Abstract

This article examines perspectives and practices related to social triage and the exclusion of criminalized and marginalized individuals in community services such as shelters, mental health, substance use, and court supports. Based on two years of fieldwork and interviews with 105 practitioners, I analyze narratives and practices related to working with people described as having (or being) complex, high-needs, or high-risk. I show that individual factors, such as risk, need, or responsivity, are but one type of factor considered when practitioners make decisions about triage or service eligibility. Building from theory about the governance of “risk” and “risky people,” I examine how organizational and systemic factors shape individualized understandings of and responses to risk. I argue that given current practices in under-resourced community supports, triage and resulting exclusions exacerbate social problems and contribute to punitive exclusions, especially for those who seek services, supports, or housing but have records of sexual offense, fire setting, drug use, violence, self-harm or so-called non-compliance. Examining these dynamics bolsters claims that we should shift the responsibilizing gaze upwards to pressure institutional and state bodies who could transform the landscape for practitioners and their clients.

KEYWORDS

triage, exclusion, risk, transformation, structural violence

INTRODUCTION

It is abundantly clear that poor, racialized, and marginalized people suffer from being both under supported and over-controlled by mainstream public, private, and non-profit structures. This governance and social exclusion involves criminal justice actors, but also community service providers. Scholars have documented how criminalized people are monitored and punished, focusing on interdisciplinary work with police (Huey 2007), courts (Kohler-Hausmann 2018), hospitals (Lara-Millán and Van Cleve 2021), paramedics (Seim 2020) and corrections-based practices around probation (Phelps 2013) or parole (Werth 2017). Others have focused on state run or community-based agencies to understand the governance of homelessness (Dej 2020), people who use drugs (McKim 2017), or to highlight anti-Black discrimination (Maynard 2017). There is much interest in how service providers care and control, making decisions about client prioritization, attributing varying levels of importance to clinical discretion, standardized tools, or structural factors.

I contribute to the body of knowledge on care/control tensions and risk1 management in ‘community corrections’ and social supports. More precisely, I engage with the concept of ‘social triage’ (Glumm and Johnson 2001), documenting and analyzing narratives, practices and logics related to the exclusion of individuals who are criminalized, and in some cases, labelled ‘complex-need2’. Similarly, Dej (2020) theorizes spectrums of inclusion and exclusion in shelters for the homeless focused on individualized, pathologizing frameworks and concepts of ‘redeemability’. What my analysis contributes is enhanced understanding of how community practitioners talk about who gets excluded across service points. I clarify how practitioners talk about individual, organizational and systemic factors related to who gets triaged out. This is important to understand, because marginalized people who have been criminalized need supports, and those who are excluded and denied services are likely to experience continued criminalization and marginalization

Individualized risk-based case management practices have been documented in many sectors of human services, including corrections (Werth 2017), mental health services (Hardy 2015), child welfare or youth justice (Swift and Callahan 2009) and shelters (Dej 2020). Risk logics offer a predictive framework for looking at problems, conceptualizing each person as responsible for making “healthy and prudent” choices (Kemshall 2016: 253) with everything from desistance to housing, substance use, relationships and personal health. Social work led the way in adopting risk-led service delivery practices, allocating extensive resources based on such evaluations, often collaborating with punitive institutions (Kemshall 2016; Webb 2007). For example, community corrections programs and specialized courts use judicial control and supervision to leverage people into changing their problematic ways, feeding the idea that ‘tough love’ helps people towards personal transformation and success (McKim 2017; Werth 2013). Practitioners are said to be increasingly risk averse, framing individual needs as generalized risk factors (Kemshall 2002; Webb 2007). However, in this paper I describe how participants talked about triage practices, in relation to client-focused factors, but also organizational and larger social factors. Borrowing from literatures on frontline discretion and risk management, I make the case that individual factors are but one set of many factors that community service providers working with criminalized people consider when making decisions about service eligibility.

Organizational risk management can also be consequential. For example, managerial pressures can limit discretion and de-skill frontline practitioners (Fitzgibbon 2011) or push them to “redefine success” (Simon 1993). Relatedly, managerial priorities, partnerships rhetoric and community safety work can combine to enhance exclusion and undermine both social service and crime control efforts. More specifically, the managerial straightjacket “requires the construction and institutionalization of ‘auditable performance’ – through the quest for performance indicators – whereby complex tasks are reduced to fit administrative codes that remain consistent even when they are arbitrary” (Crawford 1998: 249). Organizational protectionism can also lead to an obsession about compliance and can validate rituals of verification (Power 1997), undermining efforts to tackle complex problems and invest in long-term solutions. Halushka (2017) studied the effects of institutional pressure on re-entry agencies and showed how demands to track outcomes pushed practitioners to pick the path of least resistance and discipline clients into being “prudent, personally responsible worker citizens” (499). He called for research that examines these perverse effects in other institutional spaces – which this paper explores.

