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Journal of Poverty

ISSN: 1087-5549 (Print) 1540-7608 (Online) Journal homepage: http://www.tandfonline.com/loi/wpov20

Managing Multiple Disadvantages: The Regulationof Complex Needs in Emergency Shelters for theHomeless

Marianne Quirouette

To cite this article: Marianne Quirouette (2016): Managing Multiple Disadvantages: TheRegulation of Complex Needs in Emergency Shelters for the Homeless, Journal of Poverty, DOI:10.1080/10875549.2015.1094774

To link to this article: http://dx.doi.org/10.1080/10875549.2015.1094774

Published online: 05 Feb 2016.

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Managing Multiple Disadvantages: The Regulation ofComplex Needs in Emergency Shelters for the HomelessMarianne Quirouette

Sociology, University of Toronto, Toronto, Ontario, Canada

ABSTRACTPeople who face multiple disadvantages (re: poverty, crimina-lization, discrimination, addiction, health/mental health, dis-abilities) make up the majority of the homeless shelterpopulation on a daily basis. This group challenges practitionersand existing service structures, and the author shows howthese challenges shape (1) collaboration with “complex-need”clients, (2) triage and case prioritization, and (3) assessments ofhousing readiness. Pulling from policy and organizationaldocument analysis as well as 20 in-depth interviews withemergency shelter practitioners, the author argues that institu-tional recognition of people’s “complicated” needs translatesinto tighter regulation and/or decreased support.

KEYWORDSCase management; complexneeds; emergencyhomelessness shelters; risk

Introduction

Over the past few decades, responses to homelessness have consisted primar-ily of temporary shelter and supports (Culhane & Metraux, 2008; Gaetz,2010; Wagner & Gilman, 2012), with emergency types of services—shelters,jails, and hospitals—being used as rotating “solutions” to a number of socialproblems (DeVerteuil, 2003; Dowse et al., 2009; Hopper, Just, Hay, Welber,& Hay, 1997). Despite recent large-scale efforts to standardize and improveservices for the homeless, long-term and episodic homelessness is increas-ingly common in Canada (Aubry et al., 2013; Human Resources and SkillsDevelopment Canada [HRSDC], 2012; Street Needs, 2013) and in the UnitedStates (Culhane & Metraux, 2008). Often cycling in and out of other institu-tions, people who are criminalized, have legal issues, addictions, health/mental health problems, cognitive disabilities, and who exhibit rule-breakingbehavior make up the majority of shelter populations on a daily basis. Inturn, life in shelters, in jail, and on the streets can exacerbate addiction andmental health issues, lead to disease and criminal victimization, and under-mine all other aspects of wellness and stability (Bourgois & Schonberg, 2009;Frankish, Hwang, & Quantz, 2005; Huey, 2012; Hwang, 2000). Despite being

CONTACT Marianne Quirouette, PhD candidate marianne.quirouette@mail.utoronto.ca 725 Spadina, M5S2J4, Toronto, ON, Canada M5S 3L9

JOURNAL OF POVERTYhttp://dx.doi.org/10.1080/10875549.2015.1094774

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widely used multifunctional institutions, emergency shelters cannot “fix” thevery complicated problems homeless people face.

This article is about how the needs of emergency homeless shelter clientsare assessed and how this recognition shapes institutional responses andmanagement practices. Pulling from policy and organizational material ana-lysis as well as 20 in-depth interviews with frontline practitioners, I showhow difficulties associated with coordinating services for this group result ina reshaping of policy in practice. My data shows that shelters are best suitedfor “ideal clients”—those defined by a high level of motivation and ability toaccess resources, cooperate with case plans during a short housing crisis, andmove on quickly to rejoin the community. Simultaneously, shelter policiesignore the difficulties associated with delivering services to clients who aremore challenging and who do not fit the mold provided. In practice, caseloadpressures and resource gaps push shelter staff to reconsider how they arewilling to manage this group, resulting in a reframing of client responsibilityand of case work, and in a parallel reshaping of service delivery dynamics.

Practitioners must reconcile policy, organizational, and market demands withthe reality of their clients’ needs, and in this article, I illustrate how this generatesadditional barriers, remarginalizing themost vulnerable. Focusing on professionaldiscretion on the front line (see also Lipsky, 1980; Maynard-Moody & Musheno,2003), my findings support the broader argument that poverty governance todayis a “productive project of discipline” that adopts a paternalistic ethos while beingvery sensitive to managerial and market pressures (Soss, Fording, & Shram, 2011,p. 296). I argue that even in shelters institutional recognition of people’s “compli-cated” needs often translates into perceptions of heightened risk (of program/rehousing failure), leading to tighter regulation and/or decreased support.Although mandated policies claim to prioritize those with the most acute orcomplicated needs, in practice, this group is excluded from services preciselybecause of the complexity of their needs, and because of how those needschallenge organizational capabilities and professional sensibilities.

Notwithstanding policy recognition of the practical and humanitarianissues at hand (Anderson, 2011; John Howard Society of Ontario [JHSO],2012; Rankin & Regan, 2004), little sociological research considers howintersecting and complex needs are conceptualized and addressed in shel-ters or in poverty management more generally. Highlighting several coun-ter-productive service barriers, I demonstrate there is profound andsystemic denial regarding the kind of support some people need andwant. This study’s findings show how regulating case plan complianceand access to housing —by imposing or preventing referrals—becomespart of regulating the antisocial behavior of people who simply will notor cannot “get better” or fit in (see also: Dej, 2011; Dordick, 1997; Flint,2009; Lougheed & Farrel, 2013). Without access to safe housing or sup-ports, people are dealing with exceptionally difficult problems (trauma,

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poverty, mental illness, addiction, cancer), while also facing discrimination,racism, criminalization, and barriers to service, because of their beingassessed as being undesirable, risky, or difficult to work with.

In the pages that follow, I use policy, organizational, and interview mate-rial to describe how clients who are multiple disadvantaged with complex-need are defined and understood and outline some of the basic problemsrelated to service delivery, which trigger what I call a “redefining of urgency.”I offer analysis of three instances where policy is reframed in a way thataffects regulation and support for the most complex and challenging cases.Practitioners use discretion regarding (1) collaboration with clients, (2) casetriage and prioritization, and (3) assessments of housing-readiness. I arguethat institutional recognition of people’s “complicated” needs translates intotighter regulation and/or decreased support.

