organisations had in place policies and procedures relating specifically to outreach work. These policies address workers safety, professional development; support and supervision, work-place health and safety issues, working hours, accrual and management of time in lieu. These policies to varying extents contributed to, or detracted from outreach workers’ perceptions of being valued. 58 Outreach workers are employed by and housed within organisations, yet the majority of their work takes place outside the agency, and effectively takes place in the subcultural context of their target group. The implications of the location of outreach work are many and are detailed in the literature reviewed. Successful outreach requires workers to appreciate and skilfully negotiate a fluid, dynamic and sometime chaotic environment. One participant specifically mentioned outreach as a practice dependent on the outreach workers’ ability to connect with people’s sub-cultural group as a way of then connecting with individual people. This highlights the importance of understanding street rules and protocols, the ebb and flow of relationships within the group, and perceptions of services. Being immersed in the sub-cultural context gives outreach workers access to information about events and people that circulates on the street grapevine. Outreach workers operate in a grey area between agency policies, community issues and attitudes, and the immediate needs and longer-term goals of the people the work with – they work for an agency but also conceptualise their work as ‘for’ people living on the streets. As a result, they operate within different and sometimes competing rules. To successfully manage these tensions, outreach workers rely on other outreach team members and share with them the day-to-day speculation, planning and action (as well as the frustrations and challenges) that makes up an outreach worker’s day. As well as understanding the sub-cultural context of their work, good outreach practice requires outreach workers to understand and negotiate the local or community context. This context is shaped by community concerns and attitudes to public space dwelling, the police, the local business community, urban renewal and gentrification processes, the presence or absence of other supportive or competing services in the area, and the design of public space. These attitudes contribute to an environment that either supports or hinders good outreach practice. One example of this emerged during field observations. Police were active in moving people on, and the worker was unable to connect with a number of people she expected to see. The move-ons had displaced people to other areas and informal meetings that had been arranged did not happen. In cases such as these, outreach workers provide agencies with information used by the agency to advocate for the rights of people sleeping out. Policies at local, state and national level also impact on the way outreach workers go about their work. How workers frame what they do on the streets is shaped by policy (and related service delivery and funding) directions. In the course of this research, one agency when asked about assertive outreach confided that it wasn’t sure about 59 what the term meant, but had been offered funding to carry out assertive outreach and had accepted it because it allowed the agency to add outreach responses and provided a way of connecting with street present people who normally never came to the agency. They practice what they formally describe as ‘assertive outreach’ but also include aspects of what could be considered ‘traditional outreach’. This demonstrates the capacity of agencies to be flexible, and to strategically take advantage of policy preferences by reading the policy context. The organisation invited the team to observe their outreach practice, and observations showed that their activities were effective and consistent with other services that were knowingly practising assertive outreach. 60 6 DISCUSSION In the past five years, there has been keen interest in outreach, largely due to the political and public commitment to reducing ‘rough sleeping’. This commitment has prompted the need for reporting at several levels (for example, through the Council of Australian Governments under its Reform Agenda on housing and homelessness) against the goals specified in the White Paper on homelessness and subsequent inter governmental agreements. One of these goals, as already mentioned, was to halve the number of people sleeping out by 2020. These commitments explain, in part, the recent policy focus on outreach as a response with the potential to reduce public space dwelling. Housing First approaches (which include what is termed ‘assertive’ outreach) have become one of the preferred responses to homelessness in Australia. Housing First approaches are directed at reducing chronic rough sleeping. Much of the evidence for the efficiency and effectiveness of Housing First derives from the US and Canada, where it originated, and is based on data generated in a limited number of studies. While assertive outreach has been embraced as a new way of working that differs significantly from early street outreach (‘traditional), and as a way of ending homelessness (at least for individuals), this research finds no strong distinction and few identifiable differences between the practice of outreach before and after Housing First models were introduced into Australia. Given the lack of interest displayed by the majority of outreach workers we interviewed, and the misconceptions surrounding it, we conclude that the term serves no useful purpose and could be abandoned with no impact on the practice of outreach. In this final chapter, we return to the research questions and provide a summary of the answers to each of the five research questions. We then consider and discuss the implications of the research findings for the practice of research, and for some policy responses to homelessness, particularly policy focused on public space dwelling. 