Studies have documented the contemporary conditions experienced by various marginalized and criminalized groups facing poverty, lack of housing, education, income, employment, social stigma, and more. There are many issues at play. We cannot ignore the ongoing impact of colonialism and slavery, with systemic racism and discrimination exacerbating issues with police, courts, corrections, and all other state institutions, such as social services (Maynard 2017). People in conflict with law are punished, subjected to penal control, and neglected by the state (Kaufman, Kaiser, and Rumpf 2018). Criminal records create additional barriers to stability (Pager 2007), and communities are unable to provide supports for people attempting re-entry and rehabilitation (De Giorgi 2017; Miller 2014). Relatedly, literature on frontline practitioner discretion has shown the importance of resource scarcity in shaping the work of street-level bureaucrats. For instance, Alden (2015) found that in English homelessness services, negative application of discretion is driven by systemic factors such as topdown pressures and resource scarcity, leading to unlawful gatekeeping of key supports. This echoes Lipsky (1980), who also underscored the importance of inequity in resource distribution, showing how it shaped service outcomes for various groups.

I draw from a larger study about community practitioners and the criminal justice system, pulling from qualitative interviews, document analysis and field observations. I interviewed and observed practitioners to learn how they talk about and explain the triage and exclusion of clients in their own service sites or elsewhere. Focusing on practitioner narratives, this paper considers how individualized risk logics intersect with organizational priorities around protecting outcomes, partnerships, liability, and reputation, as well as systemic issues like poverty, racism and lack of housing. These shape and limit practitioner discretion and determines who gets excluded. I conclude that narratives and practices around client triage illustrate: (1) the individualization of social problems and responsibilization of marginalized people, (2) organizational risk aversion and systemic failures that amplify individualized interpretations of risk, (3) practitioners experiencing distress because they are asked to solve complex problems with limited resources, and (4) more acute triage issues for those with records of sexual offence, fire setting, drugs, violence, self-harm or ‘non-compliance’.

LITERATURE REVIEW

Community service providers and supports for the criminalized

Community service providers work with people who are criminalized and are called to engage with police, court actors, bail and probation officers. Crime control duties get downloaded to non-justice organizations (Garland 2001; Mythen Walkate and Kemshall 2012) and much of this governance work centers around assessment and triage, based on who is most at-risk or presents the most risk to others (O’Malley 2004; Rose 2000). Importantly, contradictory objectives and logics have practitioners providing care, control, rehabilitation and punishment. Research has documented the impact of risk prediction and aversion in community corrections and in social services more generally (Fitzgibbon, 2011; Webb 2007). Other work highlights the conditionality of access to services and supports (Flint 2009; Soss, Fording and Schram 2011), and the disciplinarian and often involuntary nature of supports that combine care and control (Phelps and Ruhland 2022). Scholars have theorized practices of forced inclusion (Huey 2007, Tomczak and Thompson 2019) and documented coercive interventions and social, penal and therapeutic control. For example, Kerrison’s (2018) work on the normative (white/hetero) gaze used to assess success in rehabilitation centres and Cohen, Krumer-Nevo and Avieli’s (2017) work on mechanisms of othering in soup kitchens.

Analysis by Soss et al. (2011) underscores that “case managers are rarely single-minded performance maximisers. More typically, they are ambivalent actors caught in the cross-pressures of competing values, identities and organizational forces” (219). Indeed “community practitioners spend much of their time reviewing and producing evidence about social, medical and criminal justice histories, problems and goals” (Quirouette 2022). In doing so, they cross agency and disciplinary boundaries. Also, as Bosk (2020) showed, race and gender complicate how workers can subvert rules to help their clients. Exercising discretion, they remain constrained by agency rules, local policies, legal responsibilities, availability of resources and their professional and institutional cultures (Lipsky 1980; Maynard-Moody and Musheno 2000).

Social triage and exclusions

Triage is generally associated with scarce resources in medical or military emergencies, but it can also be useful to understand in other settings, such as community supports for the criminalized. In social welfare programs, triage often refers to the exclusion of people for whom not much can be done easily or quickly (Meredith 1992:108). Reasons vary: acuity or complexity of issues, lacking resources, likelihood of good outcomes, hierarchies of who is ‘worth it’, etc. In psychiatric care, Glumm and Johnson (2001) proposed “social triage” to describe how decision-makers respond to the truly disadvantaged, who are defined as beyond rehabilitation. Financial, bureaucratic and risk management priorities are protected at the expense of clients/patients who are declared “unfit” (ibid). Unlike medical and military triage, social triage implies that those passed over might continue to live, just with their services rationed (Meredith 1992) or withheld (Sjoberg 1998). Yet, in the context of being turned away from emergency shelter for example, triage and exclusion may indirectly lead to death via overdose, exposure to the elements or other risks exacerbated by homelessness3. Managerial pressure and cost-benefit logics push organizations “to address the needs of those who are easier to reach and save, while those bodies that would require longer-term investments of time and resources are neglected” (Simmons and Casper 679). In many ways, “social triage signifies the perpetuation of structural violence” (Simmons and Casper 2012:681), sacrificing and excluding the most disadvantaged (Sjoberg, Vaughan, and Williams 1984). This also resembles what is described as “negligent penal control,” where there is absence of state supports for people who are criminalized (Kaufman et al. 2018:485). This triage, and neglect, amplify hardships for people who are criminalized.