“Standardizing” poverty management

Standardized case management strategies, which ostensibly manage risk andenhance the efficiency and accountability of service delivery, have beenadopted by homeless shelters and gained widespread internationalpopularity1 (Zufferey, 2008). The adoption of risk-based case managementpractices is also evident in other sectors of human services, including proba-tion, parole, police, social work, child welfare, and mental health (Ericson &Haggerty, 1997; Hannah-Moffat, Maurutto, & Turnbull, 2009; Parton, 1998;Robinson, 2002). As in probation work (Hannah-Moffat et al., 2009), assess-ment tools and case management policies in shelters are meant to helppractitioners establish a client’s risk/need profile and determine what kindof services, program interventions, and levels of support are appropriate.Although the professional discourse of risk management claims to legitimizethe expertise of service providers, many of them struggle with powerdynamics and the notion that their expertise should trump that of the clientsthemselves (Zufferey, 2008). Relationships between shelter staff and thehomeless are complex and framed by power differential; due to their abilityto withdraw services, case workers must negotiate competing prioritiesregarding care and control (Huey, 2007, 2008).

Accounts dating back to early 19th-century practices show how the provi-sion of basic housing and support is interlaced with the regulation of moralorder. In poor houses, for example, those who are unemployed, homeless,addicted, or mentally ill were subject to rehabilitative and punitive projects(Wagner, 2005). More recently, Flint (2009) and others (Cloke, May, &Johnson, 2010; DeVerteuil, 2006; Huey, 2007, 2008; Wasserman & Clair,2010) have shown how the increasingly intense policing and supervision ofhomeless populations (Feldman, 2004; Foop, 2002) is not simply a project ofexclusion or repression, but also include coercive elements of forced inclusion

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to therapeutic projects. Shelters typically require that clients show compliancewith rules and motivation toward change, recovery, rehabilitation, and/orhousing plans. Despite the popularity of housing-first approaches and mount-ing criticisms against “treatment first” and “continuum of care approaches tohomelessness, emergency shelters continue to be used at maximum capacity.In many cities (including Toronto) other residential options—like transitional,low barrier, recovery based shelter, or supportive/affordable long term housing—are lacking and very difficult to access. Emergency shelters often “institutio-nalize concepts of homelessness as primarily a function of mental illness andaddiction by mainly and sometimes exclusively offering services aimed attreating those conditions” (Wasserman & Clair, 2010, p. 171; Lyon-Callo,2000); this medicalization model is not a good fit for everyone.

Managers and front-line workers exercise discretion, reinterpreting andreframing institutional rules in their everyday practice. As Lipsky (1980)argued, practitioners exercise considerable political power and need to berecognized as “street-level bureaucrats” who make real and important policydecisions every day. For example, Lynch (1998) showed how parole officers useintuitive approaches to managing offenders, highlighting how macrolevelinstitutional models do not always “trickle down in a straight and directpath to the frontlines” (p. 861). Similarly, Hannah-Moffat et al. (2005; 2009)demonstrated how risk/need logics are fluid and can be restructured andreshaped by discretionary judgments to support a wide range of strategiesand practices, supportive and/or punitive. Despite working in a “standardized”context, practitioners incorporate risk logics with welfarist, religious, and otherphilosophies, building “braided strategies” (Hutchinson, 2006;– see alsoGoddard, 2012) that cannot be characterized without their inherent contra-diction and inconsistencies. Case managers in shelters put their own spin onefforts to work with clients, and for this reason it is useful to gain insight intotheir experiences of, and perspectives about, managing complex cases.

Shelter staff must overcome numerous challenges to try and respond to thecomplex needs of people who face multiple disadvantages. The success ofcase plans and referrals is dependent on many factors including resourceavailability, program eligibility, wait times, and client cooperation. Evenwhen a person’s needs have been clearly identified, waiting for programspace or housing accommodations often takes much too long. In this article,I show how structural shortcomings contribute to a redefining of profes-sional roles, case work dynamics, and a recategorization of clients and theirassessed “needs.” I respond to the call for a move beyond classic policy-practice analysis towards a more nuanced understanding of the reframingprocess as one that “generates new constituencies, molds new languages ofcontention, and constrains and enables the definition of new ‘problems’”(Schonfeld’s 2010, p. 759). New constituencies of clients with complex needsare labeled as “not housing-ready,” resistant to case work, and this

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understanding can prevent referrals to long-term supports or limit ongoingaccess to emergency services, even putting people back out on the streets.This analysis highlights how case managers in emergency shelters adapt theirmanagement strategies when supports are lacking and when standardapproaches are not effective or feasible.

Research context and method

The city of Toronto’s social service response to homelessness has longfocused on emergency-based “management” techniques; with large sheltersaccommodating hundreds nightly2 (Gaetz, 2010; Laird, 2007). Following thehomelessness “crisis” of the late 1990s, municipal policies were developed tospecify rules emergency shelters should comply with (Shelter Standards,2003). This policy shift was an attempt to standardize practice, for example,the Case Management Handbook (City of Toronto, 2005) outlines howshelter staff are meant to use a “matrix model” (includes seven stages andeight components of service) to systematically assess and respond to issues of“safety, health, personal ID, financial, legal, housing, education and employ-ment” from intake to discharge (p. 11). My research took place in 2010/2011and includes thematic analysis of municipal policy documents, (such as: Cityof Toronto, 2005; Client Support Services Framework, 2007; ShelterStandards, 2003; Street Needs Assessment, 2009, 2013) as well as secondarydata obtained online or through interview respondents (e.g., organizationalhandouts, program rules, case management policies, and performancereports). This material helped situate institutional logics about the needs ofclients and the roles of case workers. Thematic document analysis took placebefore, during, and after interviews, helping connect interviews and theirlarger contexts.