6.1 Questions and Answers The research questions we set out to explore were:  How do outreach workers conceptualise and practice outreach work?  How do people sleeping out experience street based outreach? 61  What benefits do agencies using outreach models see in outreach?  What are the elements of good practice outreach to people sleeping out?  What outcomes does good practice outreach produce for people sleeping out; for agencies providing outreach; and for funders? How do outreach workers conceptualise and practice outreach? Without exception, the outreach workers thought about and practised outreach from (and with) a deep sense of commitment to improving the lives of the people they work with, and addressing homelessness. Some thought of the work they do as somewhat marginal, while other saw outreach as central to their agencies’ broader homelessness work. Their approach to practice was intuitive, pragmatic and drawn from experiential action learning. Unique situations constantly present themselves and there is an element of risk and uncertainty not associated with centre-based case management. This could be described as an interactive and reflexive process, whereby ideas about outreach come from the experience of doing outreach and are then tested against further practical experience. This cyclical and continuous process supports and builds on good outreach practice. How do public space sleepers experience street-based outreach? Our comments in this section are based on our limited observations of outreach work, and our discussions with the workers and agency representatives that we interviewed. Generally, people sleeping out seemed appreciative of the material assistance and the information and advice they received from outreach workers. This stands in contrast to some of the US and UK literature where concerns are raised about the intrusive and coercive nature of homeless outreach. There was no indication that people contacted by outreach workers saw the workers as anything other than a minor inconvenience (at worst). Well sometimes, you know, it’s ‘Fuck off’…but we understand that. We know that maybe they’re hanging out and trying to score. So, we go back later when they’re settled again… Field observations in New York supported this point. Practical assistance appeared to be particularly valued. Resources such as swags and sleeping bags, condoms, or a hot drink serve to ease the initial discomfort experienced by the person assisted, served to establish workers’ usefulness. These material tactics were used by the majority of outreach workers we spoke with, and are an essential part of a good outreach workers toolkit. Much of this practical 62 assistance also plays a harm minimisation role, for example condoms and sharps, and helps to build workers’ social capital. What benefits do agencies doing outreach see in outreach? All the outreach services in this research could be described as ‘find and serve’ agencies but the agencies also used a ‘find and refer’ approach when client needs were considered to be too numerous or too complex for the agency alone to deal with. Several agencies had started as outreach services and evolved into ‘find and serve’ agencies where outreach has become a way of bringing people disconnected from services into the auspicing agency to access services provided there. These services included health and medical services provided on site; showers; clothing; bedding (for example blankets and sleeping bags); meals and food parcels; activities (generally sport or art); referral; and housing. In this context, the purpose of outreach is to build bridges between people in need, and the agency that can meet those needs. The majority of agencies contacted in this research saw the benefits of outreach. Some agencies benefited from the Streets to Home funding that flowed after 2008 but most of them had previously been committed to, and involved in, homelessness work. From these agencies, there was genuine appreciation of the potential benefits for their clients and a deep understanding of the issues facing public space dwellers and the potential of outreach to make a real difference to their situations. Outreach has given these agencies a proactive way of finding and assisting people who might not otherwise access services. For agencies, the benefits included: reaching a target group that did not already know about or access services; building up their client base; providing services to the people perceived as most in need of them; responding holistically to homelessness; raising the profile of the agency on the streets and with other local service providers and funders; extending the existing services offered by an agency; and enacting the founding philosophy and commitment of the agency. There was, however, one exception. This