Stages of Change
Beyond a basic intake, the first response is to ensure that the youth has something to eat, clothes to wear and is able to get some rest. Discussions and planning about next steps occur a couple days later after the immediate basic needs have been met.
The youth can stay in the crisis/shelter program and begin to develop a day plan that includes employment, education or addressing mental health or addictions issues. Moving into the Rights of Passage programs moves them further up Maslow’s hierarchy by giving them more than just safety and security but also a sense of belonging. The life skills training and support provided by staff help them move through other stages as well.
Attachment Theory is a means of understanding how early childhood development, especially in the first two years of life, determines how a child will interact with peers, adults and even future romantic partners, as they mature through adolescence and adulthood.
John Bowlby, the ‘father of attachment theory’ described attachment as a “lasting psychological connectedness between human beings”.
“Attachment theory is basically fostering positive relationships and helping youth to model relationship skills and social skills that they might have been exposed to in their home life. That really forms the basis of that relationship to the youth and understanding them and practicing empathy; to understand where they’re coming from and allowing them to work out conflict in a healthy way and manage their relationships after they leave ROP.” — Jennifer Morrison, Life Skills Worker, Covenant House Vancouver
There are several modes of attachment. Secure Attachment is considered positive while the other types of attachment (ambivalent, avoidance, disorganized) are all forms of insecure attachment and usually cause a variety of behaviours.
- Secure Attachment – a healthy attachment where the child knows a parent will respond appropriately, consistently and promptly to their needs. The child is able to separate from their parent but prefers their caregiver to a stranger and shows distress when left alone. As adults, those who have developed a secure attachment with their parents:
- have trusting, lasting relationships as adults.
- tend to have good self-esteem.
- are comfortable sharing feelings with partners and friends.
- seek out social support.
- Ambivalent Attachment – wherein the child does not view their parent as a secure base because the caregiver gives little or no response to a distressed child and discourages crying while encouraging independence. Children in this kind of relationship often feel anxious because their parent’s behaviour and availability is inconsistent. As adults, those who have developed ambivalent attachment:
- are reluctant to become close to others.
- worry that their partner does not love them.
- become very distraught when a relationship ends.
- Avoidance attachment is developed through inconsistency between appropriate and neglectful responses. The child does not seek comfort or contact from their parents and may in fact avoid them. The child does not respond well to affection, has low self-esteem and may act out negatively. As adults, those who developed avoidance attachment:
- may have problems with intimacy.
- invest little emotion in social and romantic relationships.
- are unable, or unwilling, to share thoughts and feelings with others.
- are self-critical, insecure and feel they are going to be rejected.
- may act clingy and overly dependent with partners, friends or in other relationships.
- Disorganized Attachment – is often generated by abuse (of any kind) towards the child. The caregiver may be frightened themselves or exhibit frightening behaviour. They may be very withdrawn, negative; there are communication errors and maltreatment. There may be role confusion where the child takes on roles that are typically associated with the caregiver (they take care of an alcoholic parent for example). As adults, those who developed disorganized attachment:
- may exhibit chaotic or explosive behaviour.
- they may be seen as insensitive.
- they will have struggles with trust while also seeking security
- may in turn be abusive themselves.
- may find it difficult to maintain solid relationships.
- Reactive Attachment – tends to indicate even more abuse or neglect. The parental-child relationship is extremely unattached and malfunctioning. As adults, those who developed reactive attachment:
- Cannot establish positive relationships
- May be misdiagnosed with mental health issues
Covenant House uses Attachment Theory as a basis for developing a working relationship with youth. They feel that understanding what type of attachment a youth has will allow them to improve their working relationship with that youth by better understanding the specific behaviours a youth exhibits.
At Covenant House Vancouver, a discussion of Attachment Theory forms part of the initial meetings between a youth and their Case Manager. The policy on Change of Case Managers states “CHV follows the principles of Attachment Theory. Where possible, youth are encouraged to resolve conflict when it occurs. This conflict resolution better equips youth to handle stressful situations by empowering them, ultimately increasing their independent living skills. Attachment Theory advocates that a strong alignment be established between youth and their supports.”
By teaching youth about Attachment Theory it lets youth know that conflict is normal and helps them understand how to resolve it. When a conflict arises between the Case Manager and the youth (or a conflict with any other staff) the young person will hopefully be better prepared to deal with it in a healthy way.
“A lot of these young people have an unsecure attachment style which can explain a lot of the things that we see in our day-to-day work and it really teaches our staff to be curious about behaviour. So [asking ourselves] what is the meaning behind this behaviour? Not, ‘this kid swore at me I need to discharge him’ but ‘what is this youth telling me through this behaviour’. [This] has been very helpful for staff in terms of crisis management and conflict resolution.” — Chelsea Minhas, Manager – Rights of Passage, Covenant House Vancouver.