Using snowball sampling methods, I conducted 20 in-depth semistruc-tured interviews with case managers from seven different emergencyshelters.3 The sample (quasi-convenience/quasi-representative) includesstaff from shelters that accommodate anywhere from 50 to 400+ clientsnightly, some in private rooms, others in dormitory-style bunks, and othersstill on mattresses placed on the floor. Some of the shelters housed women,men, youth, or mixed singles, couples, and/or families.4 Some were cityoperated, and others were charitable and faith-based organizations. Thecase managers I interviewed had a wide range of responsibilities (includingadministrative and managerial) but also worked on the front line managingnumerous client cases on a daily basis. Interviews focused on (1) howpractitioners work with clients with multiple disadvantages who have com-plex and interconnected needs, and covered a range of topics that highlight(2) what supports and/or limits good case management. For this project,themes were identified using “top-down,” and “bottom-up” approaches, and

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the semistructured interview guide evolved and was adjusted to incorporateemerging leads. For example, themes of risk/needs assessment, intake tools,staff burnout, system gaps, and interdisciplinary collaboration were folded in.Specifically, I asked practitioners, “What helps you understand what yourclients’ need?” “What do your clients most benefit from?” “What challengesand barrier do you encounter?” “Can you give me some examples of how youworked around this issue?” “What other professionals and agencies do youwork with // make referrals to?”

Thematic analysis is “not wedded to any pre-existing theoretical frame-work” and can be a realist and a constructivist method allowing for con-sideration of policy, process, and practice as well as for perceptions,interpretations, and experiences (Braun & Clarke, 2006). This dual strategysupports consistency while also allowing for flexibility and openness tounexpected insights (see also Fereday & Muir-Cochrane, 2006). All datasources—including interview transcripts, organizational documents, (reports,policies, handouts) and grey literature–were thematically analyzed. First,manual analysis consisted of line-by-line reading and highlighting, flagging,and writing on various sections and passages to start sorting out potentialpatterns. Coding was theoretically driven and guided by predeterminedcategories (Crabtree & Miller, 1999), and also data driven, generated ininductive and often unpredictable and ways (Boyatzis, 1998). Initial themecodes were then collapsed to narrow down to core issues: focusing on aspectsthat interview explicitly explored (e.g., assessment practices, strategies forcase management, experiences of responding to complex and interconnectedneeds, promising policies, structural gaps), as well as others that wereunplanned (e.g., “reasonable” collaboration, self-sabotage, housing readiness,cherry picking). In the following two sections, I show how shelter clients whoare multiply disadvantaged, with complex need, and who are hard to serveare understood by policy makers, researchers, and practitioners.

Complex needs and intersecting disadvantage

The emergency homeless shelter system is designed for clients who are moti-vated, cooperate with case plans, and work toward rehousing and communityreintegration. Such “ideal” clients represent the bulk of the shelter population interms of total numbers but use far less staff time and resources than clients whoare chronically or cyclically homeless with complex needs. The latter groupcycles in and out of other institutions, facing issues related to criminalization,addictions, health/mental health, cognitive disabilities, and discrimination.Several studies have now shown that that hard-to-serve client groups representless than one fourth of the shelter population, they use more than one half ofservices (Aubry et al., 2013; Culhane & Metraux, 2008; Homelessness ResearchInstitute, 2007; Kuhn & Culhane, 1998; Stergiopoulos, Dewa, Durbin, Chau, &

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Svoboda, 2010). Essentially, a small portion of the shelter population–—whichtends to comprise primarily of men who are middle age or older5 (Aubry et al.,2013; HRSDC, 2012; Mental Health Commission of Canada [MHCC], 2014;Street Needs, 2013)—predominates in the shelter system on a day-to-day basis,and is a growing cause for concern. The disproportionate amount of people whosuffer frommultiple disadvantages and also have ongoing problems with home-lessness has been well established in American (Culhane & Metraux, 2008), andU.K. studies (Fitzpatrick, Bramley, & Johnson, 2012), and Canadian research isnow showing the same pattern (Mental Health Commission of Canada, 2014;Street Needs, 2013). This is especially worrisome in the context of shrinkingsocial supports and longer average stays for vulnerable groups like children,minorities, and seniors in emergency shelters (HRSDC, 2012).

People described in policy and in practice as being “complex need”(Anderson, 2011; JHSO, 2012; Rankin & Regan, 2004) are also referred toas being “hard to serve,” “multiply impaired,” “high needs,” “difficult toplace,” and “service resistant” or called “multi-problem” offenders/patients/clients in other contexts. Borrowing from Rankin and Regan (2004), I under-stand complex needs to loosely refer to breadth of needs (multiple andinterconnected issues) and depth of need (e.g., intensity, risk, level offunctioning).6 The complexity of people’s needs is widely divergent andsubjectively determined, but this group is often described as (1) fallingthrough the cracks of other systems like youth care, mental health, disabilitysupports, long-term care, or corrections; (2) burdened by structural disad-vantage, poverty, and discrimination; (3) engaging in survival behaviorsconsidered to be high risk or self-sabotaging like drug/alcohol abuse, sexwork, and criminal activity; (4) resisting case work and avoiding essentialservices and supports; and (5) facing personal disadvantages related toilliteracy, disability, mental health, brain injuries, Fetal Alcohol SpectrumDisorder (FASD), social isolation, and/or trauma.

Describing their challenges helping clients with “complex needs,” inter-viewees talked about violence (assaults on staff, residents, and communityresidents; victimization), mental illness (psychosis, paranoia, dissociation,aggression, hospitalization), hygiene issues (poo smearing, incontinence,dressing changes, contagious conditions), self-harm (swallowing objects,pills, cutting), legal issues (arrests, jail, court, bail, probation, immigration,custody), and serious medical conditions (diabetes, cancer, postsurgery care,HIV, hepatitis, skin conditions). They also talked about clients having needsrelated to parenting, aging, culture/language, identity, self-esteem, faith,and motivation.

A senior practitioner described how some people get “stuck” in shelters:

The majority of people (75%) are here under 2 weeks. They come in, they getorganized, they get out, and those are the people that we are designed to serve.