Disaster triage literatures also offer rich engagement with the ethical frameworks of "doing the most for the most with the least resources” (Sztajnkrycer, Madsen, and Báez 2006:749; see also, Linzer, Sweifach, and Heft-LaPorte 2008). Focusing on medical resources, Sztajnkrycer et al. (2006) challenge utilitarian logics and ask ethical questions about how triage decisions should be made (according to age or social worth, for instance). Focus on triage in ecological catastrophes, social crises, and public health disasters highlights how lack of resources shapes a tiered approach to triage. This approach pushes gatekeepers to prioritize the social good, while placing undue burdens on individuals deemed to be a bad investment. While in “normal” or well functioning systems, people with acute needs will also get care, crisis and lack of resources trigger categories of people more or less deserving and socially valuable (Sztajnkrycer et al. 2006). We can also consider that structural violence and discrimination are not accidents, but political choices that dehumanize certain groups of people, excluding them from supports, punishing them for being “risky” or inconvenient. In other fields, such as public defense law, there is debate on how to best distribute scarce resources focusing either on equality, case selection, or even randomness models (Tremblay 1999). But triage practices can reify categories of clients unfit (or less worthy) of services. Triage has been well documented in some fields of practice (e.g., medicine), but my contribution is novel in mapping out how practitioners from various disciplines talk about criminalized people being turned away from services and supports.

METHODS

I draw from a larger study conducted in Toronto, Canada with community practitioners who have clients involved with police, courts and corrections. I pulled from three sources: (1) 105 in-depth semi-structured qualitative interviews; (2) document analysis; and (3) field observations. These sources and strategies were used concurrently, one informing the other over the course of two years.

Respondents included 60 case managers and 19 managers/directors, 15 justice professionals, five clinical staff and six other service experts. All 105 interviewees worked with clients who are criminalized. Approximately half worked with diversion, re-entry or therapeutic justice projects or did in-reach work in jails and prisons. The other half worked in agencies without formal connection to justice, but interacted frequently with law enforcement, courts and corrections (ex.: shelter staff, mental health case managers, harm reduction workers). Their involvement in triage processes varied. Triage and exclusions can look like (1) not selecting or accepting someone for programs or services; (2) delaying access; (3) referring applicants elsewhere (4) graduating people out prematurely (5) moving them on for lack of progress, or (6) banning people from premises or excluding them from future access to supports. Some talked about being directly responsible for client intake decisions or disciplinary service bans, while others contributed via team discussions. All 105 participants talked about contributing to these decisions and seeing their criminalized clients excluded at other service points.

The first 20 interviews were conducted between August 2010 and June 2011, the other 85 between January 2014 and May 2016. Potential participants were first identified online and contacted by email or phone. Participants helped by sharing my study in newsletters or bulletin boards. A few became key informants, sharing agency data, setting me up with peers, and providing access to community events and committees. As I attended regular community and multi-agency meetings where practitioners deplored revolving-door problems and worked on solutions, I had opportunities to explain my project and find motivated interviewees. I was purposive with my recruitment, and made attempts to include respondents with a range of backgrounds, roles and specialties. Interviews lasted an average of two hours, and were audio recorded with consent. Detailed in-depth semi-structured interviews were ideal because they allowed me to “explore many facets of the interviewee’s concerns, treating subjects as they come up in conversation, pursuing interesting leads in the course of the interview” (Becker and Geer 1957: 28). Before each meeting, I adapted my interview guide to include specific questions about their unique role and work environment. Interviews always began with general questions about occupational history and then focused on their experiences working with clients who face complex social, medical and legal issues and may be labelled as ‘revolving door’. My semi-structured interview guide was adjusted regularly to incorporate unanticipated or emerging themes, like staff burnout, personality disorders and diagnosis tools.

Observations included 30 different site visits, nine shadow shifts, 40 hours of court observation and 40 hours of local, regional and provincial committee meetings, workshops and webinars. These occurred during the same time periods as the interviews. Site visits brought me to dozens of emergency shelters, community agencies and institutional offices supporting a wide range of clienteles. Sometimes, interviewees invited me to shadow them for a day to see how they operate with clients. I did nine shadow shifts, each lasting 3-6 hours. I tried to be unobtrusive and watch events unfold, taking notes when appropriate or after I left. These shifts consisted of case management check-ups, discharge planning, court support and client intake and triage meetings.