was a mainstream agency with no previous understanding of homelessness, or contact with people sleeping out. This agency now auspices a team of outreach workers who are co-located with centre-based workers from the same service. Centre-based workers in this agency did not understand outreach work, and saw the outreach workers as a drain on resources by staff engaged in work that was not within the boundaries of the agency’s core 63 business. This was an exception, but it could signify a wider professional cultural perspective. We were not in a position to explore this further. What are the elements of good practice outreach to people sleeping out? Good outreach is made up of several elements. Good outreach practice is always underpinned by clear direction about the purpose of outreach in varying contexts, and both agencies and workers hold, review and renew this clarity of purpose. Good outreach practice is a meld of organisational factors, worker orientations to their work, workers’ outreach ‘styles’, and the attitudes of the communities where their outreach work takes place. Good outreach practice as it was described and observed in this study consists of three organising concepts that are operationalised as a series of interrelated activities. We described the three concepts (and the associated activities) in detail in the findings chapter. The categories we presented were scoping and negotiating the context; building social capital; and working with individuals. Outreach workers move between these categories, even in one interaction, and use a number of the activities purposefully to engage and work with people on the street. Our limited opportunities to observe outreach practice showed that workers’ style and ways of approaching people created an environment where people were able to talk about their needs and hopes, and that these were negotiated over time, as people’s circumstances and aspirations changed. Good outreach practice is underpinned by organisational recognition and support. Recognition and support from organisations is valued by outreach workers, and includes adequate resources; appropriate targets and outcome measures; understanding and recognition of how outreach contributes to broader, organisational goals; co-location with to other outreach team members; and colocation and regular communication with centre based workers. Good outreach practice entails fine-grained local knowledge – formal and informal. Outreach workers whose practice is good show a sound grasp of the broad context in which they work (policy and service delivery imperatives) and a grounded understanding of the history, culture and concerns of the local communities where they work. They build up over time a deep understanding of the sub culture of the target group, connections with the street grapevine and local service networks, and engage in continuous evaluation and reflection on their knowledge and their practice. 64 Good outreach practice reveals, or elicits, particular worker characteristics. Workers qualities frequently observed, and commented on less frequently by workers include: a non-judgemental stance; flexibility; focus; curiosity; bravery; openness; and reflexivity. Whether these characteristics are present before people undertake outreach work is unclear, but given the close scrutiny to which outreach workers are subjected, their street persona are likely to be consistent with their personal qualities and, in the interactions we witnessed, workers were genuine in their interest and concern and perceived to be so by the people they engaged with. Outreach has been part of good practice in the homelessness sector for decades now, and more recently adopted in mental health sector. Training in social work or youth work may be considered appropriate professional qualifications but outreach is a challenging area of work requiring a body of tacit knowledge and skills, teamwork and the competencies of an anthropologist as much as a social worker. Not everyone can do it or do it well. It is area of practice that can sometimes be risky, that deals with a lot of uncertainty and requires a degree of flexibility beyond standard case work. What outcomes does good practice outreach produce for people sleeping out; for agencies providing outreach; and for funders? Our research did not include the formal collection of data from people sleeping out. It is possible, however, to describe the outcomes that workers believe have been achieved, and to make some judgements from what we heard and saw when going out on a relatively few outreach excursions. The following were outcome related activities: Assistance with material goods Information about sources of food General health checks Mental health assessments Harm minimisation Personal recognition and genuine interest Housing advice Referrals Information about friends and members of the group Advocacy Outreach agencies already working with people experiencing homelessness benefit from providing outreach services that offer a way of expanding their existing homeless services. Outreach also takes agencies (and the services they offer) to 65 people where they are, making it easy for people who normally avoid services to access them. This builds agencies’ credibility with their targets groups, and renders the support they offer highly visible. Outreach services can also provide agencies with opportunities to form working partnerships in their local community, pursue new funding opportunities, and enact their commitment to addressing homelessness. Without doubt, outreach services improve the lives of people sleeping out in terms of immediate needs. Other research shows that there are cost savings associated with assertive outreach and Housing First models, but those cost savings are often realised in parts of the service system whose core business is not homelessness – and therefore not necessarily attributed to homeless services, including outreach teams. 