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These other folks really need permanent housing, but there is no supportivehousing in the community, there is no place for them to go, there is no agencyprepared to work with a guy who’s got a brain injury, smokes crack, has schizo-phrenia, has behavior issues, is aggressive and tells you to fuck off on a regularbasis. There is just no program for him! Other than . . . shelters. Last year we served5,000 human beings . . . 300 of that 5,000 are here non-stop. We are housing thosefolks; we’re not providing emergency shelter. . .. So yeah, society hasn’t realized yetthat it would be much cheaper if there was support for them. (T011-85)

This description highlights the limitations of shelter based responses tohomelessness, and the challenges that practitioners face when dealing withstructural and individual factors that intersect and complicate case manage-ment plans.

Each agency has a different definition of what makes a person “hard toserve,” “complex need,” or even “resistant,” and studies have shown to whatextent assessments can differ from one professional to another (Toch, 1995;Vagg, 1992). For example, Vagg (1992) studied the case management of“difficult-to-place” people in psychiatric facilities, social and legal services,and found there was very little agreement between professionals as to whatexactly was wrong with clients or offenders. In one particular client case, “twoagencies concerned identified 12 problems between them but only one wasmentioned by both of them” (Vagg, 1992, p. 132). Needs are assessed accord-ing to organizational goals and are defined as complex by the institutionalcapacity to respond to individuals shortcomings, not by self-identification.Focusing on how people have “complex-needs” is only and ever useful insofaras it informs the delivery of better services. If we imagined that resources wereabundant and practices were flexible, wemight not find it necessary to describepeople as being complex need or hard to serve at all.

Resistance, failure, and self-sabotage

In emergency shelters, people who are chronically or cyclically homelessness areoften understood as being responsible for their failure to “move on.” At times,the “complexity” of their “needs” is primarily defined by their resistance to casemanagement or their lack of general compliance with agencies (Padgett, Gulser,& Tsemberis, 2006). In some cases, formal assessment can be at odds withclient’s self-reported needs, and this can produce further marginalization.Disagreeing with professional assessments, they are often seen as being in denial,and their resistance or mistrust characterized as antisocial behavior or paranoia(Lyon-Callo, 2000). Assessed and labeled as being complex-need, hard-to-serve,and/or resistant, people inherit a status that marks them as being difficult,leading to a reduction in the quality of services received.

The literature that has focused on clients who are hard to serve is rich withaccounts of why it is so difficult to work with complicated—and often

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involuntary—clients (see Kryda & Compton, 2009; Scanlon & Adlam, 2008;Stanhope, Henwood, & Padgett, 2009; Stanhope, Tiderington, Henwood, &Padgett, 2012). Often ill suited to fit institutional molds, they may not wantor be able to comply. In shelters, this dynamic is often complicated by (1) theinvoluntary and oppressive nature of case management (Rooney, 2009), (2)deeply engrained antisystem or antiauthority attitudes (Gowan, 2010;Wasserman & Clair, 2010), and (3) the fact that mobility (institutional transi-ence) and resistance can be a mechanism by which people can exert limitedautonomy and freedom (DeVerteuil, 2003, Henwood, Stanhope, & Padgett,2011; Wasserman & Clair, 2010). The theme of self-sabotage dominated manydiscussions with front-line staff who explained barrier to successful caseworkand progress.

Interviewees spoke of client resistance and lack of motivation as a productof shelterization, explaining how “people have accepted where they are, theylive on the street, they identify as homeless. They see the system is keepingthem where they are and it’s hard to convince them to move on” (T003–165).This attitude was described as the result of growing up in youth care,experiencing trauma, being entrenched in drug culture and street families,and getting stuck in the institutional revolving door. Many clients describedas service resistant are also on the “institutional circuit” (see Hopper et al.,1997; Stanhope et al., 2009) and may share characteristics with clientsdescribed as low functioning and complex need. Some however, weredescribed as highly intelligent, educated and able bodied, yet “refusing” tosettle, resisting normative understandings of their “problems,” and “sabota-ging” plans toward change (see also Scanlon & Adlam, 2008; Stanhope et al.,2012; Wasserman & Clair, 2010).

In some cases, resistance is overt and clients react to case plans as if theyare punishments. One shelter manager explains:

I have identified people who are housing ready, who should be moving on, with noreason to be here. You start sort of pushing them, and they’re like “who me, howcome I have to do it? You know that guy that sleeps in the bed across from me; he’sbeen here for 6 years, why are you picking on me?” And it’s like “well, I want the verybest for you which is not staying in the shelter.” It’s astounding the number of peoplethat have said: “when you house that guy, that guy and that guy, then you come talkto me and I’ll go get housing.” I’m like are you serious? Like, really? (T008–661)

Interview respondents understood resistance as linked to institutionalization(growing up in Children Aid Society (CAS), time in jail, rehab, hospital), andto the overpolicing and punishment of the homeless by various heavy-handed institutions.

Interviewees reported feeling manipulated by clients who “work the sys-tem,” “tell them what they want to hear,” and who play on their emotions toget what they want, explaining how it “makes it difficult because your case

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management plan blows up in your face and you have to start all over again”(T005–283). Shelter staff use “practice wisdom” (Stanhope et al., 2009) toidentify covert “resisters” and prevent misusing time or services on them.People who are homeless and refuse to cooperate and reintegrate into themainstream are stigmatized by policy and shelters practices alike. Violatingclient agreements, they do not fulfill their duty to work on approved goals inexchange for access to shelter services. One of several incumbent problemswith this situation is that clients who do not genuinely adopt case work goalsor who fail to comply are often punished and excluded from having access toservices like long-term supported housing and specialized program referrals.