Stages of Change, also known as the “transtheoretical model” is a means of examining the various stages that someone goes through while dealing with an addiction and working to change their addictive behaviour. The originators of the theory James Prochaska and Carlo DiClemente also identify 10 processes of change, which are used throughout the stages.
Most people who are trying to end an addiction or change a specific behaviour go through the various steps in the Stages of Change model many times before they are able to successfully end their addictive behavior. Obviously, the young person may not know about or understand the model himself or herself, but the staff use it to help evaluate an individual’s readiness for change, so that appropriate interventions are used as effectively as possible. Prochaska and DiClemente state, “we have determined that efficient self-change depends on doing the right things (processes) at the right time (stages)”.
“So the pre-contemplative is when a youth is not quite ready to come forward and have insight about their addiction. So our goal there is to give them as much information as possible, around addiction services and discussion around—‘This is the behaviour we’re seeing is going on.’ Contemplative, we’re starting to see them [say], ‘Ok, maybe I do have an addiction issue’ and at that point we start saying ‘Are you ready to get connected to work on these issues?’ Move into Action, and then Maintenance and then we see the Termination. Any time within there we can see a relapse, so we’re always watching out for that. The youth here, when we work with them we can definitely see when there’s some struggles going on. Our goal is to get that relationship going in order for them to come to us saying, ‘I’m struggling right now.’ And then we work on, ‘Well what do you need?’ Most of the time some of the youth already have the connections, but they’ve disengaged, so it’s just getting those connections back.” — Lisa Ronaldson, Case Manager, Covenant House Vancouver.
Both locations embed their evaluation methods in this theoretical approach. The Outcomes Star and The Youth Engagement Scale (discussed in the Evaluation chapter) tie in this theory to the way in which a youth’s progress is measured. This means that program milestones, youth engagement markers and other indicators of success are not based only in the need for evaluation measures but in a concept that explains and elaborates upon a youth’s behaviour. It allows staff to more fully understand why a youth does something, what that behaviour would look like at each stage and to guide the youth in a more positive direction.
While the youth themselves may not always be aware of the theoretical models being used, they are impacted by them. In talking about relationships with staff Kevin says,
“For me, I don’t really have too many people out here, and just having someone that I could look up to, someone who understands some of my life experiences, and yeah, obviously judgment is the biggest thing. Like, you know, staff that [says] ‘Hey, you know what, you made a mistake, that’s fine. We’re not here to judge you, we’re just here to help you’.” — “Kevin”, 26, former ROP participant, Covenant House Vancouver.
Covenant House Toronto uses a model for building resiliency that was created by Dr. Kenneth Ginsburg, Director of Health Services at Covenant House Pennsylvania and an adolescent medicine specialist. His evidence-based model uses the principles of Covenant House to help staff manage relationships with youth.
“In terms of our philosophies around how we feel it’s best to work with youth I think one of the things that we’ve really focused on is resiliency. We’ve done a lot of training with our staff around a resiliency model that we’ve tried to infuse in every piece of our program. [It] starts at the point that the youth comes to ask for help, through to when they leave our programs. You know, these kids come with lots of deficits, based on the experiences that they’ve had and the lack of opportunity that they’ve had. So, for both the youth and my staff it’s really important that we try to shift our focus and focus on what the youth do well. And they do have strengths and they are very, very resilient when you look at the kinds of experiences they’ve had. It’s just up to us to really shine a light on that and both for the staff and for the young person so that they can see that they've got things to build on and a place to move to.” — Carol Howes, Director of Program Services, Covenant House Toronto
CHT’s website explains that Dr. Ginsburg’s model uses “Seven Cs” of resiliency:
Confidence - Kids need to recognize their strengths, so they can develop the confidence to find their place in the world, think creatively and recover from setbacks.
Competence - When we notice what young people are doing well and we give them opportunities to develop skills, they feel competent. When we don't allow them to recover from mistakes themselves, we undermine their sense of competence.
Connection - Feeling connected is the single most important factor in overcoming challenges. Other people, schools and community groups give youth the validation and confidence to pursue their goals.
Character - Kids need clear guidance on right and wrong. They must learn to live with integrity.
Contribution - When youth contribute to the well-being of others, they receive gratitude instead of condemnation. Kids discover that it feels good to contribute to others and they are more likely to ask for help without fear or shame.
Coping - Young people who have developed a range of healthy coping skills will not turn to higher risk “quick fixes” like drugs or self-harm.
