Homeless Healthcare Los Angeles: The Stages of Change

The first of a two-part series on the services provided by Homeless Healthcare Los Angeles.

The sign outside the Beverly Boulevard location of Homeless Healthcare Los Angeles.

The clients who walk through the doors of Homeless Healthcare Los Angeles share many of the same stories: homeless, jobless, struggling with addictions, estranged from family or friends who could support them through addictions and medical crises.

They’ve come on court orders or hospital referrals or their own will power, hoping one of the city’s most unique homeless support programs can give them what they need.

That raw need is what empowers the employees of HHCLA. They hope that instead of shoehorning their clients into a certain plan or program, they can help them with whatever they need. HHCLA dreams of getting rid of homelessness someday, but in a city where one in 100 residents is a transient, that won’t happen soon.

So instead, HHCLA attacks the problem of homelessness with a uniquely holistic approach called “harm reduction” — addressing the immediate needs of the homeless, whether that means medical care, education or drug treatment.

In the almost 20 years since Homeless Healthcare Los Angeles was created, it has expanded to include a handful of locations around the city, each offering different services.

“Our clients come from all walks of life, with all different kinds of histories,” said Delia Mojarro, the Community Assessment Service Center director for HHCLA. “Our goal is to improve their quality of life, whatever that might mean.”

The entire operation is overseen by Los Angeles County, and funded through a combination of private donations, government money and grants.

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The bars on the front doors of Homeless Healthcare Los Angeles reflect a hot, quiet street just east of Downtown Los Angeles.

The main HHCLA location, on Beverly Boulevard about two miles east of Downtown, is the program’s Community Assessment Service Center — a hub of activity where case workers refer clients to the correct HHCLA service or to an external program.

To qualify for HHCLA’s services at the Beverly building, clients must be homeless or, in some cases, referred by CalWorks, courts, country hospitals or the Department of Children and Family Services. The primary function of the Beverly building is triage: funneling clients to the program that fits them best.

“We give them the best possible care and the best possible options,” said Angelica Skouras, case manager and HIV service advocate.  “That’s what assessment is about. Making the good match. Trying to get the right program for the right needs, so they can be successful.”

About 15-20 people come through a day — up to 450 a month, Mojarro said. That number was closer to 700 until budget cuts hit HHCLA about a year ago and reduced most of the program’s in-house patient services.

Still, the main program at the Beverly building is patient treatment: an outpatient program for addiction treatment, said Kevin Kelley, that program’s director. Through a series of interviews that dissect the reasons a client behaves why they do, case workers help the homeless develop their own plans for changing.

“We create discrepancy between where a client is and where they would like to be in the future,” Kelley said. “You peel that open, slowly, until you create what’s known as a decisional balance, and they come to the conclusion that the cost of staying the same outweighs the cost of changing. That’s the moment when people change.”

The Beverly Boulevard location of Homeless Healthcare Los Angeles is also the CASC for one portion of Los Angeles County. The organization sees 450-500 clients a month.

HHCLA’s harm reduction approach means they don’t require abstinence, which they say only encourages relapses later on. That approach is the standard of healthcare in many countries, but takes a back seat to abstinence enforcement in the United States, Kelley said.

About 20 percent of people with a substance abuse disorder treat it without any help.

“But we like to say that we’re for the other 80 percent,” Kelley said. “We begin the process by saying, ‘You may say you’re stuck. That’s an illusion. You’re changing.’”

Clients enter a year-long program that’s based on a psychological theory called the five stages of change.

The first stage is pre-contemplation: Basically, “What problem?” Second is contemplation, or “Yes, I have a problem, but I’m not going to do anything about it.” The third step is preparation: “Yes, I need to get ready to do something about this problem.” The fourth step is action, and the last is maintenance, in which the client continues to live in a different way. The outpatient treatment groups at HHCLA are tied to the last three.

As the clients work through their substance abuse disorders, the employees often to struggle to live up to their philosophy of letting change happen at its own pace, Mojarro said.

In the group treatment rooms, clients work with Kelley and other case managers on motivational interviewing and other techniques designed to reduce alcohol and drug dependency.

“We have to believe what we say: you can lead a horse to water but you can’t make them drink,” Mojarro said. “We may think we know what’s best for people, but we have to honor their choices, and accept the reality that if they choose to go back to the streets, that’s just that — their choice.”

It’s not uncommon for people in the program to die, overdose or simply disappear. If someone doesn’t show up for 30 days, they’re cut. Not taking those failures personally can be hard, Kelley said. Internalizing the struggles of their clients is also a common problem, known as “Vicarious Trauma Syndrome.”

“We hear pretty tragic stories here, day in and day out,” Kelley said. “We have a saying on the staff: ‘If you take responsibility for the successes, then you’ve got to take responsibility for the failures.’”

But the successes can be staggering. Patients go from the sidewalk to having an apartment and a job, going to school and training for a new career, or getting Section 8 vouchers for guaranteed housing.

At the last meeting of the program, clients gather in Kelley’s office to talk about where they’ve come from, how different their life is from 12 months ago, how they can’t believe they’ve changed despite themselves.

“Twelve months later, they’ve transformed,” Kelley said. “They’re facing the end of a year here, and they’re saying, ‘A year seemed like forever, and how did it go so fast?’ Hearing that is an honor.”


About ljnelson

Laura is a student journalist based in Los Angeles whose work has appeared in multiple metropolitan dailies, including the St. Petersburg Times, the Los Angeles Daily News and The Kansas City Star. She is a junior at the University of Southern California majoring in French and print and digital journalism.
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