The present study reinforces Scanlon and Adlam’s (2008) contention thatthere is a widespread social refusal to recognize the existence of people whoare homeless and who refuse to “play the games” of mainstream life. Suchdenial is dangerous because “no matter how politically correct the policy, orhow sophisticated the needs assessment tools, such belief systems are settingup socially excluded people, and the workers charged with trying to reach outto them, to fail” (Scanlon & Adlam, 2008, p. 530). In some shelters, non-compliers are moved on and referred elsewhere quickly; in others, they stayfor long periods of time on the “back burner” until they violate shelter rulesor are referred for infractions rather than noncompliance. The tensionbetween supporting clients’ decision to live in shelters long term and impos-ing discharge came up in many interviews. Practitioner accounts illustrate arange of strategies for dealing with people who are chronically homeless, oneextreme focused on results-driven “tough love,” and the other focused onbeing “low-barrier” and not turning anyone away. Despite negative connota-tions related to warehousing, low-barrier shelters that tolerate disruptivebehavior create important spaces of care (Evans, 2011) for those who cannotbe served elsewhere. Respondents did identify some promising options forlow-barrier service points in the city but were clear limitations stemmingfrom scarcity of available spots, exclusion criteria, and long wait lists. Becauseresources are scarce even for cooperative “ideal” clients, those who resist aredeprioritized and their service disengagement is anticipated.

Policy pipe dreams

City policy identifies specific circumstances when level of support must beincreased for clients who (1) “have been in shelter more than 3 months,(2) have had repeated admission, (3) have health, mental health, or otherescalating issues, (4) have service restrictions, (5) have experienced seriousincidents, have (6) barriers preventing their engagement in service plan,or (7) have issues of compliance with case plan” (Client Support ServiceFramework, 2007, p. 4) This is problematic because shelter service pat-terns in Toronto clearly show that though recurring and long-term users

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represent only 12% of the shelter population overall, they use 60% of thebeds available day to day (Aubry et al., 2013, p. 6), and the average lengthof homelessness for shelter clients is around 3 years (Street Needs, 2013).According to mandatory policy, shelter staff should “increase contact,increase case plan evaluations, increase referrals to community serviceorganizations, set up case conferences with other parties and seek addi-tional support with managers and supervisors” Street Needs, 2013, p. 4)for those who meet these criteria. The majority of shelter clients who fitthis profile require supports, advocacy, and time-consuming personalengagement to access housing supports and services; yet interviews revealthat case workers are far too overloaded and underfunded. As the follow-ing three sections show, the gap between shelter goals and policies onpaper and practices on the frontlines has significant consequences.

Collaborative management

The official goal of shelter case management is to discharge through optimalreintegration in the community and engagement that is “guided by the clientand shelter worker in partnership” (City of Toronto, 2005; Client SupportServices Framework, 2007). Shelter residents are formally responsible forworking with staff to “improve their housing situation within their capacity”(ibid., p. 15, emphasis added). Clients have the right to be involved in caseplanning and the right to staff support if they “identify reasonable goals theywish to achieve” (ibid., p. 15, emphasis added). This type of “conditionalhospitality” (Darling, 2009) means access to help and services is dependenton clients’ desire to work toward normative goals and ability to be reasonableand responsible. The service delivery framework in shelters ignores theexistence—let alone the prevalence—of clients who cannot be successfullyintegrated into a process of identifying and working towards mainstream“reasonable” goals.

For example, clients who suffer from mental health issues, intellectualdisabilities, acquired brain injuries (ABIs), or fetal alcohol spectrum disordermay have difficulties with impulse control and with conforming to socialnorms (Dej, 2011; Lougheed & Farrel, 2013; Lemsky & Godden, 2014).Despite reported commitment to client-led service delivery, respondents’anecdotes made it apparent that collaborative case management is not alwayspossible. One respondent stated that many clients, “don’t even realize they’rein case management” (T010–95). These cases call for a reframing of ideasabout client responsibility and the role of shelter staff. As this intervieweeexplains, clients are often unable to develop suitable case plan goals:

Ideally I would like to support the resident in their plan and do what I can to seetheir plan met, but there are times when that’s in conflict with our mandate or ourpolicies—or even it compromises safety.. . . I’ve got one guy whose plan, sometimes

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it’s to live in a carpet, sometimes it’s to buy land. Well he doesn’t have any moneyto buy land so that’s just not going to work. (T004–25)

These clients do not fulfill their responsibility as it is defined by policy.Breaking the rules—even if unintentionally—people who are low functioningor cognitively impaired often fail to follow case plan and are generallydescribed as unable to properly make choices for themselves.

When shelter clients are seen as making non-normative choices, casemanagers reported having to say: “if that’s what you want, this is not theplace for you” (T004–162). Although some interviewees vocalized a strongdesire to support self-determination, they also voiced frustration regardingclients “with mental health issues, who will not take their meds, who will notshower” explaining that “having lot of say in their own health is a good thing,until it becomes a danger for themselves and others” (T010−180).Interviewees had varying levels of tolerance for clients who are noncompliantwith aspects of their case plans, defining it according to risk to self or others,deception, and lack of transparency or lack of personal potential or progress.Shelter staff must find their own ways to “artfully maneuver clients towardspreferred outcomes in ways that protect organizational interests” (Spencer &McKinney, 1997, p. 199). They negotiate competing demands from culture,policy, and front-line realities and must overcome barriers related to lack ofsuitable resources and the difficult dynamics of working with people whoface many disadvantages and also resist, break rules, and misbehave.

Respondents shared numerous anecdotes about how they push alongclients to help them, taking time to build relationships and even “tricking”clients into cooperating with shelter rules and case plans. One respondentdescribes techniques:

When you’re dealing with a client with really high mental health needs, who is notcontrolled and has no supports in the community, there are things that you aredoing for them that have never been done before. Some have been mentally ill onthe streets for ten years. They may not have had a shower in 5 or 6 years, seriously,like: SERIOUSLY. They have not had a haircut, they have had no money . . . theyhave the clothes on their backs if they’re not falling off and that’s it. So first youbuild a relationship with stuff. “Hey man, here, let’s go for a cigarette . . . hey,whenever you need a cigarette you come and see me” so that starts for a couple ofweeks. They knock at the door; you say, “you need a smoke? Here.” Then the 3rdweek he’s knocking at the door and asks for a smoke, so “yeah, but let’s get youcleaned up first, let’s have a shower and get you some clean clothes,” then latereven, “let’s get you some ODSP7 papers” . . . and then a health card, then “I wantedyou to meet a friend of mine, Damian8” (the psychiatrist). . .. We do what we haveto do to work with clients where they are at. (T001−139)

What this quotation clearly illustrates is the time-consuming nature of build-ing trusting relationships with shelter clients who are highly marginalized and

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hard to serve. In addition, this shows the creative component of case work,highlighting how some clients need accommodated supports.