Control - When youth understand that privileges and freedom gradually increase as they demonstrate responsibility, they learn to make better choices.
“The thing with resiliency…is that is has to be something real. So it’s not just being a cheerleader and saying ‘yeah, yeah, you’re doing great, rah rah rah. It’s about real stuff that they’re accomplishing and building their self-esteem and confidence by what they’re doing and having them reflect on it.” — Stacey Rees, Life Skills Coordinator, Covenant House Toronto
Motivational Interviewing (MI) is a style of working with a client that focuses on allowing the client to direct the change rather than telling the client what they need to do. It is about having a conversation about change. MI is considered to be an evidence-based practice that has proven to be successful. It is usually considered to be “a person-centered, goal-oriented, guiding method to enhance motivation to change” (t3 website).
In a video interview by Mark Howarth from Invisible People, Ken Kraybill from t3 (think. teach. transform) says “we must try to have a conversation that draws out from the person what their own needs/desires are, what kind of life they really want to have, how that’s dissonant from the life they’re living. Not to guilt trip them but to just to help them shine a light on it”.
In MI the goal is to work with the client in a partnership rather than the case worker seeing themself as the expert. It includes meeting the client “where they are at” (also a key component of harm reduction) and recognizing that a client brings many strengths to the table. Helping the client recognize their own abilities and therefore the opportunity to make choices for themselves is a key component of motivational interviewing.
At Covenant House, staff use motivational interviewing techniques when working with youth, particularly in the development of case plans. Creating the plan with rather than for a youth means more buy-in from the youth and therefore a greater likelihood of success.
As mentioned in the Covenant House Toronto and Vancouver Overview section many of the youth involved in the two agencies have experienced extensive trauma, which in many cases led to their homelessness. Almost 3/4 have fled physical, emotional and/or sexual abuse or been kicked out of their home, about half have mental health or addictions issues and about 1/3 have been engaged in sex trade work. Homeless youth also experience a high level of violence – physical and sexual – during their homelessness. Additionally, a number of homeless youth have been through the child welfare and/or corrections systems. Even when someone has not directly had a traumatic background, research is emerging that shows the experience of homelessness itself can be considered traumatic.
All of these experiences mean that staff and volunteers working with this population need to develop and implement trauma-informed services to provide the best support possible for their clients. According to SAMHSA “A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for healing; recognizes the signs and symptoms of trauma in staff, clients, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings”.
“At ROP, and at Covenant House in general, we realize that the young people that are coming to our door have often times histories and experienced journeys that they’ve experienced some trauma. The reality of having to experience homelessness or under-housing, in and of itself, is a traumatic experience. I think in really basic form we try to exercise being trauma-informed in realizing that the people we are blessed to interact with might have some experiences with trauma. That awareness, in and of itself, I think grants the opportunity for us to pause [and] to consider the person that we’re sharing space with is bringing a lot to the table. That this step that they’re taking to share a space with us is huge, and is significant, and we need to honour and work from that place. The behaviours that we might see are grounded in a really, really positive and effective coping from what they’ve experienced. So just appreciating that.” — Dillon Dodson, Team Leader, Covenant House Toronto
Like Motivational Interviewing, a key component of trauma-informed services is to “meet people where they are at.” It also involves recognizing that often the very work aimed at helping people tends to re-traumatize them. Creating a case management system that avoids someone having to continually tell their story is helpful. Providing a space that is structured and secure yet flexible, allowing for input from the affected individual, providing opportunities for the development of safe and trusting relationships and recognizing that “one-size-does-not-fit-all” are keys to developing trauma-informed services.
Both CHT and CHV provide many opportunities for youth to have input into their individual case plan (including full development of the plan in later steps at CHV), as well as the workings of the house. CHT provides opportunities for residents to hold their own meetings, independent of staff, that provides an open forum for youth to share concerns without feeling restricted because of the presence of staff.
Homeless Hub Thoughts:
While some of these theories may sound very academic and confusing, the reality is that most youth-serving agencies and non-profits tend to use many of them in day-to-day operations, even if they did not know what they were called. Considering the theoretical underpinnings in developing your program will help you justify certain activities and evaluation methods to funders.
If you have an existing program and do not know what theories are in place, consider partnering with a local university or researcher. Have them observe your case management practice and examine your program and evaluation methods. They will likely be able to point out several theories that you are already using.
The theories you need to develop will be informed by your clientele and their presenting needs. Your specific program may also influence this. We feel that trauma-informed care, resiliency theory and motivational interviewing are all key when developing a theoretical approach that honours the knowledge and experience of the youth that you serve.