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Chapter 2

Design & Principles

LEAD's Goals

All of LEAD’s principles and practices are laser-focused on solving one primary challenge – how to reorient our systems to provide effective and sustainable alternatives to the criminalization of behavioral health needs and extreme poverty.

  • Reorient collective response to safety, disorder, and health-related problems
  • Improve public safety and public health through research-based, health-oriented, and harm reduction-based interventions fostering recovery as defined by SAMHSA
  • Increase access to high quality, effective, community-based resources for people with complex behavioral health needs and/or income instability
  • Undo racial disparities at the front end of the criminal legal system
  • Sustain collaboration of local, state, and federal public partners to scale LEAD over time to match the scope of need
  • Strengthen relationships among diverse stakeholders

Core Values

LEAD core values are rooted in respect, partnership, equity, safety, and pursuing what works.

Advance Racial Equity

LEAD acknowledges that many systems, including the social service, child welfare, banking, housing, and health systems, have long been deeply fraught with racial injustice. LEAD seeks to shift discriminatory systems and decision-making through changes in policies, practices, beliefs, and investments, not only in the criminal legal system but in adjacent systems that have too often failed to provide sufficient or any assistance to people for whom only the criminal legal system has regularly responded.

This is a Core Principle
Create Shared Intention

No single organization or person owns LEAD. Stakeholders may have differing reasons for approaching the table and may have varied faith in its capacity to foster meaningful change, and partner involvement and commitment may ebb and flow accordingly. But maintaining a threshold level of commitment from all necessary partners is one of the primary duties of project management. Project managers must identify the organizational interests and needs of each partner and work to ensure that LEAD contributes to improving each partner’s situation and addresses each partner’s legitimate needs. Stakeholders committing to share responsibility for both achievements and difficulties is one of the key tenets of a LEAD project.

This is a Core Principle
Orient Toward Multi-System Change

Changing complex systems requires patience and commitment. There are real public safety, order, and health issues that affect our communities and that demand action. Any effective transformation of past approaches must grapple with the legitimate need of all people for safety and security. LEAD was constructed in recognition that systems outside the criminal legal apparatus have frequently failed to provide the kinds of care, support, and investment that could effectively prevent crime and disorder.

It is not enough to divert individuals from the criminal legal system into other processes that defeat, reject, and fail them – LEAD is committed to helping communities build a pathway to recovery that is geared to the specific needs of people who too often have been either consigned to enforcement systems or abandoned without resources.

Building consensus for a better approach requires questioning long-standing articles of faith about how communities tackle common problems, making room for the insights generated by many diverse points of view. That’s what the LEAD framework provides.

Do What Works

LEAD guides communities to do what will successfully reduce harm, foster stabilization and recovery, reduce crime, and improve safety. Succinctly put, “Do what works and doesn’t make it harder for people to stabilize and recover.” All operational partners are asked to make decisions within their authority and discretion that are most likely to actually foster behavior change, based on individual circumstances and information available to them as a result of their participation in LEAD.

This is a Core Principle
Foster Relationships

LEAD recognizes relationships – in and of themselves – as a core resource and a primary method for change; this is as true for stakeholder partners as for LEAD participants. All relationships are important in LEAD, including participants with case managers, case managers with police and prosecutors, project managers with neighborhood leaders and public officials, and policy-makers with one another. It is not unusual to hear partners invoke the maxim that “relationships are the resource.”

This is a Core Principle
Put People First

LEAD emphasizes participant-driven goals and intrinsic motivation over compulsory- or compliance-based expectations and systems. This evidence-based approach, using motivational interviewing and trauma recovery techniques, is both ethical and pragmatic. It recognizes that recovery is non-linear, that trust, safety and confidence-building are among the greatest resources relevant to recovery that we can foster.

This is a Core Principle
Take Harm Seriously

Whether it’s the distressing evidence of human suffering on our streets, the disruptions and fear caused by public disorder, or the harm and setbacks caused by entanglement in the criminal legal system: LEAD recognizes that it’s in everyone’s interest to do far more to address the human needs that cause problematic behavior. This is actually a core principle of the harm reduction movement:

Harm reduction does not attempt to minimize or ignore the real and tragic harm and danger that can be associated with illicit drug use.1National Harm Reduction Coalition, “Principles of Harm Reduction”

This is a Core Principle

Harm Reduction

Harm reduction is possible for both individuals and systems.

All harm is serious

As a health and safety strategy, LEAD takes all forms of harm seriously – both individual and systemic. This includes harm people can cause themselves, their families, and the community through disruptive or unlawful conduct that can stem from unmet behavioral health needs, substance use disorder, poverty, and living unsheltered.

It also includes the harmful failure of many systems to meet the legitimate needs of many people – quality education, housing, health care, financial resources and physical safety – and recognizes the setbacks and tragedies experienced by so many who were unnecessarily pulled into a punitive system when meaningful support would have been the best response to their situation.

