LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team LEAD Program Evaluation: Describing LEAD Case Management in Participants’ Own Words Seema L. Clifasefi Susan E. Collins Harm Reduction Research and Treatment Center University of Washington – Harborview Medical Center Revised November 1, 2016 This report was written and prepared by the University of Washington LEAD Evaluation Team with important contributions from the LEAD Evaluation Advisory Committee and others acknowledged on the back page. 1 LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 2 Executive Summary • • • • Background: Seattle’s Law Enforcement Assisted Diversion (LEAD) program offers people suspected of low-level drug and prostitution offenses legal assistance and harm-reductionoriented case management as an alternative to prosecution and incarceration. The UW LEAD Evaluation Team has published three reports on LEAD to date. Findings from these evaluations have shown that—compared to the system as usual (i.e., booking and prosecution)—LEAD is associated with significantly fewer arrests and felony charges as well as less legal and criminal justice system utilization and associated costs. Further, LEAD participants are more likely to acquire shelter and housing, join the employment continuum, and obtain legitimate income and benefits subsequent to their program involvement. Taken together, these findings indicate very positive LEAD outcomes. However, no reports to date have represented participants’ perspectives on their primary point of contact with the program: LEAD case management. Purpose: This report documents participants’ experiences with and perceptions of LEAD case management in their own words. Methods: LEAD participants (N=32) were interviewed between June 26 and August 13, 2015 and were asked about their experience with and perceptions of LEAD case management. Semistructured interviews were administered to gather data about the program’s advantages and disadvantages, how LEAD compared to other social service programs, participants’ relationships with police before and after LEAD, and participants’ perceptions of how LEAD case management impacted their lives. We used conventional content analysis to provide a description of participants’ experiences with and perceptions of LEAD. Findings: All but one participant reported having a positive experience with and perception of LEAD case management. That participant had a mixed perception of LEAD, with his primary frustration centering around not finding housing through the program. About a third of participants reported LEAD was the first social services program they had ever participated in. All participants said LEAD had changed their lives for the better. o LEAD case management is perceived as client-centered, holistic and effective. LEAD’s client-centered, advocacy-oriented, harm-reduction approach made it stand apart from other social services programs LEAD participants had experienced. § Participants felt it was helpful that LEAD did not require abstinence from substances for service provision. § The LEAD case managers’ interpersonal style was perceived as nonjudgmental, compassionate and advocacy oriented. LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 3 LEAD case managers cultivated trust. Providers were perceived as doing “what they say they’re going to do.” § The LEAD case management approach was holistic, personalized and put clients’ stated needs first. It was viewed as a “one-stop shop” where clients could get all their needs met efficiently and effectively. § Because LEAD case management supports autonomy, participants felt they were positively and actively involved in their own case management. § A small minority of participants (n=2/32) indicated dissatisfaction with specific aspects of the program: personality conflicts with a case manager (n=1) and lack of housing stock for individuals with active substance use (n=1) were mentioned. o Life after LEAD was better than before. Participants said that life after LEAD was better than before. Conversely, many LEAD participants expressed the belief that life without LEAD would not have resulted in positive outcomes for them. o LEAD was associated with improved relationships with police officers. Prior to LEAD involvement, most participants perceived their interactions with police officers as being negative. Of the individuals who originally reported negative experiences, about half said these experiences had become positive after their LEAD involvement. Nearly half of all participants reported little to no further contact with law enforcement after LEAD involvement. o LEAD case management may be misunderstood by nonparticipants. LEAD participants were concerned that nonparticipants perceive LEAD as a “snitch program.” None of the LEAD participants endorsed this view. Discussion of Findings o Nearly all participants interviewed viewed LEAD positively and would recommend LEAD to others. Participants felt their involvement in LEAD had helped them meet their basic needs, work towards important life goals, and improve their relationships with and perceptions of law enforcement. o Recommendations for LEAD programming include: § Allowing participants to request another case manager to optimize clientprovider fit; § Communicating more clearly about LEAD goals and processes (e.g., providing brochures, involving peer advocates) so the wider community, including potential participants, police officers, community members, potential landlords and housing agencies, better understand LEAD; § Increasing housing stock available to LEAD participants; and § Ensuring that all case managers are, as one participant noted, “empathetic, down to earth and nonjudgmental.” § • LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 4 Introduction to the LEAD Program Background and Rationale for the Law Enforcement Assisted Diversion (LEAD) Program Despite policing efforts, drug users and dealers frequently cycle through the criminal justice system in what is sometimes referred to as a “revolving door.”1 The