“How can we ethically, properly, and effectively motivate homeless individuals to take advantage of resources made available to help them?"
Part One – Effectively Motivating Homeless Individuals
Many are now recognizing homelessness as the defining humanitarian crisis of our time in the United States. As a result, federal, state, and local governments are pouring more financial resources into homeless initiatives than ever before. In California in 2021, Governor Gavin Newsom announced a $12 billion, two-year initiative to address the homeless crisis in a responsive magnitude never witnessed in state history. With national resources being directed toward homeless mitigation in a scope and scale never witnessed before, homeless shelters and supportive housing initiatives are springing up across much of the United States in robust numbers.
Increased homeless services capacity has underscored a previously underestimated civil liberty challenge. Even though much greater homeless services capacity is being brought online, many homeless individuals are still opting not to take advantage of new resources, shelters, and even personalized solutions such as hotel conversions via California’s Project Roomkey. This problem is the focus of this literature review: How can we ethically, properly, and effectively motivate homeless individuals to take advantage of resources made available to help them? For too long, elected officials have viewed the homeless crisis through a logistical lens. In essence, conversation usually centered almost exclusively around where and how many shelter beds and supportive housing units could be built. Now, community leaders are beginning to better comprehend that addressing the civil liberties aspect of homelessness is a major piece of any effective homeless mitigation strategy. Successfully breaking the homeless cycle in an individual’s life requires a fully engaged partner in the process. Therefore, discovering effective motivational pathways with the homeless population presents as an increasingly important topic.
Part Two – The Scope of the Problem
“Quality of Life” policing that focused on a punitive approach to homelessness was on the dramatic rise across the United States for the past ten years. Inspired by programs in New York City, Los Angeles and San Francisco, hundreds of cities passed ordinances that banned public sleeping, sitting, loitering, and even sleeping in cars. Some went so far as to ban the feeding of homeless and criminalize repeat offenders that tried to pass through metropolitan areas. Here is a table illustrating the percentage of Colorado homeless residents who had been contacted, arrested, or cited by police in the previous six months (Robinson, 2017):
Such “Quality of Life” policing activity came to a sudden stop in 2019 when the Ninth Circuit Court of Appeals issued the noteworthy Boise ruling. This ruling effectively instructed cities that they could not enforce “anti-camping” laws unless they had a shelter bed to offer the homeless resident. Almost overnight, cities across the nation suddenly began scrambling to rapidly erect shelters. Such expanded shelter capacity would enable communities to practice what some call a Shelter and Enforce policy approach toward homelessness. Shelter and enforce is a reference to an effort to build enough shelter capacity to enable local law enforcement to legal enforce anti-camping ordinances to dismantle homeless encampments.
As shelter capacity increased, there is often a community expectation that subsequent homeless populations would dwindle, and future Point-in-Time homeless numbers would decrease. The reality, however, has been more nuanced. Although there are typically greater sheltered homeless numbers in communities that have expanded capacity, the Shelter and Enforce model has – to date – failed to mitigate homeless populations to the degree anticipated. Analysis of why this is so frequently points to the fact that many homeless individuals choose not to take advantage of shelter and service capacity. The early expectation was that local police and sheriff departments would “offer shelter or threaten jail.” Incarceration has become an empty threat in many local communities for at least two reasons. First, incarcerating the homeless is expensive. By some estimates, it often costs over $80,000 annually (Murillo, 2010). Second, it is recognized by many elected officials that arresting and jailing people for being homeless is not typically regarded as a humane and moral response to the problem. Thus, the net result is the “enforce” aspect of Shelter and Enforce has devolved into a hollow homeless policy.
And so, the discussion turns robustly toward the questions surrounding the effective motivation of homeless individuals to become partners in efforts to assist and move toward comprehensive life change.
Some of the scientific literature seized upon the concept of “Care Avoidance” to describe homeless individuals that did not access or participate in service and support efforts. Interestingly, Klop, et. al., noted that the homeless individuals themselves rejected this characterization and took offense that the label places all the responsibility exclusively on them (Klop, 2018).
Other scientific literature brought attention to the critical importance of supportive relationships – especially family – as a positive force for motivating homeless individuals to access services and support. For example, a quantitative study of 12 previously homeless individuals who had sought help and maintained their housing for at least 24 months revealed an emphasis upon improving relationships with significant others as key motivational factor in seeking and accepting help (Thompson, 2004).
Repeatedly, the scientific literature recognizes the unique role in which the perception of personal autonomy plays in the mental health and overall motivational level of homeless individuals. In this respect, the homeless individual needs to feel like the initiator of their behavior with complete cooperation and affirmation of the choices they are making. Weinstein and Ryan felt this issue was substantive enough that they went so far as to develop a much-lauded Index of Autonomous Functioning to help assess the level of perceived autonomy in a individual’s life (2012).