Policies about being “client led” are appealing but do not always reflect therealities of where clients are at. In the Toronto context, resources in theemergency shelter system typically do not allow for intensive relationshipbuilding and one-on-one, flexible support for all those who need it.Consequently, case managers are left to their own devices and must oftenovercome obstacles in the margins of official policy. They do this with varioustypes of education, training, and practical experience, and many respondentsreported feeling ill equipped, using a spectrum of strategies ranging from“forcing” casework to dropping it off the agenda entirely. In contrast, casemanagers in two of the seven shelters I visited reported being more comfor-table and able to support clients with complex needs on their own terms. Theyattributed this to their organization’s explicit mandate to offering low-barrierand client-centered services for hard-to-reach populations—offering harmreduction, trans-friendly, and pet-friendly spaces, for example.

Triage and client prioritization

Respondents reported daily caseloads ranging from 30 to 75 clients9 andexpressed frustration when describing their professional roles, comparingcase work demands to triage. One practitioner explained, “We assess what’sthere, prioritize, look at the available resources and match the resources tothe need. With triage, there are a lot of battlefield connotations, you know,limited resources, which soldiers..” (T001–464). This battlefield referenceserves as a reminder of the brutal realities of shelter and street life. Thenotion of triage is even more important because shelter staff working withlarge caseloads and limited energy, time, and resources must adopt methodsof prioritizing clients. Case managers in my sample all reported a similarprioritization schema of responding to acute emergencies and crisis, andfocusing on clients who were younger and newly homeless.

Many respondents rationalized their prioritization by arguing that it isimperative to reach people who are vulnerable and newly homeless beforethey become entrenched in the lifestyle or suffer serious consequence, likevictimization, addiction, and criminalization. As the following excerptillustrates:

if someone has been here 5 years, works a bit with scrap metal, then comes backand drinks, for me, he’s not high needs. I like to concentrate on the new ones thatare coming in, the younger guys, you know . . . university students who end uphere because they are now schizophrenic. So those ones are the ones who you wantto get to quickly, to make sure that they are not here for the next ten years of theirlives. (T004–120)

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This illustrates that case managers downplay the needs of clients who arechronically homeless and how prioritizing clients who show promise for anormal life is rationalized. This respondent argues that some clients are inneed of more prompt intervention and supports this claim by mentioninguniversity attendance and the recent development of mental illness.

Policy defines clients who are “high-need priority” as those who arechronically or cyclically homeless; who have restrictions; issues with com-pliance; struggle with health, mental health, or other barriers; and havesuffered trauma (Client Support Service Framework, 2007), however, thedefinition changes in practice. Prioritizing in real time is about investingenergy and resources where positive outcomes are more likely rather thanwhere need is most acute. In the hopes of promoting positive outcomes,shelter staff deprioritize those who have become regulars on the institutionalcircuit and who are difficult to motivate. Practitioners have to make assump-tions about client intent and rehabilitation potential to decide where to investeffort and resources. As a result, a client who is chronically homeless may belabeled by City tools “high priority,” and reassessed otherwise in practice by acase manager.

Interviews indicate recurring concern with the lure and danger of streetlife, shelter culture, crime, alcohol and drug use, and shelter clients are oftendescribed as “tainted” by their environment. For example, one managertalked about addiction, stating that, “there are only 2 people in the wholeshelter that I know for sure don’t smoke crack” (T008–38). The prevalence ofclients with serious addictions and the lack of effective service responsesavailable contribute to staff “burn-out” and forces them into “practical” triageand “realistic” client management. This was presented as support for prior-itizing clients new to the social, legal, and health-related problems ofhomelessness:

I often disagree with the housing team’s strategies, they think “we need to get thisguy housed because he’s been here 7 years,” but for me, it’s the person who justcame in off the street, never been in a shelter before, newly homeless, that’s mypriority. Buddy who’s been here 7 years, he’s gonna be here next year too, so puthim aside for a minute and jump on these ones, because if they get sucked into thatsort of black hole of homelessness and it’s really easy for them to stay there. I can’ttell you how many times I’ve seen them come through, they’re not really drugaddicts, they drink a bit, they experiment with drugs and the next thing you knowthey are sucking on the crack pipe 24 hours a day and it really gets them. Thepriority should be the newly homeless because they don’t want to be in a shelter,they are freaked out; so the more intense case management you can do at thatpoint the better. (T008–188)

For clients who have lived on the streets for many years, the “emergency”status of their situation is downplayed based on assumptions that they do notwant to be helped, that it would simply be too difficult, or that “it can wait.”

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As I discuss in the following section, this also means shelter staff strugglewith the risks of either allowing clients to live in shelters too long or ofpushing them too hard to fit into the “proper” client mold.

Housing first and foremost

Housing-first principles have gained international popularity and imply thathousing should be made available to people who need it “immediately,” andin a way that is not conditional upon sobriety or any type of treatmentcompliance (Gaetz, 2010; MHCC, 2014; Tsemberis, Moran, Shinn,Asmussen, & Shern, 2003). This approach can be defined in contrast towarehousing, treatment-first, or continuum of care approaches, which posi-tion housing as a potential outcome rather than an essential input. Targetingclients who have been traditionally hard to serve, housing-first practices havebeen used with people with disabilities (Tsemebris, Gulcur, & Naka, 2004)and with mental health and substance abuse problems (Padgett, Gulcur, &Tsemberis, 2006). Some have voiced concerned about its application withpeople who have very serious addictions (Kertesz, Crouch, Milby, Cusimano,& Schumacher, 2009), but overall, this philosophy has being enthusiasticallycelebrated and adopted as an alternative to continuum-of-care approachesand numerous studies have highlighted the potential and value of widespreadimplementation (Culhane & Metraux, 2008; Culhane, Metraux, & Hadley,2002; Larimer, Malone, Garner et al., 2009; Kertesz & Weiner, 2009; MHCC,2014; Somers et al., 2013).