traditional approach of incarceration and prosecution has not helped to deter this recidivism.2 On the contrary, this approach may contribute to the cycle by limiting opportunities to reenter the workforce, which relegates repeat offenders to continued work in illegal markets.3 This approach also creates obstacles to fulfilling people’s basic needs, including obtaining housing, benefits, and drug treatment. There have thus been calls for innovative programs to engage these individuals so they may exit the revolving door.1 LEAD Program Description This need for innovative programs to prevent recidivism inspired the development of the LEAD program. The LEAD program was established in 2011 and is a collaborative, prebooking diversion program for individuals suspected of low-level drug and prostitution offenses. LEAD comprises three primary components: 1) an initial program entry process, which includes diversion from the criminal justice and legal systems; 2) harm-reduction-oriented case management; and 3) higher-level coordination of legal system involvement. LEAD program entry. People suspected of violations of the uniform controlled substances act (VUCSA) and/or prostitution offenses are arrested as usual and brought to the police precinct. There, they are screened for LEAD eligibilitya by an on-duty officer. Eligible individuals are offered the option of participating in LEAD instead of undergoing standard criminal booking and prosecution. An additional pathway to LEAD is available by which individuals are referred as ‘social contacts.’ The social contact pathway was added at the behest of officers so that individuals who are known recidivists need not engage in new criminal activity and be arrested before offered participation in LEAD. Social contacts are individuals who are eligible for LEAD but are referred outside of a criminal incident because they are known to engage in drug-related crime or sex work within the program’s catchment areas. Individuals may be referred by officers or by other community partners. In the latter case, community partners refer potential participants to project managers at the Public Defender Association. Project managers introduce potential a Participants are deemed eligible if they appear amenable to diversion and do not meet the following program exclusion criteria : a) the amount of drugs involved exceeds 7 grams; b) the suspected drug activity involved delivery or possession with intent to deliver and there was reason to believe the suspect was dealing for profit above a subsistence income; c) the individual appeared to exploit minors or others in a drug dealing enterprise; d) the individual was suspected of promoting prostitution; e) the individual has a disqualifying lifetime criminal history (i.e., conviction for murder 1 or 2, arson 1, robbery 1, assault 1, kidnapping, Violation of the Uniform Firearms Act 1, sex offense, or attempt of any of these crimes), or within the past 10 years, has a conviction for robbery 2, assault 2 or 3, or burglary 1, or within the past 5 years, has a conviction for domestic violence assault 4, violation of a domestic violence no contact order/order of protection, burglary 2, or Violation of the Uniform Firearms Act 2; or g) the individual is already involved in King County Drug Diversion Court or Mental Health Court. LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 5 participants to officers who determine eligibility and continue with the intake process. Continuous community engagement by project managers helps community partners engage with LEAD as an alternative paradigm for responding to their legitimate public safety and public order concerns. LEAD case management. Regardless of the path of entry, interested individuals are referred to a LEAD case manager who completes an intake assessment and enrolls them in the LEAD case management program. The case management component is delivered by the REACH homeless outreach program. REACH is part of Evergreen Treatment Services, which is a Western Washington-based nonprofit organization that delivers substance-use treatment, and provides outreach and harm-reduction-oriented case management to individuals experiencing homelessness and substance use disorders. The LEAD population served by REACH includes a high percentage of individuals who have been repeatedly involved in the criminal justice system and are considered vulnerable and ‘hard-to-reach.’ REACH is guided by the mission of “joining with individuals through outreach, relationship building, advocacy, and bridging gaps to reduce harm and support healing” (K. Craig, personal communication, February 8, 2016). REACH offers trauma-informed case management, which is a strengths-based approach recognizing the impact of traumatic incidents in individuals’ lives. It emphasizes creating physical, psychological, and emotional safety for providers and affected individuals and aims to promote individuals’ sense of autonomy and empowerment. REACH also espouses a harm-reduction philosophy, which entails meeting individuals ‘where they are at’ in their communities and in their own motivation to change substance use.4 The program’s case management model is highly individualized and uses a nonjudgmental, collaborative approach in which the client’s own needs and priorities are the primary focus of attention. In this model, the goals are to engage and retain individuals in services by listening attentively to clients’ needs and connecting them with appropriate community resources, such as housing placement, medical care, legal advocacy, job training, mental health counseling, and chemical dependency treatment.b To do this work, REACH employs a diverse and interdisciplinary team of professionals and paraprofessionals with backgrounds in nursing, social work, chemical dependency counseling and related disciplines. REACH case managers emphasize building and maintaining a trusting and supportive relationship with clients. Case management is provided on the streets, in clients’ living situations, and onsite at REACH’s home