Substance abuse is a long-recognized, defining adversary in the battle to end chronic homelessness. Some scientific literature touched on the impact that substance abuse played in de-motivating individuals from seeking help or participating in program services. A qualitative study of experienced leaders in the field of homeless care noted the coercive power of personal addictions: “Their addictions – those things take over, and usually end up deciding the fate of everything “(Dennis, McCallion & Ferretti, 2012).
In summary, homeless individuals who exhibit enough motivation to avail themselves of the shelter and services being offered often must navigate a hostile law enforcement environment, they must gain a measure of personal victory over any substance abuse issues they may have, and they must overcome broken relationship systems. To address these elements comprehensively, a holistic lens that can unify theory is called for. For many, that lens appears to be Self-determination Theory.
Part Three – Causal Explanations of the Problem
This paper has identified aspects of the general homeless population that suggest personal motivation may be compromised due to a mosaic interplay between such forces as broken interpersonal relationships, the dramatic impact of substance abuse, and a lack of sense of personal autonomy. This can all lead to behaviors that some social scientists have termed “Care Avoidance.” It is of value to explore this on a deeper theoretical level, however, and begin to press the data for insight into actual casual explanations of observed motivational behavior.
It was a quantitative study of cognitive disorders amongst the homeless population of Paris, France that first introduced this author to phrase biopsychosocial causes. Specifically, the research team noted, “Social rehabilitation can only be effective when the biopsychosocial causes of homelessness are also addressed” (Chevreau, 2021). The Biopsychosocial model is both a philosophical and practical care model. In the philosophical sense, it underscores how suffering and illness are impacted by multiple levels of interaction from the molecular level to societal systems at large. And at a practical care level, the biopsychosocial models emphasize the importance of the subjective experience of the individual efforts toward positive treatment outcomes (Borrell-Carrió, F., Suchman, A. L., & Epstein, R. M. 2004).
The biopsychosocial model recognizes that there is an inherent link between causality and complexity. In the specific instance of homeless motivation, is the primary issue a personal sense of lack of autonomy? Is it the emotional and psychological debris of a trailing wake of broken relationships? Is it the ravaging effects of substance abuse? Biopsychosocial models would say “Yes.” In fact, these models reveal to us a series or pattern of “feedback loops” which reinforce broken behavior over an extended period of time, a pattern the scientific literature refers to as “circular causality” (Mackie, 1965). In contrast to circular causality, “structural causality” approaches understanding the problem from a different direction. Structural causality places the emphasis on a series of hierarchical relationships that produce a “cause and effect” result (Borrell-Carrió, 2004). In the case of homeless motivation, when the recommendation is made to deal with a substance abuse addiction as a first step, it is suggesting that substance abuse addiction has an a priori position as the leading cause of observed “Care Avoidance.” A qualitative study of motivational and cognitive correlates amongst homeless Veterans emphasized “motivational disturbances” and suggested that mitigating these disturbances was a central key to effective homeless community integration (Horan, 2020). This study introduced two tools to assess individual motivation levels. The Clinical Assessment Interview for Negative Symptoms (CAINS) utilizes a Motivation and Pleasure subscale of nine items that assess irregular sociality mindsets. The Defeatist Performance Attitudes Scale (DPAS) is a 40-item scale designed to detect both the presence and intensity of dysfunctional attitudes (Horan, 2020). In such occurrences, Cognitive Behavioral Therapy applications are a popular clinical and therapeutic response approach.
A comprehensive literature review of the subject of motivation and homelessness inevitably leads to the doorstep of Self-determination Theory (SDT). Self-determination Theory stands as a leading lens to help unpack the psychological and environmental factors informing a homeless individual’s level of perceived and observed motivation. SDT emphasizes three concrete themes: autonomy, competence, and relatedness (Krabbenborg, 2017).
SDT models work with autonomy because it recognizes that an individual needs to believe that they have a true personal volition and the ability to make decisions that shape their present and future realities. A perceived lack of personal autonomy is a leading causality of poor motivational assessment scores in the lives of homeless individuals. For correlative support, a qualitative study of women’s psychological well-being as it relates to leisure time physical activity recognized the key importance of autonomy. Specifically, the study found that women were more motivated to participate in leisure time physical activity when it was offered in a supportive context that facilitated the women’s freedom of choice to participate (Lloyd, 2010).
Self-determination Theory demonstrates that personal motivation can perhaps be best understood on a continuum which moves from external, introjected regulation, identified, integrated and onto intrinsic motivation (Ferguson, 2015). External motivation happens an individual is compelled through punishment or reward. Introjected motivation comes because of feelings of guilt, shame, or attacks upon the ego. Identified motivation is an expression of personal desires that our important to us. Integrated motivation occurs when our actions are expressions of who we perceive ourselves to be and our sense of self. And finally, intrinsic motivation happens when there are inherently interesting characteristics of the behavior itself. A qualitative study collecting data from 7500 undergraduates in Canada underscored the importance of intrinsic motivation when seeking long-term engagement in a project or process. Specifically, the three sub-dimensions of intrinsic motivation understood as 1) to experience stimulation; 2) to know; and 3) to accomplish (Ferguson, 2015). This perspective of Self-determination as expressed on a continuum is very helpful in unpacking the causality of deficient homeless motivation. For example, it can be said that threats of incarceration – representing the lowest expression of motivation on the continuum scale, external – would have only nominal effect in producing desired long-term behavior.
