Pretreatment and the core skills of engagement
The idea of a psychologically informed environment, a PIE, first appeared in the context of the UK, as part of an overview of creative and constructive practice as found in homelessness resettlement work there. This approach however has many points in common with some new approaches developed in the US and Canada, such as "Trauma Informed Care" - or TIC - "Safe Havens", and "Pretreatment".
The concept of pretreatment was first used in the context of substance abuse and the engagement and harm minimisation strategies used by the treatment agencies in this field. Extending and developing the ideas in homelessness work has largely been the work of Jay Levy, a social worker in the US. These ideas are especially valuable in outreach work. But the engagement skills that it promotes are applicable across the whole range of services.
As developed and articulated by Jay Levy, pretreatment has a number of key principles, which he identifies as:
- promoting safety
- forming a relationship
- developing a common language
- facilitating and supporting change
- taking into account cultural and 'ecological' considerations.
To then unpack that a little, pre-treatment in outreach work focusses first on forming a relationship with the (potential) client, through finding, negotiating or constructing what Levy calls a common language, a way to describe the situation and the possibilities that both worker and client are at home with - and that may also mean finding a language that connects the client with other services and eligibility for benefits.
Only then can the worker look to facilitating and supporting any possible change; always promoting safety. especially as a central issue for the homeless client; and bearing in mind a range of other, cultural or ‘ecological’ considerations, by which Levy means an acute awareness of how the client is situated and lodged in their world, with their own concerns.
However, if from that it might appear that the 5 key elements of Pretreatment follow in sequence, a staged engagement, this is not so. These are all simultaneous processes to take into account continuously in our work, and, for example, in ongoing assessment.
In a video interview ( see opposite column for links) Levy himself has also described the essence of pretreatment as : "One: to get where the client is at. Two: to always ask ourselves, 'how do our words and actions resonate in the client’s world?” and Three: to really understand that the engagement relationship process, the foundation of our working well, are skills and interventions that are required for common language development, as the main tools ....." (Levy 2014). This stress on attention to language underlies all of Levy's writings, which use narrative to illustrate his key points.
See also the book review by Lynn Vickery for a quick summary; and the section from Robin Johnson's editorial comment in that issue of the J. Housing Care and Support journal itself, which comments both on the review of Levy's book, and how it may relate to other debates and discussions on new forms of creative engagement work, such as Trauma Informed Care, and the development of PIEs.
NB: In a recent interview with Dr Alan Chartock, on North East Public Radio, Chartock and Levy discuss the issue of how to respond when some members of the public, politicians and other funders, may say: "surely they have chosen to live like this?" Here Levy outlines very clearly the importance of finding common ground and common language with those who seem to reject the offers that mainstream society makes.
See also several video and other presentations, and links to Levy's own website.
See Jay Levy's own website for a wide range of material on pretreatment.
But, by permission of the author, we have three full chapters from Jay Levy's recent books, re-edited for the web:
"Entering the House of Language: Andrew's narrative' from "Homeless Narratives and Pretreatment Pathways; from Words to Housing"
'The Challenges of Helping Homeless Couples: Janice and Michael's narrative' from "Pretreatment Guide for Homeless Outreach & Housing First"
"Making meaning; the art of common language construction" from "Pretreatment Guide for Homeless Outreach & Housing First"
Book review by Lynn Vickery of "Pretreatment Guide for Homeless Outreach & Housing First" (from J. Housing Care and Support)
Editorial comment Robin Johnson (from J. Housing Care and Support)
An interview with Jay Levy, talking on his work, on US TV.
Homeless engagement: 5 principles of pretreatment: Jay Levy in discussion with Ray Middleton.
North East Public Radio interview with Dr Alan Chartock
Finally, Victoria Aseervatham's video of her Top tips for commissioners of services cites Jay's work as one of her inspirations.