Interviews and observations were analysed along with policy documents and secondary data obtained online or through participants (ex.: vision statements, policy manuals, performance reports, intake tools, partnership agreements). This material helped situate institutional logics, the roles of practitioners, and the criteria used to assess clients. Analysis began during fieldwork through observation and post-interview memos. Memo-writing took place before, during and after interviews, helping connect them to each other, their larger contexts and key themes. I annotated and sorted documents according to their type or subject matter. Notes for prominent themes were compared, tracking similarities and differences in how ideas were framed. A method-focused notebook also helped track decisions, refine the interview guides, and justify activities in the field. Field notes, memos and interview transcripts were organized and thematically analysed using both manual strategies and NVivo software. A primary sample of 20 transcripts was coded twice, to refine themes and plan next steps. My approach most resembled that of “codebook thematic analysis”, in that it was a compromise between predetermined and unplanned theme structures (Braun and Clark 2021: 333). Coding was theoretically driven and guided by predetermined categories (Crabtree and Miller 1999), but also data-driven, generated in inductive and often unpredictable ways (Boyatzis 1998). Thematic analysis can be useful for scholars working in many theoretical traditions, supporting realist and constructivist approaches, allowing for consideration of policy, process, and practice as well as for perceptions, interpretations, and experiences (Braun and Clarke 2006).

Ethnomethodology and Foucauldian discourse analysis strategies can be combined to generate strong qualitative research that accounts for both agency and structure. Ethnomethodology is about what people do every day to construct social life, and Foucauldian discourse analysis looks at how systems of power/knowledge help people make sense of the world (Holstein and Gubrium 2003). Both consider the “constitutive power of language,” but one looks at “discourse-in practice,” and the other at “discourse practice.” This combination is effective in highlighting both the standardized “ecology of knowledge and power” and the “artful ways” in which people resist and negotiate, using “interpretive recourses” to get by in their everyday life (Miller and Fox 2004:46). This approach is well suited for my study, as it facilitates the examination of legal mandates, organizational factors, while also recognizing the importance of discretionary techniques of governance and the rationalities that inform them.

FINDINGS

My research documents how service providers working with multiply disadvantaged and criminalized clients talk about triage and exclusion, and engages with the concept of social triage to highlight key issues related to findings. Interviewees invoked a broad range of considerations, focusing on individuals and the risks they pose to themselves and to others, while also paying attention to how organisations and social institutions contribute to problems. This paper does not explicitly examine how clients are triaged at particular agencies, or in specific programs, but rather reports on the general experiences and concerns practitioners report. I show that two contrasting sets of factors dominate narratives about triage and explanations about who gets excluded and examine how individualized risk logics intersect with organizational and structural factors.

Individualized factors can have social, medical or legal dimensions, focusing on a person’s situation and behaviors – often those related to housing, mental health or substance use. These are then framed as complex needs related to perceived risks of recidivism, relapse, decompensation, violence, self harm, housing loss, non-compliance etc. Individual factors and ‘complexity’ are usually assessed via tools and screeners and informally through interactions with practitioners. Organizational and structural factors include location, physical accessibility, eligibility criteria, waitlists, case loads, scope of programs and time limit for supports, information sharing policies and service ban requirements. They also include organizational concerns related to staff wellbeing, pressure to show outcomes to secure funding and manage partnerships and liability issues. These organizational factors are discussed in relation to the larger structural context, for instance, highlighting the impact of the current affordable housing and emergency shelter crises, or of ongoing harms related to colonialism and structural racism.

INDIVIDUALIZED FACTORS

Complex Needs and Risks

Though it carries forward a pathologizing frame that individualizes social problems, the term ‘complex-needs’ is an important and common term for practitioners that refers to multiple interlocking and compounding experiences spanning social, legal, and therapeutic dimensions. The organizing principle of ‘complex-needs’ dominates in many fields of practice like corrections, psychiatry, and interventions with people who use drugs or experience homelessness (Anderson 2011; Keene 2001). Borrowing from Rankin and Regan (2004), I understand the term to refer to both breadth of needs (multiple and interconnected) and depth of need (intensity, risk, level of functioning, ability for need to be met). Multiply disadvantaged and justice-involved individuals are described (in policy and in practice) as having complex needs or being complex – often because of their criminalized status and the barriers those records represent. Practitioners describe complex-need clients in ways that highlight both their inherent riskiness and their being ‘needy’, or ‘at risk’, connecting the micro to meso or macro considerations.