A quantitative study of 109 patients who completed a patient treatment questionnaire before entering an alcoholism clinic gives further insight into the causality of motivation. A lack of motivation is one of the most frequently cited reasons for substance abuse patient dropout. This study challenged the standard line of questioning, “How motivated is the individual to change?” and instead draws upon the findings of Self-determination Theory, which emphasizes that the source of motivation is as important as the perceived intensity (Ryan, R., Plant, R., & O’Malley, S. 1995). Important to this literature review, this study documented that many alcoholics are coerced into treatment and, therefore, the outcomes are poor. The study condensed Self-determination Theory into three expressions of motivation: External motivation (“If I remain in treatment, it will probably be because I get into trouble if I don’t.”); Introjected motivation (“If I remain in treatment, it will probably be because I will feel very bad about myself if I don’t.”); and Identified motivation (“If I remain in treatment, it will probably be because it’s in my best interest to complete treatment.”). The implications for motivation in the homeless community space is clear. Causality for high levels of “Care Avoidance” can be traced to predominant External motivation strategies with the homeless individual.
Part Four – Existing Policies or Intervention Models
In 2019, the conversation about how to motivate the homeless population to participate in help and services offered took a dramatic and unexpected turn when California Assemblyman Mike Gatto proposed establishing “Homeless Court.” This court would be vested with the authority to convict a homeless individual and sentence them to up to a year in jail, a year in a court-referred substance abuse program, or a year in a mental health facility. This is, perhaps, the ultimate expression of an external, punitive motivation strategy with respect to the homeless population. The proposal did not garner enough support to be made law, but it is a conversation topic in the homeless services industry to this day. What would be the likely effect of Homeless Court? It would, for all practical, clean up much of the street and community tent encampments. This would be regarded as an immediate, if likely short term, public policy victory by many. However, Self-determination Theory suggests the policy victory would be short-lived, as the motivational force behind decisions made would lack most any sense of personal autonomy. In other words, the homeless individual is likely to fall out of the program and back on the streets in a relatively short time frame. Health policy advocate Jen Flory of the Western Center on Law & Poverty wrote, “Forcing people into institutions is imprisonment by another name. Criminalizing homelessness will not make the issue go away. It would be expensive, and in most cases, illegal” (2020).
There are very real Diversity, Equity, and Inclusion problems with criminalizing homelessness as well. Today, black residents make up only 7.9% of the population of Los Angeles County, and yet they comprise a startling 40% of the county’s homeless population. As recently as May of 2021, Federal Judge David C. Carter publicly rebuked Los Angeles County officials for causing homelessness through “structural racism” (Oreskes, 2021).
As an alternative to “Homeless Court,” there are efforts underway to incentivize homeless individuals to voluntarily participate in therapeutic treatment programs that focus on work readiness, sobriety, and community integration. For example, The Salvation Army is experimenting with incentivizing homeless individuals to complete a 6-month therapeutic rehabilitation program by offering substantial “Supplemental Placement” financial support upon program graduation. This support could be used for things like housing, transportation, and even small business development. The jury is still out on how effective such efforts will be. A qualitative study summarizing the collective data on the role of fiscal incentives to change health behaviors points out that it has been demonstrated that people react more to losses than to gains of equivalent magnitude. Loss aversion tells us that a person who loses $10 will lose more satisfaction that a person who gains $10 from a surprise windfall (Vlaev, I., King, D., Darzi, A., & Dolan, P. 2019).
Some of the most promising developments can be found in paring the best principles of Self-determination Theory with the technique known as Motivational Interviewing. Motivation Interviewing is a strategy that seeks to explore and resolve personal ambivalence through four key components: expressing empathy, developing discrepancy, rolling with resistance, and offering support for self-efficacy. Markland and Rollnick suggest that attempts to directly persuade an individual to change most often fail because it involves taking one side of a conflict the individual is already experiencing. They write, “Instead, motivational interviewing allows the client to overtly express their ambivalence to guide them to a satisfactory resolution of their conflicting motivations with the aim of triggering appropriate behavioral changes.” (Markland & Rollnick, 2005). Thus, the role of the counselor or care provider shifts from working to encourage changes in behavior to encouraging the individual to work through issues of ambivalence until they reach of point of making decisions to progress themselves, encouraging overall autonomy and a sense of personal competency.
References
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