Threatening the long-term role of the emergency shelter sector, housing-first practices have been widely popularized across Canada thanks to the AtHome/Chez Soi study (MHCC 2012; 2014). Although the City of Torontohas formally adopted a modified housing-first approach to solving home-lessness (Falvo, 2010; MHCC, 2014), my respondents expressed skepticism,claiming that this type of service delivery sets up clients for failure, wastingprecious housing resources without providing the right supports to peopleonce they are housed. Aligning themselves with more of a “continuum ofcare” or treatment-first approach, most implied that people who are chroni-cally or cyclically homeless and have complex needs have to gain skills andsecure transitional supports to be ready for independent living. Respondentstold stories of clients being placed in independent housing prematurely andsuffering negative consequence like (1) being unable to make ends meet,prepare food, or otherwise maintain health and home; (2) being bullied andhaving the apartment overrun by drug dealers or “friends”; (3) becomingmore isolated from services, supports, and socialization.

Shelter staff use discretion to redefine and categorize client needs in theprocess of identifying who is “housing-ready.” Clients are labeled as housing-ready once they are determined to be stable and suited for available

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community living. Interviews show there is no official definition of whatbeing housing-ready actually entails:

there are all these assessments around clients being “housing-ready” but no oneknows what that really means. For some case managers it means that you are notusing, or it means you have addressed your anger management issues, and forothers it means you are hooked up with a primary health care giver or a psychia-trist . . . or it really just means you are interested and willing to go into housing.(T006–4400)

This points to the unclear conceptualization of housing readiness and to thegatekeeping that takes place in emergency shelters. Indeed, many respon-dents noted that they were careful not to place clients in housing before theywere ready to succeed.

To show they are housing ready, clients with “complex-needs” are oftenforced to jump through hoops designed to mitigate risk of continued home-lessness such as job searching, anger management, medical or psychiatricservices, drug treatment, and/or life skills training. Interviewee explainedwanting to prevent tenancy failure and returns to homelessness. Becauseaccess to specialized or low-barrier housing (wet houses,10 transitional,supported) is limited, clients with complex needs fail to comply, and manydo not reach the goal of planned discharge because they resist, misbehave,and/or are conceptualized as not housing ready.

A case worker explained how she conducts intuitive assessments ofwhether clients are housing ready or not, explaining what she sees as “red-flags”:

The ones with really serious addiction issues, you just know they are not going tobe able to sustain themselves, that’s a red flag. Because even if you can house them,there is no way that the assistance that they’re receiving from either ODSP orOW11 is going to be enough for them to live on, and you know that they are goingto spend all of their money on their drug of choice and having them access likefood banks and stuff is difficult because they just don’t care, right. So that’s a redflag. The ones who are extremely depressed or you feel that they might end up likesocially isolating themselves, that’s another red flag. (T006–499)

This interviewee outlined characteristics she sees as preventing clients frombeing housing ready (addiction, apathy, lack of money management skills,depression, and isolation) and indicate that intervention is needed prehous-ing. To avoid case work failure and resource wasting practitioners intuitivelydevelop intuitively developed typologies and strategies regarding who is likelyto “succeed” once housed. Identifying clients likely to sabotage their ownsuccess, one case manager recalled telling housing workers:

You can house this person but you know what, next month they are not going topay the rent. They are going to blow all of their money on crack and they’re goingto be right back here at the door again. So it’s not the right time. (T008–63)

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These findings support what Stanhope et al. (2012) found in that casemanagers tend to respond to perceived resistance and sabotage with emo-tional frustration, cynicism, and cautious levels of effort.

Redefining urgency in emergency shelters

Even when clients are compliant and their needs are well understood,resources are essential for effective case management, transitional, or long-term supportive care to take place. All interview respondents spoke about theabsence of specialized services (i.e., detox) and supported housing options forpeople who need higher levels of support (i.e., geriatric drug users), and thisis echoed in the policy literature. Respondents also spoke of the difficulty inkeeping clients motivated while trying to secure services within an acceptabletime frame, “They expect homeless people to put in an application and thenfollow the application for 5 years, change their address, change their phonenumbers when they don’t even have one. It’s ridiculous and also impossible”(T015–856). One interviewee compared the absurdity of this situation togoing to the hospital emergency room bleeding from an artery and sittingin the waiting room for 3 months. Voicing frustration about people in crisisnot being treated with urgency, she—and many others—talked about howthis slow and ill-suited response encourages feelings of disengagement,resentment, and mistrust in the system.

For specialized programs, exclusion criteria and wait times are also seriouscause for concern. Structural gaps and deficits are so great that basic housingand support needs cannot be met. Clients who are disruptive, transient,violent, or severely cognitively impaired are often considered poor candidatesfor in-demand services and programs because of their high-risk behavior andlow chances of predicted success, further contributing to the service gapaffecting the most marginal clients (Anderson, 2011; Wong, Park, &Nemon, 2006). One seasoned practitioner and manager explains how thetoughest clients are often denied services and excluded from programs:

When housing programs are permitted to cherry pick who they serve, they pick thepath of least resistance. They pick folks that are easy to work with. They do notpick the guys who are downing wine and smoking crack in the washroom,pounding on each other, that have active MRSA’s,12 open wounds and sores 90%of the time, or IV drug users that have HIV. They don’t want to pick those guysand they don’t have to! (T011−82)

Organizations need to demonstrate efficiency to secure ongoing funding, andevidence of success is difficult to generate with clients who are hard to serve.Interviewees demonstrated how they devise their own classification criteria tofilter who is most “high need” and who is more or less likely to succeed andsupport program success. This practice of “creaming off the best functioning

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individuals among the homeless, while denying critical services to the mostin need for service-rich housing placements” (Wong et al., 2006, p. 88) hasbeen criticized before and shows how urgency is redefined on the ground.