Describing who has needs that are complex, interviewees most often talked about people experiencing a multitude of issues related to homelessness, mental health issues, cognitive issues, developmental delays, acquired brain injuries, dementia, Axis II disorders, substance use, social isolation, victimization, abusive and predatory relationships. Most importantly, they talked about people who are not being served, who are ‘falling through the cracks’, and who are experiencing hardship because of organizations, institutions and social neglect, stigma and punishment. One case worker expressed frustration about how:

With FASD, we fail. They tend to also have addiction, mental health, criminal justice involvement and other things (and) by default, people with really complicated situations end up bouncing back to jail. But you can only offer what you have to offer, right? (MH002)

Practitioners can get overwhelmed, discouraged or angry working with clients experiencing intersecting discriminations, traumas and numerous barriers to accessing services. One report from a local supportive housing network indicated that “among applicants who were declined by housing providers, nearly 40 percent were identified as having support needs too high for the provider to meet. These applicants were considerably more likely to be homeless, to have substance abuse challenges and criminal justice involvement, and to have safety risks involving harm to themselves or others” (Sirotich et al. 2018). Perceptions of risk can prevent effective responses to human needs (see also Milner and O’Bryne 2002), and practitioners know how much harder it is to access supports for clients with certain profiles. A recent report about emergency shelter bans, also found that people who are criminalized, who engage in sex work and who use drugs are more often excluded (Kerman et al. 2022).

Records of violent or sexual charges are especially problematic for people who need supports, like elderly individuals with dementia or mental illness that depend on access to Long-Term Care Homes. Several interviewees talked about their policy to ban anyone with such charges, which meant geriatric clients would find themselves on the streets, in shelters or prison, or sometimes, in a costly act of desperation, kept in hospitals or psych wards4. Medical needs can also factor into safety management practices. Some shelters only allow certain clients in if they have their psychiatric medication with them. These policies are problematic when clients are discharged from jail without personal belongings or pharmacy access. Some programs offer personal care, medication management and in-house nursing, but most shelter spaces cannot offer such intensive individual supports. One outreach nurse explained that people who have cancer and are homeless have been denied treatment because emergency shelters have shared bathrooms, and chemotherapy patients could expose other clients to health risks. Others talked about disabled people being turned away because facilities are not accessible.

Practitioners have different, and situated, conceptions of what makes a person ‘complex’ (Toch 1995). Appreciating the problematic aspects of labelling people, some participants noted that everyone has complex needs. Yet some people have overwhelming and interconnected unmet needs that are particularly challenging for them, and for practitioners who work with them. Unmet ‘complex needs’ are characterized and institutionalized as risks to be measured, managed, passed on or avoided. Unmet needs can variously represent risk to self, to others and to organizations, and it is common to accept the notion that “need is reciprocally linked to understandings of risk” (Hannah-Moffat 2004: 42). Others, like Goddard and Myers (2017) expand on this, writing about how risk management agendas in youth justice programs have transformed trauma and adversity into risk, enhancing discrimination and exclusion in the process. I build on this notion that organizational and structural factors can amplify interpretations of risky individuals.

Compliance and normative reform

Practitioners talked about difficulty finding supports for clients whose behaviours and priorities do not conform to the standard practices. For example, clients who reject psychiatry but seek out homeopathy, mindfulness meditation or religious ceremonies. When clients are seen as unrealistic or unmotivated, they are often labelled as ‘not housing-ready’ or as a ‘poor fit’ for supports given their perceived likelihood of losing housing and jeopardizing program success. Access to support is often conditional on clients adopting normative goals and ‘reasonable behavior’ (see also Darling 2009; Flint 2009; Quirouette 2016). Case management practices, treatment models (ex.: cognitive behavioral therapy) and the criminal justice system are said to be based on “assumptions about brain function that are often incongruent with actual cognitive abilities of persons with FASD5” (HSJCC 2014: 26).

Sometimes the “complexity” of clients’ needs is determined predominantly by their lack of general compliance or conformity, whether by choice or circumstance. Potential, capability and interest for change were described as important criteria to qualify for services. One manager said: “We’ll even work with people who have committed murder, sex offences, or arson, but we screen out paraphilias and pedophiles. We’re not going there because it’s a fixed part of the person, right? We can’t change that.” (T021) Interviewees stressed that many people they work with are not “responsibilizable” in the typical sense and are punished as if they were making intentional (bad) choices or had (good) alternatives. They were often explicit about how clients “fail” because they lack good options. And when they fail to make the right choices, they are held responsible and suffer more exclusions, further limiting Some call this “gating” a strategy for “protecting” people who are really unwell and vulnerable.Even with social services (outside corrections), the message is that precarious subjects need to show they are redeeming themselves, or at least show that they want to change themselves and their circumstances (see also Dej 2020). As one worker put it: “What I’m looking for is their level of interest in actually following through with their goals” (C028). Another explained: “My rule of thumb is, “If I’m working harder than you, it’s not a good relationship” (C014). Client engagement and compliance are expected in exchange for services. Other research has also shown how perceptions of “deceit and/or non-compliance” affect moral judgment about who is worthy of support (McNeill et al. 2009:432). Regulating case plan compliance and access to housing —by imposing or preventing referrals— becomes part of regulating the behavior of people who are not or cannot “get better.”