office. In the context of LEAD, case b LEAD entailed neither housing ‘set asides’ nor preferential access to housing or other services for LEAD participants. This “nondisplacement” principle of LEAD stemmed from the understanding that the program was meant to achieve communitywide gains in public order and safety if taken to scale. If LEAD participants had gained access to services with a waitlist, thus driving other similarly situated people further down or off the waitlist, the net impact on the community might have been neutral or negative, even if results for individuals in LEAD were more positive. The nondisplacement principle makes it difficult to compare LEAD with programs that do have priority access to housing stock. The present findings show what can be accomplished within the existing system with the benefit of additional legal assistance, case management, and monies to support case management efforts (e.g., for treatment, emergency shelter, rent assistance). LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 6 managers also have access to funds for the fulfillment of participants’ basic needs (e.g., motel stays during cold weather, food, clothing, treatment). Overall, REACH’s client-centered, theoretically grounded approach aims to promote self-efficacy and motivation to change by facilitating access to services and developing a flexible and compassionate outreach relationship. Legal assistance. In addition to initial diversion and case management, the LEAD program features coordination with the criminal justice system for participants’ cases that are not eligible for diversion. Prosecutors make discretionary decisions about whether to file charges, recommend pretrial detention or release conditions, reduce charges, recommend incarceration after conviction, and/or dismiss charges for LEAD participants. Thus, the prosecution can support rather than undermine participants’ tailored intervention plans with an eye toward maximizing community health and safety. Rationale and Aims of the Current Evaluation Report The primary aim of the LEAD program is to reduce criminal recidivism. Secondary aims include reductions in criminal justice service utilization and associated costs, as well as improvements for housing, employment and income/benefits. Previous evaluations conducted by the University of Washington LEAD evaluation team have shown promising results, indicating associations between LEAD participation and reduced recidivism; decreased criminal justice utilization and associated costs; and improved housing, income/benefit and employment outcomes. Given the initial success of this innovative approach, the next step was to document participants’ perspectives on LEAD. Such a description is positioned to highlight components that are contributing to the program’s success as well as elucidate potential points to consider for program enhancement and replication. The current evaluation therefore explored participants’ experience with and perceptions of LEAD via one-on-one qualitative interviews. Because participants’ primary point-of-contact was with LEAD case managers, this analysis focuses on participants’ experience with the case management component of the LEAD program. LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 7 Methods Design We used qualitative data analysis to describe participants’ perceptions of and experiences with LEAD case management in their own words. Data were collected during cross-sectional, individual interviews. Setting and Participants Setting. The setting for the case management and data collection was Evergreen Treatment Services’ REACH Homeless Outreach program in Seattle, WA. REACH provides LEAD case management services. Participants. A convenience sample (N=32) was drawn from the larger pool of program participants who were referred to LEAD between October 2011 and August 13, 2015 (N=330). All LEAD participants were suspected of recent violations of the uniform controlled substances act (VUCSA) and/or prostitution offenses and were deemed eligible for the program by Seattle Police Department (SPD) officers. SPD considered individuals ineligible if they met any of the following criteria: • The amount of drugs involved exceeded 3 grams, except where an individual was arrested for delivery of or possession with intent to deliver marijuana or possession, delivery or possession with intent to deliver prescription controlled substances (pills). • The individual did not appear amenable to diversion. • The suspected drug activity involved delivery or possession with intent to deliver (PWI), and there was reason to believe the suspect was dealing for profit above a subsistence income. • The individual appeared to exploit minors or others in a drug dealing enterprise. • The individual was suspected of promoting prostitution. • The individual had a disqualifying criminal history as follows: o Without time limitation: Any conviction for murder 1 or 2, arson 1 or 2, robbery 1, assault 1, kidnapping, Violation of the Uniform Firearms Act (VUFA) 1, any sex offense, or attempt of any of these crimes. o Within the past 10 years: Any conviction for a domestic violence offense, robbery 2, assault 2 or 3, burglary 1 or 2, or VUFA 2. o The individual was already involved in King County Drug Diversion Court or Mental Health Court. This exclusion criterion served to ensure the LEAD program was not combined with other models of intervention and case management. LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 8 Interviewers and Interview Materials Interviewers. Interviews were conducted by college students who participated in internships at the Public Defender Association in the summer of 2015. The college students’ work was overseen by a LEAD project manager. Interview materials. Semi-structured interviews were designed by LEAD project managers in collaboration with faculty at Whitman College for the purposes of a larger qualitative exploration of LEAD participants’ experiences in the program. Interviews comprised primarily open-ended prompts that