Harm reduction for individuals

Harm reduction education and training are essential to ensure that LEAD stakeholders understand the efficacy, research base, logic, and value of harm reduction-based interventions to support behavior change for individuals with complex needs and high barriers. Case managers and supervisors should be well-versed in the logic and practical skill set required to operate effectively in a harm reduction program.

In working with people, harm reduction refers to a philosophy and practice of meeting people where they are, without preconditions, and working with them on concerns that matter to them, building over time, as they are able, to reduce behavior that is risky for them, and actions that are problematic for others. Harm reduction is a change strategy that is strength-based, trauma-informed, and highly pragmatic; it is based on connection and non-judgmental care, but it is not indifferent to the problematic situations individuals face.

LEAD’s harm reduction case management supports participants to build resources and strength to tackle behaviors that undermine their own goals or pose problems for others This is a core tenet of the LEAD model.

This is a Core Principle
Systemic harm reduction

Harm reduction is commonly considered a direct-service methodology, a way to deliver care to individuals. But it can be viewed through a wider lens, as well. The LEAD model provides local stakeholders with the opportunity to reduce systemic harms by collectively shifting both policies and practices:

  • At the policy level, stakeholders work to reduce harm by ending overuse of the criminal legal system for challenges that can be better addressed as issues of public health. This includes cultivating shared commitments to build voluntary, non-punitive diversion pathways to community-based responses and care.
  • In day-to-day practice, LEAD replaces the office- or clinic-based care model with street-based, low-barrier, non-contingent intensive case management for the people LEAD is intended to reach. Case managers are a “golden thread” that stays with participants no matter what, and helps navigate hostile systems, recruit needed resources, and buttress participant confidence and strength to tackle important goals. Demonstrating the efficacy of this approach can catalyze systemic shifts in how care strategies are designed. The reduction in harm is both for individuals, who receive more effective care and support, and for communities who enjoy reduced disorder and problematic behavior.

By shifting systemic policies and practices and making space for a new kind of low-barrier, street-based direct services and case coordination, the LEAD model fosters systemic harm reduction.

This is a Core Principle
Reduce racial harm

LEAD acknowledges that many systems, including the social service, child welfare, banking, housing, and health systems, have long been deeply fraught with racial injustice. LEAD seeks to shift discriminatory policies, systems, and decision-making through changes in policies, practices, beliefs, and investments, not only in the criminal legal system, but in adjacent systems which have too often failed to provide sufficient or any assistance to people for whom only the criminal legal system has regularly responded.

  • Capture and Review Racial Data
    Sites should establish mechanisms to capture and review race data throughout the LEAD continuum, including diversion-eligible arrests, rates of arrest diversions, social contact referrals, and community referrals, enrollment, retention, and service provision. Sites should assess the relationship of various operational choices on racial disparity, adjust policies and procedures to reduce disparities if any are discerned, and provide transparent insight to partners regarding any barriers they encounter in the effort to ensure that this intervention reduces, and does not exacerbate, racial inequities.
  • Consult Experts, Advocates and Agencies
    LEAD sites are encouraged to work with civil rights, racial justice, and harm reduction advocates and agencies to ensure that a commitment to reducing racial disparities and equity is at the forefront of collective intention. These partners should be at the governing table and should consult regularly on technical design questions.
This is a Core Principle

Stages of Change

Reducing harmful and self-sabotaging behaviors requires committed and ongoing effort, as anyone who’s ever made a new year’s resolution can tell you; this is all the more true for people who have endured complex trauma, as is true of most LEAD participants.

The Stages of Change model (also called the Transtheoretical Model) recognizes that people’s readiness to change their habits follows no steady course – it can come slowly, may suffer setbacks, and is sparked by internal motivators. With behavioral changes, it’s often two steps forward, one step back. Motivational Interviewing is an evidence-based practice used by LEAD case managers to encourage reflection, reconsideration and change.

SAMHSA’s Definition of Recovery

Often, harm reduction and recovery have been framed as distinct concepts. Revisions to the SAMHSA working definition of recovery in recent years have unified these frameworks. Today, SAMHSA defines recovery2Defining Recovery, SAMHSA as “a process of change through that individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”

Note that this holistic concept of recovery contains no predetermined objectives, thresholds, or requirements. This modern definition accepts that recovery is a non-linear journey that typically includes relapse and setbacks and which is individually defined; recovery may end in abstinence from psychoactive substances, but it also may not. This definition embraces concepts of harm reduction and gradual improvement of life prospects, rather than applying black and white litmus tests.

SAMHSA’s recovery framework recognizes four primary dimensions3The Four Dimensions of Recovery, SAMHSA:

  • Health: Overcoming or managing one’s disease(s) or symptoms, and making informed, healthy choices that support physical and emotional well-being
  • Home: Having a stable and safe place to live
  • Purpose: Conducting meaningful daily activities, such as a job, school volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society
  • Community: Having relationships and social networks that provide support, friendship, love and hope

Fully aligned with these precepts, LEAD’s harm reduction-based intensive case management is grounded in the evidence of what best supports people living with complex needs.