Individual background, training and philosophy impact how practitioners make sense of the problems and efforts they see client making. While no interviewee blamed clients for mental health related issues, many expressed judgments towards people who use drugs, and admitted they had a hard time shaking off these deeply ingrained perceptions. One explicitly stated they viewed drug-related self-sabotage as different, and as a matter of making a ‘bad choice’:

“It’s frustrating to see someone choose to do the same thing over and over again when, you know, if they could just change some behaviors, their life would be quite different. Whether it’s spending all their money on drugs and not having any food for the rest of the month. (C008)

This worker (and others) noted a difference between intentional and unintentional behaviors and related these distinctions to the perceived value of interventions. For practitioners who adopt a more law and order rather than disease model approach to drug use, these perceived ‘bad choices’ can contribute to practices of exclusion.

Coercion is also a key aspect of social work with many groups, and service delivery can be complicated by the involuntary nature of case management (Rooney 2009), by mistrust in the system or anti-authority attitudes (Wasserman and Clair 2010) and by the fact that ‘resistance’ can be a mechanism for people to exert limited autonomy and freedom (DeVerteuil 2003). Community practitioners care about assessing non-compliance, level of functioning, insight, and interest in transformation work, partly because they cannot force their clients to do "what’s best for them" (unless they are working in collaboration with legal players who impose judicial conditions). Many practitioners talked about feeling powerless, encountering clients with whom they are not successful or able to work. One manager explained: “if somebody has a pervasive pattern of disregard for authority, rules and potentially psychopathic traits, you know, manipulative, parasitic, then it’s much less likely that they’re going to succeed at all.” (M014) When clients do not comply, practitioners can either discharge them, bar them from service, and/or report to authorities if they breach conditions or commit crimes.

In many institutional settings, assessments of risk, needs and responsivity determine if and how individuals can be seen as "transformable subjects" (Hannah-Moffat 2004). These slippery categories of risk-need-responsivity engage different aspects of managerial and rehabilitative agendas, but focus blame and redemption pressure on the individual. Homelessness is interpreted as an individual risk to be mitigated to reduce recidivism, and the need for housing then becomes a justification for increased therapeutic intervention and monitoring (Quirouette 2016). The conflation of need and risk is particularly relevant when we recognize that exclusionary policies directly limit people’s ability to comply and ‘transform’ and also access essential services and supports. Working within specific parameters, community practitioners must determine who ‘can change’ on an individual level (Dej 2020; Halushka 2017; McNeill et al. 2009). And when people are left without supports or housing, they are set up to fail, they cannot “comply” or conform, and this drives criminalization – often through breach of court issued conditions and related punishments.

Conflict and crisis

Interviewees spoke of struggling to manage interpersonal dynamics with clients, especially when they had unpredictable moods, engaged inconsistently and were embroiled in multiple ongoing conflicts and crises. Many highlighted challenges related to supporting people described as having personality disorders. One explaining “we have a lot of clients with borderline personalities and we’re finding workers are getting burned out because every day it’s crisis. And the way they talk to and treat workers – it’s very very difficult.” (M017). Another said flat out: “BPD? (Borderline Personality Disorder) I won’t touch that with a ten-foot pole”, explaining they get sick of working themselves “into the ground” just to see the whole plan crumble because the client’s mood and consent “changes with the wind” (M020). They described these clients as "draining, compulsive in creating conflict and requiring massive amount of attention" (ibid). As opposed to major mental illness, where psychiatric pharmaceuticals can be used to somewhat control symptoms and manage behaviors, no medication effectively treat people with Axis II diagnoses, dementia or brain injuries6. Some people are not easily responsibilized, normalized or made compliant. This is part of why practitioners report that “if somebody gets the anti-social personality disorder label, no one wants to work with the” (and) “Personality disorders can be a kiss of death in terms of access to services... (C031). This was mentioned most often for women, and interviewees talked about the political, and gendered dimensions of diagnosis, stressing that borderline personality disorder is a label used to describe ‘maladaptive’ responses to extreme and long-lasting forms of trauma and disadvantage. Despite contextualizing these behaviors as reactions to terrible life circumstances, practitioners still talked about prioritizing individuals who are able to engage productively and work toward normative goals. Even practitioners trained to support extremely marginalized people, providing harm reduction and mental health crisis support on the street for instance, described clients who have personality disorders as challenging to deal with productively.

ORGANIZATIONAL & SYSTEMIC FACTORS

Staff burnout

Respondents highlighted how staff burnouts and vicarious trauma are a serious issue for frontline workers. They talked about the impact of witnessing suffering, self-harm, clients dying, being killed, and experiencing recurring and often extreme traumas. Some recalled knowing clients for decades, having worked with them in different capacities and at different agencies, bearing witness to struggles, successes and setbacks along the way. Practitioners described how their work-related distress led to problems like insomnia, anxiety or depression. Many explained how staff turnover and team morale can be challenging, especially when supporting people labelled ‘complex-needs’, who are extremely marginalized and get excluded from services. Even the Mental Health Commission of Canada released a guide (2012) promoting better protection of employees’ psychological health and safety. Locally, committee meetings and webinars I attended during fieldwork highlighted key issues around operational stress and PTSD as an organizational risk.