assessed participants’ perspectives on various topics pertaining to LEAD, including perceptions of the LEAD program and its elements, interactions with police officers prior and subsequent to LEAD involvement, and LEAD’s impact on participants’ lives (see Appendix A). Procedures Potential participants were identified by LEAD staff on site at the REACH offices and were then approached by interviewers who inquired whether they would be interested in participating in a confidential survey to find out more about their experiences with and perceptions of the LEAD program. Interviewers informed potential participants of the purpose and procedures of the interviews, as well as their rights and role as participants in the program evaluation. Participants were informed that their participation in the interview would not affect their service provision, and that comments would be aggregated and shared with REACH program staff without individual attribution or identifying comments that would defeat the confidentiality promise. Participants were provided written, informed consent prior to taking part in the interview. Semi-structured interviews lasted between 15-45 minutes. Participants received a $5 fast food gift card for their time, and were assured prior to the interview that they would receive this incentive regardless of what they had to say. Data Management Demographic data and LEAD intake date were obtained from the REACH case management database (AGENCY Software, Seattle, WA). Interviews were audio recorded and transcribed. Transcripts were stripped of personally identifiable information prior to qualitative data coding. Data Analysis Plan The goal of the analysis was to construct a thematic survey or description5 of key aspects of participants’ experiences with and perceptions of the LEAD program. To this end, we used conventional content analysis, which is a qualitative research method used to interpret the content of text data through a systematic classification process involving coding and identifying themes.6,7 In conventional content analysis, the researcher does not start with preconceived, theory-based notions about what kinds of codes or categories of codes will be found. Instead, the researcher allows the data to drive the codes and categories.6 LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 9 Atlas.ti version 7 8 was used to manage and code qualitative data. Initial coding was conducted by the first author (SLC) using an incident-by-incident technique. A codebook was created pooling codes and removing or collapsing idiosyncratic or redundant codes. Thematic coding was conducted by the first and second authors (SLC, SEC). Both LEAD participants and LEAD case managers had opportunities to review the findings. Their feedback served as a means of assessing usefulness, fit and resonance of the data interpretations and was integrated into this report. Sample Description Participants (N = 32) completed their initial LEAD intake between December 5, 2011 and June 8, 2015 and spent an average of 613 days in the program (Range: 23-1312 days). The LEAD program had been in operation for 1,365 days (three years and nine months) at the time of the interviews. Participants had an average age of 45.60 (SD = 10.29) years and were predominantly male (31.25% female; n = 10). Seventy eight percent of the participants in this sample were homeless at the time of their interview. The racial and ethnic diversity of the sample is shown in Figure 1. The demographics of LEAD participants represented in this sample are similar to the samples documented in our prior reports (see http://leadkingcounty.org/lead-evaluation/). Figure 1. Race/Ethnicity of LEAD parVcipants American Indian/ Alaska Nanve/First Nanons 13% African American 42% White/European American 36% Mulnracial Asian 3% 6% LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 10 Primary Findings In their interviews, participants characterized the LEAD case management program, discussed how their lives would be with or without LEAD, talked about their relationships with police both prior and subsequent to their LEAD involvement, and shared about other community members’ perceptions of LEAD. Characterizing the LEAD Program Participants’ had primarily positive perceptions of LEAD case management as a refreshing change from their typical experiences with social services agencies. They characterized LEAD as being harm reduction based, client centered, advocacy oriented, holistic and effective. LEAD case management was viewed as a positive change from other social services participants had received in the past. LEAD’s approach stood apart from other social services programs participants had previously experienced. In fact, all participants reported they had never experienced a program like LEAD before: I just don’t know of any program quite like LEAD. I don’t. You have service centers where you can go and hang out or shower and get a little something to eat or something but to have someone that really was interested in helping you to deal with these things…That wasn’t existing. Other participants were surprised that this novel approach was supported by government agencies: “For the first time in my life--as long as I’ve been involved in this dope game, which is a long time--I’ve seen local government reach out and offer a hand to us.” Another participant noted, “I think it’s one of the best programs as far as being in the criminal justice system…You’ve got welfare offices, DSHS…but [LEAD] is dealing with you. Saving your life pretty much. That’s what I’m saying, you see. It’s saving your life.” Participants appreciated LEAD’s harm-reduction approach. Participants reported that they could be seen for services even if they had been using substances. As one participant noted, “You don’t have to be clean to be in LEAD.” This aspect of LEAD case management is salient for participants who have attended traditional, abstinence-based programs in the past and have been turned away if they were using or had relapsed. One participant noted that, in