6.2 Policy In a 1994 evaluation of the Supported Accommodation Assistance Program (SAAP), Professor Terry Burke speculated about the connections between ideologies, policies and homelessness. His hypothesis was that policies that tend to rely on market mechanisms are least helpful to the most disadvantaged and more likely to result in higher rates of homelessness. The number of people who will experience homelessness, those groups most vulnerable in the population, the various forms of homelessness, and how people’’ experiences homelessness are the effects of other policy positions. Changes in the labour market or income policy or the rental market in boom areas, for instance, have the potential to contribute to increased homelessness. In general, homeless policy does not ‘talk to’ these other policy areas, but it does deal with some of their outcomes. In 2008, the focus on ‘rough sleeping’ came with a major policy commitment to addressing homelessness more broadly, and that was widely supported and welcomed. However, the emphasis on the most visibly homeless runs the risk of playing into the stereotype that homelessness is rooflessness. In the United States, removing rough sleepers from the streets of New York is supportable in terms of how it is being approached by the workers and organisations engaged in outreach, but it can be argued that this policy and the funding attached to it, has other ulterior motives when examined from a City Government standpoint. The promotion of ‘assertive outreach’ in some of the literature is curious, rather more like rebranding something and selling it as new when it is really not a new thing at all. Our conclusion on this point rests on a conceptual analysis, but also the evidence 66 from workers in the field both in Australia and the US. One US outreach team leader, with years of experience and a masters degree in social work when asked about assertive outreach replied: ‘what’s that?’. Is assertive the correct term if what is really meant is persistence in the face of disinterest or even hostility. Persistence can be respectful of people’s rights. Is assertive the right word if what is meant is outcomesoriented outreach? In the Streets to Home model the outreach is certainly conducted with the ultimate aim of facilitated a chronic rough sleeper into supportive housing. Assertive outreach is a term (and a practice) that was adopted without qualification and probably should be quietly retired from public discourse. Outreach and street homelessness in particular locations The fourth report of the CAOG Reform Council (2013) contained the most recent national review of homeless strategies and actions against targets and key performance indicators. The report found ‘good progress in reducing the number of rough sleepers in Australia, based on a fall in the number of rough sleepers’ from 7427 in 2006, to 6813 people in 2011. A closer examination of the geographical distribution of this reduction shows that there are high concentrations of people sleeping out in particular states, and in certain locations in those states, and suggests success is in some places and not others (COAG Report 2013). This reduction has, however, been achieved in the context of a rise in the overall number of people in experiencing homelessness. Prima facie, there is some evidence that it has been possible to reduce the number of people sleeping out in some locations but as yet we can only speculate about the role of outreach in contributing to the outcome, and about why outreach and the other initiatives targeting people sleeping out appear to have been highly effective in some locations (for example, in Brisbane) but not at all effective in others. What we don’t have in place is a planned and systematic systemic approach to inner city street homelessness, where well-resourced specialised outreach teams have access to a small steady stream of supportive housing units. The importance of establishing systemic linkages between housing and homelessness is recognised in both the NAHA and in the NPAH. Initiatives under the NAHA have increased the supply of affordable housing, but it is not possible to tease out the connections between the decrease in the number of people sleeping out, the increase in the amount of housing afforded to people who had been sleeping out, and reform in the specialist homeless service system. In the present context, the adoption of Housing First models - and of assertive outreach as one component of these models – is 67 almost a logical outcome of the political and policy contexts. What is needed is a inner city plan with good data so that the exit pathways can be made available in a sufficient number and in time for outreach workers to be able to deliver an opportunity for housing to someone who ended up alienated from the service system or who had failed to maintain housing in the past. In New York, outreach is funded