Dozens of respondents also spoke about how self-harm or refusal to medicate can create concerns about liability and secondary trauma to workers and other clients who “can’t handle it”. They shared stories about the logistic, legal, health and psychological problems caused by clients’ threats of suicide and self-harming acts like cutting, burning or swallowing knives7, as illustrated in this excerpt:

“I’ve got a client who has done serious self-harm when unwell – he decompensates really quickly so it’s hard to intervene… So, it’s stressful… we’ve been talking as a team about compassion fatigue and that type of thing and that certainly comes into play when working with people that have a serious mental illness. You end up having to protect yourself from being too hopeful. (M011)

Some respondents talked about being threatened by suicidal clients, describing frequent and strategically timed threats as emotional terrorism. Many focused on how psychiatric supports are hard to access, and how very few programs are willing to work with people described as ‘complex’ or ‘hard to serve’.

Overall, practitioners talked about being stressed out by (1) what their clients say and do, and (2) what agencies and the system do – and don’t do – to support them. Unable to facilitate desired outcomes, many expressed how defeated they felt, wanting good things for clients who suffer the consequences of bad institutional policies, systemic failures and social injustices. A growing body of evidence shows the extent to which secondary traumatic stress, compassion fatigue and burnout are common and problematic for professionals doing emotionally demanding work (Cherniss 1980; Kerman et al. 2022a; Newell and McNeil 2010). Increasingly, the notion of “moral injury” has been used to describe, “the challenge of simultaneously knowing what [clients] need but being unable to provide it due to constraints that are beyond our control.” (Dean, Talbot and Dean 2019: 401). This relates to notions of systemic violence and injustices witnessed by professionals.

Liability, safety and shared space

Practitioners spoke of their responsibility for their clients’ wellbeing and safety, as well as for protecting other clients, their agency, and the public from their clients. They expressed concerns with sexual predation, violence and psychiatric decompensation or crisis brought up as threats to staff and other clients’ safety8. One housing worker put it this way:

The ethics of housing individuals who we know have set fires are super tough... That’s like the hardest person to house - they’re destroying their environment and putting people at risk. So we have to err on the side of caution. We do the duty to warn thing and I constantly have to make judgment calls about what I share about someone’s criminal history to a housing provider. (M007)

This can be hard to navigate, and yet as another worker explained: “working with justice-involved clients elevates accountability, especially in apartment buildings shared with residents who aren’t part of their program.” (M021) Looking beyond their client’s immediate needs, they also have to consider how others could be impacted.

Frontline practitioners often have their hands tied when it comes to policies denying residential services to those with sex offence or arson records. One case manager talked about triaging a young man, saying:

“I don’t think we’re going to accept him, and I don’t know where he could go. I don’t know what he needs really. He’s a young man who has a diagnosis of schizophrenia, personality disorder, Asperger’s. He’s highly intelligent. However, he has a lot of difficulty in social settings. He has no insight into his illness; he has no remorse about his charges. And, you know – he was in a youth shelter and set a bed on fire with somebody in it. It’s going to be a problem. AND he doesn’t want to be on medication. Doesn’t want to be on injections. It’s like, where does someone like that, with those behaviors and illness, go and be safe? It’s really sad that there’s no place but jail. (M011)

This quote suggests that medication compliance, psychiatric treatment and appropriate displays of emotion could have mitigated the risks posed by a history of violence and arson.

Characterized as dangerous or as bad investments, some clients get labelled as ‘hard-to-house’, not ‘housing-ready’ or ‘housable’, and consequently get stuck on the street, or in emergency shelters (Quirouette 2016), which are often unsafe and criminalized spaces not suited for people who are facing other complicated disadvantages9. One worker described her frustration with those kinds of triage policies:

If you’ve had a sexual offence, you’re blacklisted. Even if you’ve been found not guilty (!) I had a client who they accepted, but then they asked him questions. He was charged 21 years ago. His sister-in-law alleged he’d abused his nephew; he went to trial and was found not guilty… He is honest, so he said “Yes, I was charged, but this is what happened.” Blacklisted anyways… Come on, that’s pretty frustrating! We formally made a complaint about that policy. Went to their Board, and they said that’s just “where they’re at” with sex offenders. I mean, emergency shelters don’t even want them, nobody does! So you’re toast. (M025)

This counterproductive exclusion leaves individuals without supports they need to overcome cycles of criminalization, but protects organizations from perceived risks.

Respondents talked about the pressure they face to share information about potentially dangerous clients with other professionals to mitigate legal issues. Bill 168 amended the Occupational Health and Safety Act with respect to violence and harassment in the workplace and dictates that it is the “employer’s duty to provide information, including personal information, related to a risk of workplace violence from a person with a history of violent behavior if the worker can be expected to encounter that person in the course of his or her work” (clause 27 (2) (a)). This requirement applies to intra and inter-agency work; referrals to community resources are all affected by this mandated layer of risk screening. As one mental health worker explained: “we’re responsible now, so if I sent a guy to the social resource center and he ended up killing them, then the whole question is, why weren’t people warned right? You had massive files on this guy and yet you let him go near innocent people and he’s now committed murder.” (M018) Duty to report was invoked most often when practitioners talked about clients with records of violence, sex offending or fire-starting. Passing on information is a strategic practice meant to increase safety and prevent potential liability.