Participants Do Not "Fail Out" of LEAD

Consistent with its evidence-based approach, LEAD focuses on supporting people on this sometimes bumpy road. Thus, people do not “fail out” of LEAD. Once referred and enrolled, participants are not required to comply with a fixed schedule or timelines. Participants may be characterized as “active” or “inactive,” but they are not removed from LEAD for failure to achieve or sustain any specific goal.

However, the case management team can and should discharge individuals who are not benefitting from the program after an extended period of effort by the case manager, either due to sustained lack of engagement or because there is no observable behavior change for an extended period. This is to ensure that valuable resources are allocated to individuals who can best benefit from them. Participants who are officially discharged may return, if circumstances change.

Of course, participants may also be discharged at the discretion of case management supervisors in the rare instances where they threaten or harm a staff member, or if the location or dynamics of program staffing makes continuation in the program inconsistent with the safety of other participants.

Behavior Change for Stakeholders

The Stages of Change theory is often mentioned in reference to supporting a desired behavior change with LEAD participants. But it should be mentioned that the LEAD recognizes that the Stages of Change theory is also relevant to the development of positive new behaviors among all of LEAD’s stakeholders, whether high-level decision-makers, direct-service staff, rank and file officers, reform advocates, or community members.

In LEAD, everybody is encouraged to continuously re-assess their assumptions, policies, and actions to reduce harm and make space for positive change. In a healthy LEAD ecosystem, it can be expected that the perspectives and approach of all partners will change over time due to the mutual learning everyone has the chance to experience.

This is a Core Principle

Motivational Interviewing

Motivational Interviewing (MI) is a foundational technique for LEAD. An evidence-based approach to supporting positive behavior change, MI is a client-centered, collaborative style of communication designed to help people identify and achieve their goals by eliciting and exploring their own reasons for change. Using a guiding (not directive) style of communication, MI meets people where they are, regardless of their readiness to change.

MI is particularly useful in working with people who are not yet thinking about change, are ambivalent about change, or are not confident in their capacity to change.

In LEAD sites, all client-facing staff should be trained in MI theory and practices, and all partners should be trained in its theory, principles, and implications.

This is a Core Principle

Housing First

At its heart, the Housing First approach is about tearing down the barriers of policy or practice that stand between people and what they need as human beings. Especially for LEAD, it means that everyone involved should be constantly committed to trying to connect people to the resources they need as readily as possible, whenever possible. This means thinking creatively, adaptively, and oftentimes unconventionally to recognize and remedy the sometimes invisible barriers erected through established policy and common practice.

This means that at all times, LEAD stakeholders should be driven by a simple question: What can we do, in any given circumstance, that would actually improve someone’s ability to stabilize and recover?

Housing First is an evidence-based approach to fostering stabilization by connecting people to housing as quickly as possible. It recognizes that a safe and consistent place to live is an essential precondition for other kinds of positive behavior change. Consistent with harm reduction principles, Housing First emerged as an alternative to approaches that required people to “achieve” certain behaviors in order to “earn” their eligibility for housing or that imposed preconditions such as sobriety, treatment or service participation. Housing First recognizes that safety, security and a decent living environment is the first step toward reducing ongoing trauma, and that trauma recovery is almost impossible while trauma is ongoing.

Adopting Housing First policies does not mean that a given community has sufficient capacity to house every person who wants housing; it also doesn’t mean that people should be required to be in housing before they are allowed access to other forms of support. LEAD field-based case management is still helpful to people who are living unsheltered; among other things, LEAD stakeholders can be important voices to advocate for additional housing and shelter placements. But embracing Housing First policies reflects a collective commitment to advocate for system change so that housing resources are understood to be a key to behavior change for many people exposed to the criminal legal system due to ongoing struggles with behavioral health and income instability.

This is a Core Principle

Avoiding Net-Widening

It is important to safeguard LEAD against what is known as “net-widening.” Net-widening is the phenomenon in which a society or community increases the array of behaviors (and thus people) subject to control by the criminal legal system. Net-widening can occur when policies and practices explicitly intended to reduce criminal legal involvement paradoxically result in a larger number of people being caught in the criminal legal net.

Two features of the LEAD model guard against net-widening: (i) social contact referrals by law enforcement and community referrals, for which neither arrest nor calling 911 for police response is necessary and (ii) focusing approval of community referrals on those who are likely to otherwise be exposed to the criminal legal system in the absence of LEAD.

Understanding net-widening

Though “less punitive,” some forms of control can subject more people to criminal supervision.

Net-widening can occur when intended criminal legal reforms result in a larger number of people being subject to criminal legal supervision. For example, when probation or electronic monitoring are perceived as “less punitive” alternatives to jail, their use can end up increasing the overall number of people subject to carceral supervision and control.

Thus, it is important that LEAD initiatives forge alternatives to the criminalization of people living with unmanaged behavioral illness without unintentionally deepening or broadening its criminal legal involvement.