and operated on a citywide basis as a systematic and systemic program of engaging with chronic rough sleepers and chronic homeless to assist them eventually into supportive housing somewhere. The organisation of outreach is not tied to any one housing provider and has responsibility for every locality across the city. The Manhattan Outreach Consortium is funded to undertake outreach throughout the five boroughs of New York and the Bowery Residents Committee is funded to do outreach in the subways. What was hastily put together in 2008, in Australia has not yet approached this level of sophistication. Outreach and Housing The importance of housing in supporting and sustaining effective outreach services cannot be overstated. The availability of housing that is affordable to people receiving Centrelink benefits, well located and available in a timely way is one of the main justifications for current funding to outreach programs. Many reports (for example Parsell & Jones 2012; Wylie & Johnson 2012) have already detailed the consequences of not being able to house people contacted by outreach workers, from disengagement by street dwellers when they learn that housing is not available, to the sense of ethical unease experienced by workers. We have no wish to labour the point, or to imply that the only useful activity undertaken by outreach workers is encouraging people off the streets and into housing. The current research, however, indicates that this situation has not improved and every agency we spoke with expressed frustration and disappointment that housing to support their positive work was still not available. This underscores how dependent assertive outreach programs based on Housing First approaches the S2H model are on resources, such as housing and services. Thus what has been identified in the relevant literature as a defining difference between traditional and assertive outreach approaches comes down to the availability of housing stock, rather than any intrinsic substantive or defensible difference. 68 Success measures and outcomes A grounded appreciation of the nature of outreach leads to expectations of performance and outcomes that reflect the nature of the work, and all the elements of it that contribute to ‘successful’ outcomes. Expectations of significant changes in the lives of each and every person sleeping out (for example from the streets to stable housing) rest on an acknowledgement that some will need a long period of engagement and continuing support after they are housed to establish the community connections that lead to social inclusion. Expectations must also be tempered by an acknowledgement of the role of agency and the right of people sleeping out to refuse – and continue to refuse – assistance. For these reasons, there may always be some people who sleep out. One unspoken expectation of governments is that funding responses to primary homelessness will result in cost savings. This expectation is consistent with some research in Australia (for example Paul Flatau’s work on the costs of homelessness) and other research from the US, England, Scotland and other European countries that shows that housing and supporting people sleeping on the streets is cost effective. However, the savings that are reported are outside the homelessness service system - most often in the health system (through a reduction in the use of emergency wards and acute care psychiatric admissions) and the correctional system (again through a reduction in incarcerations). Expectations that taking services to people living on the streets will reduce the cost of responding to homelessness may be justified, but the benefits of spending on outreach services are not immediately clear and are often attributed to other parts of the service system. Funding for outreach by the agencies we interviewed came from several sources (primarily health; and family and community services), each with its own expectations related to core business. For funders, the literature and our research suggest that good outreach does result in savings, but it should be noted that these savings are not always recovered in the part of the service system where funding originated. Finally, targets and outcome measures help to make and hold funded organisations and workers accountable for the funding they receive. However, targets should be achievable and the means of achieving the outcomes must be accessible to outreach workers and the people they work with. External factors have a major impact on the outcomes achievable from outreach. The lack of affordable housing is an entrenched issue in Australia and is a major problem hindering efforts to end and prevent homelessness. Until a stream of supportive housing is made available in a planned 69 way for chronic rough sleepers, consistent and ongoing success of the work to reduce rough sleeping in the cities around Australia will be difficult to achieve, whatever the skills and commitment of outreach workers or the desire of people sleeping out to be housed. Locating outreach services The implications of location for good outreach practice relate primarily to logistics, workers safety and ethics. In order to work most effectively, outreach workers need access to appropriate resources and technology, and these should be designed for the purpose so that the majority of workers’ time is devoted to doing the work and only a minority is spent mastering and