contrast to traditional programs, “[LEAD case managers] are not saying, ‘You gotta stop [using substances] right now’ or the program’s not gonna be available or they’re not gonna help me.” Participants characterized LEAD as client-centered. Client-centered care is a humanistic approach that supports clients’ autonomy and features a provider style that is compassionate, nonjudgmental and authentic. This is how participants described LEAD case managers’ approach. Regarding case managers’ interaction style, one participant noted, “[The case managers] do help, and they do listen, and they don’t judge addicts and what they do.” Another LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 11 participant spoke to LEAD case managers’ unconditional positive regard: “They don’t look at you like you’re a waste of money, and they don’t look at you like you’re a crazy crackhead that needs to go somewhere. They actually look at you like you’re a person.” The accurate empathy or congruence that is essential to client-centered practice was perceived by one client who said that LEAD case managers are “real. They won’t lie to you. They are truthful and genuine.” This client-centered approach helped clients regain self-worth after many years in the system. As one client put it, “My case manager—from the day I walked in here, not knowing, not understanding anything—made me realize I was worthy. You lose your sense of self-worth in this industry. But [my case manager] made me remember I am worth it.” The client-centered approach also helped LEAD case managers cultivate trust in their clients. One participant indicated that her case manager’s dedication in working with her made her feel she could “trust that person and not think other people are gonna judge you.” LEAD case managers were perceived as doing “what they say they’re going to do.” The fact that LEAD case management was predicated on a client-centered interaction style was very important in building trust. This trust was reinforced by the fact that case managers were perceived by participants as then doing “what they say they’re going to do.” Participants felt this was a change from other social services they had participated in, in which providers “promised they were gonna do this and were gonna do that. And they did nothing.” Another participant said that in “other places they give you an appointment a month away, and you barely get to see anybody, and they just want you to do paperwork, and they send you back out on the street. [At LEAD], I did paperwork, and I was in a motel in a week.” Case managers have been able to help participants meet their basic needs, such as housing, that as one client noted, “I never in a million years imagined I would have.” LEAD case management supports autonomy. While participants asserted that LEAD case managers help them, they also acknowledged they were expected to “put in [their] part of it.” One participant noted, “It’s not a program of give, give, give. You get out of it what you put into it.” This was a notable experience for participants in that it made them feel they were an active part of their own intervention. One participant noted that LEAD case managers are “pretty much leaving it up to me. They make suggestions or offer a little bit of information, [but] it’s more about me trying to take care of myself.” Another participant talked about working in collaboration with LEAD case managers: “LEAD helps you, but…I feel like I’m a part of helping also together with my counselor.” LEAD case managers take a holistic view of clients and case management. In supporting participants’ autonomy, LEAD case managers have to meet participants where they are at, and this engenders a more holistic view of participants and their case management goals. As one participant noted, “They’ll help you with anything that you want to do as long as you want to do it.” Another participant said that LEAD provided “aid in any endeavor I wanted.” LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 12 In this way, LEAD was viewed as a kind of ‘one-stop shop’ where participants could work together with case managers to get their various needs met efficiently and effectively. One participant simply stated, “LEAD: They do everything.” Another said, “They really tackle all the problems that you face.” Other participants were more explicit about the various tasks LEAD case managers helped them with, including “my dental, my medical, my psychiatrist…when I needed bus fare, she gave me some bus fare.” This holistic service provision was contrasted with other social service programs participants had previously experienced: Usually, you have to go somewhere for one thing only: one place to get help for treatment, you gotta go to another for housing or shelter, or you have to go somewhere for this and that. And with LEAD, they help with all that. Just one place, and you get everything handled. LEAD case managers advocate on behalf of their clients. Participants reported that navigating the system to fulfill their basic needs was daunting. In response, LEAD case managers were perceived as advocates on participants’ behalf within the system and in connecting them with services. One participant stressed how important it was to have someone to “back [him], or be in [his] corner, or right with [him].” LEAD case managers filled that need. Another client noted that “if you can’t figure out how to make things work for you, you have [a LEAD case manager] that is advocating for you, that can help you.” Another participant stressed the importance of the client-provider relationship, stating that, “the relationship you have with your case manager has the potential to make or break you.” This participant added a recommendation for LEAD programs: Any case manager that is brought on to the project should be, empathetic, down to earth and nonjudgmental. They should want to be here, and if there is one thing I can emphasize, it’s making case managers aware of the impact they have on us. Make sure they know how much the work they do impacts people’s