Conclusion

Emergency shelters for those who are homeless are designed to help peoplein need of temporary shelter who are motivated and have normative goals,not those in need of intense, specialized, and long-term support. However, itis now increasingly clear that the majority of clients in North Americanshelters on any given day do not “fit” these ideal characteristics. My researchshows how in emergency shelters, the disparity between policy on paper andfront-line reality leads to logistical problems of service delivery. For example,sophisticated assessment tools help assess clients’ needs that cannot be met(because of structural gaps) and case managers must frequently deal withclients with whom mandatory standard approaches are not effective (becauseof compliance expectations). The same types of problems are also experi-enced by correctional officers, social workers, probation officers, and policeofficers (see Lipsky, 1980, Maynard-Moody & Musheno, 2003). Workingwith very disadvantaged and often difficult populations, they too strugglewith restrictions placed on them regarding how they gatekeep resources,promote stability/wellness, manage/punish risky individuals, and deliverpositive outcomes.

Overwhelmed with organizational demands and confronted with frustrat-ing system gaps, service providers make do within the field they areemployed in and must negotiate important policy decisions in their dailypractice. The incongruence between policy and operational context meanspractitioners must use compromise and discretion to assess and triage clients,negotiate client/practitioner dynamics, and develop housing and interventionstrategies. Standardized case work policies, system gaps, and market pres-sures limit how emergency shelter staff can find time, space, and resources tocare for clients with complex needs, thus generating frustration, burnout, andoften encouraging conceptions of such clients as “bad investments.” Asked todo too much with too little, case managers often talked about resisting andreinterpreting shelters policies, rules, and mandated case goals. Pulling fromvarious logics some focused more heavily on “tough love” and managementwhereas others focus on problem solving and low-barrier approaches.

Interview content shows that the knowledge produced about clientsenables shelter staff to (1) support ideal-type clients deemed able and willingto work toward socially acceptable goals, (2) connect some individuals withhigh needs with specialized services/supported housing options, and (3)exclude clients who are characterized as unlikely to succeed, resistant, unable,or unwilling to comply with case plans. This unofficial triage process is

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highly discretionary and undermines the goal of efficient service delivery,“accountable” systems, and case management standardization. Shelter clientscannot all be offered the services and supports they are assessed as needing,so policies are drastically circumvented and practitioners are often compelledto follow the path of least resistance when prioritizing who and what they canmanage.

Despite the overwhelming popularity of housing-first ideals (MHCC,2014), emergency shelters for the homeless are often gatekeeping accessto housing. The promise of housing referrals or shelter service gets used asleverage in case management and is characterized as a privilege that mustbe earned (see also: Henwood et al., 2011). Regulating compliance—bypreventing referrals to housing or evicting clients from shelters—becomespart of regulating the antisocial behavior of people with complex problemswho simply will not or cannot “get better” or fit in (see also, Dej, 2011;Dordick, 1997; Flint, 2009; Lougheed & Farrel, 2013). At a number of levels,access to housing or shelter is regulated as a way to govern the marginaland punish resistance and perceived irresponsibility. My findings lendsupport to claims that even when implemented by well-intentioned practi-tioners, mandated case management programs that use housing as leverageinherently support the idea that homelessness is caused by deviance andpathology, reinforcing patterns of self-blame and punishment at theexpense of advocacy and people’s long-term well-being.

Focusing on supports and referrals for compliant and promising clients,service delivery exacerbates inequality, perpetuating ideas about some peoplebeing street entrenched, hard to serve, or generally hopeless. Clients labeledas complex needs are de-facto deprioritized and often remain in emergencyshelters or back out on the streets. It is counterintuitive, but even in institu-tions designed for social service delivery like shelters, recognition of people’s“complicated” needs often translates into tighter regulation and/or decreasedsupport and access to services. This, increasing odds of the people who aremost vulnerable getting caught—or staying caught—in destructive cycles inshelters, jails, and hospitals, with diminishing overall well-being and stability.More studies should explore how intersecting/complex needs and challen-ging behaviors are conceptualized and addressed in shelters or in povertymanagement more generally. It is of the upmost important that we avoidperpetuating structures and practices that catalogue and analyze people’sproblems and shortcomings without emphasizing structural inequality orembracing much needed social, legal, and policy change. Future researchshould also track how long-term adoption of housing-first frameworksaffects our current over-reliance on emergency shelters for dealing withvulnerable people who face multiple disadvantages.

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Notes

1. Although this may not be adopted in a “uniform fashion” in Canada, the UnitedStates, or internationally, attempts to standardize shelter services have certainly beennoted in Toronto, Calgary, New York, and even as far away as Australia.

2. Recent efforts to roll out housing-first models (Mental Health Commission of Canada,2012) have not yet decreased dependence on emergency shelters, and recent countsshow that though there are roughly 5,250 homeless people in Toronto, the city hasslightly fewer than 4,000 shelter beds to offer (Street Needs, 2013).

3. Each interview lasted approximately 2 hours, and my visits were typically accompa-nied by a tour of the facilities/programs and some time “hanging out onsite” betweeninterviews.

4. Transitional housing, recovery-based, or long-term supportive housing providers werenot included because the goal was to focus specifically on issues related to the over-representation of people with complex need, multiple disadvantages, and vulnerabil-ities in emergency shelters for the homeless.

5. This is in part because women’s homelessness tends to be less visible, with womenoften avoiding shelters (Perez, 2014), trading relationships or sex for accommodations,therefore avoiding being labeled as chronically homeless (Mosher, 2013). Recentevidence also suggests that in Toronto, groups such as lesbian, gay, bisexual, andtransgender youth, First Nations/Inuit/Métis, and seniors are especially vulnerable andoverrepresented in shelters (Street Needs, 2013 ).

6. Although I use the two terms throughout this article, I recognize that ideal orcomplexneed are subjective categories that are fluid and should be thought of in terms of aspectrum, not a binary.

7. Ontario Disability Support Program.8. All names have been changed to protect anonymity.9. With the exception of youth shelters where caseloads remain smaller (10–12).10. Facilities and residences which allow people with alcohol addictions to consume

onsite.11. Ontario Works, aka welfare.12. Staph infection aka Methicillin-resistant Staphylococcus aureus: An infection that is

contagious and very difficult to treat.

Acknowledgments

The author thanks Kelly Hannah-Moffat, Paula Maurutto, Phil Goodman, and Laura Hueyfor their guidance during the research and writing processes. Any errors are, of course,entirely my own.

Funding

The author thanks the Baxter & Alma Ricard Foundation for funding this research.

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