using technology. Challenges to both worker safety and in negotiating ethical dilemmas can be addressed by supervision focussing on outreach practice and outreach team dynamics (rather than on line management issues) and the costs of supervision for outreach workers should be an integral part of funding for outreach services. Opportunities for team building and maintenance should also be considered essential support for outreach workers, who rely heavily on their co-workers on the street. Without these opportunities, there is a risk that the work that takes place outside the agency stays invisible to – and therefore not understood or valued by - centre based workers. Where organisations have developed this understanding, co-location of outreach workers with centre-based workers can encourage communication, information sharing and collaborative work. There are mutual benefits in these colocations. Agencies without this understanding are not conducive to good outreach practice, although this can be off-set (to some extent) by the co-location of outreach workers within these agencies. Our research suggests that co-location in homeless services with an understanding of homelessness and public space issue are more successful at supporting outreach worker, even those relatively new to outreach. This suggests that outreach service might be best located within agencies with – at a minimum – an understanding of street homelessness and, ideally, established contact with people who sleep out. The policy argument would be to provide for some critical mass and accumulated expertise in an agency where outreach is seen as an integral part of the agency’s work. Such an agency would work with a number of housing providers. Following this line of thought would deploy funding for Streets to Home programs somewhat differently to how this was done in 2008. 70 Public space One of the policy conundrums raised by this research arises because of the distribution and location of concentrations of street homelessness. The major stakeholders in homeless responses to date have been the Australian, state and territory governments. However, street based homelessness manifest itself visibly at a local level and is most often responded to (at least immediately) by local governments. Some local government bodies, for example the Council of Capital City Lord Mayors have provided leadership, funding and innovative responses to inner city homelessness such as the annual Homeless Connect Australia events. In other areas, hotspots point to a lack of engagement with homelessness, or willingness to to engage with public space dwellers as legitimate community members. To address public space dwelling effectively, the idea of place-based response could be revisited. As a starting point, local governments should be seen and engaged as essential stakeholders in policy deliberations and development. Policy priorities Continuing political commitment to homelessness cannot be assumed in the present context. There is a real possibility that homelessness will again become a secondary issue for government. If this proves to be the case, the policy challenge will be prioritising options, for example whether to focus on newly emerging groups experiencing homelessness and target them for rapid rehousing, or to focus on the most vulnerable and disconnected groups – who are also the most visible. Economic arguments establishing the efficiency of outreach responses and their outcomes can be made. It may become increasingly difficult, however, to justify continuing investment of funds to address the needs of a relatively small proportion of people experiencing homelessness. Further research This initial piece of exploratory research reveals a need for longitudinal studies that can monitor over time the outcomes for people who have made a transition from street homelessness to stable accommodation. Such research can contribute to making a case for the continuation of outreach programs, which plays a vital role in supporting and housing public space dwellers. Also, research to more rigorously distinguish between ‘chronic rough sleepers’, and recent ‘rough sleepers’ and between people new to homelessness and people experiencing chronic homelessness will serve to expose the nuances of what is 71 happening on the ground. Agencies generally keep data for a relatively short period of time after people are supported into housing. Longitudinal data will help establish whether people are able to maintain housing once support is discontinued and provide evidence about whether outreach leads to long-term and successful transitions from homelessness. This phase of extended follow-up research will build substantially on the existing information about outcomes for people who are housed after exiting primary homelessness. The research team has a Stage 2 of outreach research under consideration for a partnership with the outreach providers. A software App has been developed to manage the data collection. 72 REFERENCES Anderson, P., Hume, A., Rogers, N. and Stephenson, T. (2003). It’s No Palace: Boarding Houses – the sector, its clientele and its future, Adelaide: Department of Human Services. Andersson, B. (2011). Finding ways to the hard to reach - considerations on the content and concept of outreach work. European Journal of Social Work, 116. Australian Bureau of Statistics (2006). 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