lives. This work is life changing. There is a lot of power in that. Very few LEAD participants expressed dissatisfaction with the program. A small minority of participants (n=2/32) indicated dissatisfaction with specific aspects of the program. One participant was frustrated he was unable to obtain housing during his time in LEAD and was concerned about the lack of housing stock available through the program for individuals who he perceived were not able to maintain a “clean and sober” lifestyle: If you don't do clean and sober, [LEAD] is not able to do a damn thing for you. And that's basically what [LEAD is] saying to a certain degree. It's hard to swallow when I've been doing drugs for 20 – damn near most of my life I've been in this drug era. Another participant said a personality conflict with her first case manager initially dampened her enthusiasm for the program. Early on, however, she “told [the LEAD case management supervisor] that I needed a different person, and she worked with me to find me LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 13 someone [whom] I fit better with.” This participant reported that she’s “had a great experience ever since, and my case manager is the best.” Life Before and After LEAD Many participants said that not being involved in LEAD would have resulted in negative longer-term outcomes for them. One participant estimated he would “still be doing a lot of the stuff I used to do: abusing myself, living on the streets, trying to survive from day to day.” Other participants thought they would be in prison, would lose their children to foster care, or would be dead. On the whole, participants reported that life after LEAD was better than before. As one participant asserted, “The [LEAD case management] program has helped me stay off the streets. It’s helped me be clean. It’s helped me become a better mom. It’s helped me be stable.” Interactions with Police Officers Before and After LEAD Prior to LEAD involvement, more than half of the participants interviewed perceived their interactions with police officers as being negative (N=19/32). As one participant noted, “I didn’t have good interactions. It was all bad. I was fucking up. I was in alleys getting high and going in and out of jail…That’s how I interacted with them, just criminal stuff.” Of the participants who originally reported negative experiences, however, about half said these experiences had become positive after their LEAD involvement. One participant said that police officers regularly asked about their LEAD participation and were happy to hear about their positive progress in the program: Every time I go by them, I say, ‘Hi!” They say, ‘Hi!’ to me. ‘How are you doing? What are you doing?’ They like to see me doing good. They’re congratulating me, and I look way different now. So, they’re surprised to see me now the way I am, so it’s kind of awesome. Some participants reported continued interaction with police officers due to criminal activity. Most of these participants, however, said these interactions had improved since their LEAD program participation began. One participant related that he had “been arrested since [starting in the LEAD program] a few times” but that he had “had more positive interactions.” He related a recent experience: “I ran into the police on Saturday, and I introduced them to my sister, and we had a good conversation, which is something that wouldn’t have happened before.” Another participant indicated he was “still occasionally [involved with the police].” He continued, “I might give them a little beef. But then again, when I see the [police officers] who got me into the program, I always stop those officers and say, ‘Thank you!’ It’s a love-hate.” Nearly half of all participants reported little to no further contact with law enforcement after LEAD involvement. However, some reported still seeing the officers that had recruited them into LEAD. One said, I have not [had any police involvement] since entering LEAD. I did bump into them approximately 3 months ago, and told them I had started [the LEAD program]. I thanked them both very much for what they’ve done for me. I got a high five, and they said, ‘Well, LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 14 great! Good!’ They have not seen me on the streets at all since because I just don’t go around there. Other Community Members’ Understanding of LEAD As discussed in the above sections, LEAD participants were very clear on the purpose of LEAD. However, some participants reported that some nonparticipants perceived LEAD as a confidential informant or “snitch” program. As one participant said, “I heard somebody the other day, ‘Oh, you’re on that LEAD program?’ And I was buying some drugs, and she said, ‘Oh, that means that they’re leading the cops to a drug dealer.’ Like that’s gonna get them busted. Like I’m gonna snitch.” That said, no LEAD participants endorsed this view of LEAD. In fact, the same participant said he tried to correct that misunderstanding: No, that does not mean that you’re a snitch! [LEAD case managers] get you off the street. They lead you to a new life, dumbass. If you want it, they’ll provide it. You just gotta do something for yourself instead of laying there waiting for somebody to drop something out of the sky. When asked where they thought this misperception of LEAD was coming from, participants indicated there was a lack of understanding of LEAD’s goals and procedures in the larger community. Some participants ascribed this to community members’ “ignorance and stupidity” or making false assumptions (i.e., “I think it comes from people in jail not knowing what’s going on or people who are arrested who think, ‘How did he get off?’ So, they make assumptions. They’re just wrong.”) One participant, however, suggested that the police and policy makers involved with LEAD need to do “a better job advertising LEAD and communicating what LEAD is all about.” Discussion The aim of the current report was to provide a thematic description of participants’ experiences with and perceptions of LEAD in their own words. Because participants’ primary point-of-contact was with LEAD case managers, the report focused on the case management component of this program. Participants’ characterization of LEAD case management was primarily positive. Overall, participants experienced LEAD case management as a positive change from other social services they had received in the past. In fact, LEAD appears to have engaged a hard-toreach population: 35% of participants indicated they had never connected with social services prior to their LEAD involvement. Perhaps part of the improved engagement is attributable to LEAD’s low-barrier, harm-reduction approach that does not require abstinence from substances for service provision. Also in keeping with a harm-reduction approach, participants LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 15 characterized LEAD as a nonjudgmental, compassionate and advocacy-oriented program that supported their autonomy in reaching their goals and helping them with “whatever they needed.” This interpersonal style used by LEAD case managers was important in initiating a positive client-provider relationship. Case managers then continued to build trust by showing strong follow through and “doing what they said they were going to do.” Participants felt they were better off after they were engaged in LEAD. In addition to their positive engagement with case managers, participants said that the program had improved their lives and speculated they would be worse off had they not participated in LEAD. Further, nearly half of all participants reported little to no contact with the criminal justice system subsequent to their initial arrest. Those who did have further involvement with law enforcement nonetheless indicated that they had improved interactions with police officers. Many participants said the police officers who referred them to LEAD had asked about their progress in the program and had given them positive feedback. Participants had recommendations for LEAD program enhancement Despite the fact that LEAD was perceived positively by participants, some indicated that other, nonparticipating, LEAD-eligible community members misperceived LEAD as a confidential informant or “snitch” program. LEAD participants, none of whom endorsed this perspective, felt that this misperception stemmed from a lack of understanding of the LEAD goals and program procedures. Participants suggested clearer communication about LEAD to disabuse community members of such misperceptions. Several participants referred to the client-provider relationship as the key to the program’s success. Participants offered program administrators some advice on the essential characteristics of LEAD case managers: “[They should be] empathetic, down to earth and nonjudgmental.” Finally, one participant expressed concern about the availability of housing stock for individuals with active substance use. In fact, subsequent to the data collection for the current report, Seattle’s mayor and city council declared a state of emergency regarding homelessness. Thus, although increasing housing stock is not under LEAD case managers’ control, and this specific recommendation was not offered directly by the participant, efforts are underway to address this city and county-wide issue. In the meantime, LEAD program administrators may be able to address this issue by working with local government and housing agencies to establish housing set-asides dedicated for this population. Limitations Some limitations of this report should be noted. First, participants were approached at the LEAD case management offices rather than through community outreach. This convenience sample was thus potentially skewed toward individuals who were more engaged in and had more positive perceptions of the program. Future studies should also include the perspectives LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 16 of individuals who are less engaged with LEAD to learn about barriers to engagement and additional challenges. Second, a review of the interview transcripts revealed that interviewers often responded to participants’ statements with value judgments (e.g., “Oh, that’s wonderful!“ “That’s great.”). Such statements may have inadvertently solicited and rewarded socially desirable responses from participants. In future efforts, interviewers should be trained and regularly supervised on how to engage participants with open-ended prompts and neutral responses. Because the evaluation team did not receive the transcripts until after the interviews had been completed, there was no opportunity to adjust the interview process to further explore and follow up on emerging themes. Fortunately, the evaluation team had the opportunity to share findings and ask clarifying questions (i.e., member checking) in focus groups with both LEAD case managers and participants. Despite its limitations, this report provides useful information about the LEAD experience from participants’ perspectives, as well as essential program components for program staff and policy makers to consider in program enhancement and replication. Conclusions and Future Directions Participants characterized LEAD case management as a positive change from other social services they had experienced. They appreciated its client-centered, advocacy-oriented, harmreduction approach. Participants reported their engagement in the program had helped them meet their basic needs, improve their lives, and rectify their relationships with and perceptions of law enforcement. The client-provider relationship was cited as key to the case management program’s success. Collectively, the findings from this and three prior evaluations indicate that LEAD is a promising program that warrants replication. As one participant concluded, LEAD is about people helping people, people caring about people. For years I didn’t have any trust, but through LEAD, I was proved wrong. People are worth it. People are worth saving. Don’t give up. LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 17 1. 2. 3. 4. 5. 6. 7. 8. References Warner TD, Kramer JH. Closing the revolving door? Substance abuse treatment as an alternative to traditional sentencing for drug-dependent offenders. Criminal Justic and Behavior. 2009;36:89-109. Wormith JSO, M. Offender treatment and attrition and its relationship with risk, responsivity and recidivism. Criminal Justice and Behavior. 2002;29:447-471. Fletcher DR. Offenders in the post-industrial labour market: Lubricating the revolving door? People, Place and Policy. 2013;1:80-89. Collins SE, Clifasefi SL, Logan DE, Samples L, Somers J, Marlatt GA. Ch. 1 Harm Reduction: Current Status, Historical Highlights and Basic Principles. In: Marlatt GA, Witkiewitz K, Larimer ME, eds. Harm reduction: Pragmatic strategies for managing high-risk behaviors (2nd ed). New York: Guilford. http://www.guilford.com/excerpts/marlatt2.pdf; 2011. Sandelowski M, Barroso J. Classifying the findings in qualitative studies. Qualitative Health Research. 2003;13:905-923. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qualitative Health Research. 2005;15:1277-1288. Krippendorff K. Content analysis: an introduction to its methodology. Thousand Oaks, CA: Sage Publications Ltd.; 2004. Friese S. ATLAS.ti 7. Berlin: Scientific Software Development GmbH; 2012. LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 18 APPENDIX A LEAD Participant Interview Guide Conditions of Arrest/Diversion • • • • Please tell me how you made it into the LEAD program, and how you felt at the time? o In particular, we want to establish if it was an arrest referral or social contact referral. o What was the process of his/her arrest/diversion? How are the cops making their decisions? What is your relationship with the officer who recommended the program to you? (Did you know him/her prior to LEAD? What kind of contact have you had since?) What are people saying about LEAD on the streets? What did you know about LEAD before getting into it? o Establish what people know about the program. Police Relations • • • Before LEAD, what kinds of interactions did you have with police? Always in Belltown? Why were you most typically involved with the police; what were you doing? Have you been involved with the police since you entered the LEAD program? Yes or No; if Yes, then: What kinds of interactions have you had with police since LEAD? Can you please describe a typical interaction with the police now? What would be the most typical reason for involvement with the police now? What would you most likely be doing? • Can you please describe your last experience with the police since being in LEAD? Can you describe a typical interaction with the police? o Establish their crimes, drug activity and situations. o How long have they been active on the streets? Why? • • • • History with Social Services • • • • Is the LEAD program different from other social service programs you have been in? Yes or No; if Yes, then: ○ Can you please describe how the LEAD program is different? Tell me more about why you sought out that/those other programs? o We want to know if the person chose to be in other programs or was mandated to participate in them. o Do they perceive LEAD/features of the program as effective and positive? LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 19 Personal LEAD Experience • • • • • • • • Why did you decide to accept the LEAD program? How would other options have impacted your life? o How would going to jail currently impact your life? § What are the advantages of participating in LEAD? What are the disadvantages? What did you expect to get from the program? What do you need from the program? What are you actually getting from the program? o Looking for a description of his/her experiences with the LEAD program. For instance, interactions with the staff at LEAD, timeliness of services, tailored intervention, etc. Would you say that your life changed because of LEAD? o Have things changed for better or for worse? Can you describe them? Would you recommend LEAD participation to others? Why and have you? What advice do you have for people running the LEAD program? Were there aspects of the program that were not helpful? What parts of the program are working for you? Is there anything you feel that would have enhanced your experience as a LEAD participant? Is there anything about LEAD that didn’t work for you? (if so, can you tell me about that?) LEAD Evaluation: Qualitative Report UW LEAD Evaluation Team 20 ACKNOWLEDGMENTS The authorship team for this report included Drs. Seema L. Clifasefi and Susan E. Collins. We acknowledge Dr. Heather Lonczak for her contributions to data management and initial coding efforts. We would also like to acknowledge the Whitman interns for conducting the qualitative interviews, LEAD case managers for providing feedback and insight into these data and most importantly, LEAD participants for sharing their words and experiences with us. We would like to thank the current and former members of the LEAD Evaluation Advisory Committee, including Mark Baird, Mary Barbosa, Mark Cooke, Kelley Craig, Clifton Curry, Lisa Daugaard, Ian Goodhew, Chloe Gale, Ron Jackson, Jutta Joesch, Anita Khandelwal, Alan Lee, Kris Nyrop, Amy Tsai, Christa Valles, Natalie Walton-Anderson, and Mike West, for their valuable contributions to this report. Finally, we thank all of our Harm Reduction Research and Treatment (HaRRT) Center staff for their additional administrative and data management contributions. Interviews for this report were conducted by Lily Monsey and Uma Trivede (Whitman College) under the supervision of Dr. Suzanne Morrissey (Assoicate Professor, Whitman College) and Kris Nyrop (Public Defender Association). This evaluation is supported by a grant from the Laura and John Arnold Foundation to Susan E. Collins and Seema L. Clifasefi. LEAD services and project management have been funded by the Ford Foundation, the Open Society Foundations, the RiverStyx Foundation, the Vital Projects Fund, the Massena Foundation, the City of Seattle and King County (starting in 2016).