The expanding reach and significance of individual risk management combined with pressure to share information has amplified organizational orientations to reputational risk (Power et al. 2009). The management of risk is a “constitutive sense-making project for organizations” (Hutter and Power 2004; 9). Practitioners assess and manage risks to themselves, their colleagues, other clients, the public, and their agency, in part via formalized assessments, information exchanges with other stakeholders and screening interviews.

Outcomes, Partnerships and Funding

Practitioners talked about ‘recruiting clients for outcomes’ and making sure not to undermine good partnerships, referral sources or funding by sending bad clients, alluding to what Halushka (2017) calls "defensive institutionalism". They are under pressure to track services and produce measurable outcomes to satisfy partnership and funding requirements10. One outreach worker explained why this can be challenging as: “some goals are too ‘little’ or too hard to measure. Funders are like: “how many people did you house?” But what if we got somebody in hospital who never agreed to medication before, or who opened up? They don’t consider other components... I find it really, really hard.” (M008) Aware that funding is based on specific metrics, she and many others explained how the outcomes measured are not always compatible with the work they do. With some case work or harm reduction practice, ‘progress’ can be hard to measure, relatively slow, and require resources invested in developing relationships of trust.

Clients who are described as non-compliant or low-functioning are often not seen as proper candidates for in-demand social services and programs, thanks to high-risk behaviors and low chances of predicted success. One housing worker explained, “our system is expecting people to jump through hoops. It’s ridiculous, and I think it’s because everyone’s so afraid of liability. Everyone’s so terrified they pass the buck.” (C031) Ironically, many systems meant to support poor, marginalized and oppressed people exacerbate problems by excluding and shuffling around those most vulnerable, who are often unable to benefit from goal-oriented, conditional supports. Highlighting similar dynamics, Horst Siebert’s "cobra effect" (2001)11 and Harcourt’s "ratchet effect" (2007), both refer to situations where institutional solutions and performance incentives end up making problems worse. In the latter scenario, actuarial methods in the criminal justice system are said to amplify inequalities rather than eliminate them.

Practitioners often described feeling ‘stuck between a rock and a hard place’ (see also Scanlon and Adlam 2012). The pressure to perform with limited resources to meet the needs of vulnerable clients and reduce harms is experienced as distressing and unfair. Despite the disconnect between assessed needs and services provided, funders are always looking for normative success stories:

The number of times I’ve been asked: “Lisa*! We need a success story”. It’s actually quite hard for me to come up with their idea of a success story, because for me, a success story is somebody who keeps their appointments to come see me, who switched from reusing needles to only using their own, to safely disposing of those needles, to keeping their appointments with me... That’s a massive change, but that’s not a good enough success story because they are still using and they haven’t got housing... When you’re working informally with clients who are difficult to engage with and have difficulty themselves in trusting people and building a good, working, helping relationship, that is extremely difficult to evaluate, and to keep a funder happy. (T008)

Lisa and many of her peers face pressure to show outcomes that measure up to formal expectations. This lends support to Power’s arguments (in Hutter and Power 2005) that “risk management routines may have more to do with a certain kind of organizational legitimacy and responsibility framing than with having the organizational capacity to encounter risk inventively and intelligently” (18).

Many practitioners talked about being burned out by the systems they work in, shifting blame away from clients. Still, they make difficult triage decisions and manage various sources of abstract risk in ways that reflect specific institutional interests (Power et al. 2009). Clients considered risky, traumatizing or unable to change are triaged out and "sacrificed" (Glumm and Johnson 2001) to protect the agency, employees, other clients, and to save resources and staff time for clients that are deemed to have more potential. Practitioners are not just risk averse because of actuarial pressures; they avoid certain types of risky individuals because they want their work to be meaningful and do not want to be blamed for negative outcomes (Deering 2011; Hutter 2010; Webb 2007). Some appreciate that risk tools enhance the defensibility of their decisions.

It is important to recognize the overlap between systems for regulating clients and systems that discipline service providers. Soss et al. (2011) show how performance management reshapes practitioner agency with perverse effects including goal displacement (205). Client triage is partly shaped by requirements that organizational performance be measured and evaluated (Crawford 1998; Hardy 2015; Hutter and Power 2005). This can lead to ‘creaming’, where services are directed towards (1) motivated clients with fewer barriers to success12, or (2) narrow client subgroups, (ex: people who use the ER 20+/month; people who are terminally ill with less than 3 months to live). Practitioners have vested interests in collecting data about their clientele, tracking successful interventions and demonstrating positive outcomes to funders.

Systemic risks and resource issues

Assessment tools and scope of intervention are mostly locked onto individual pathology and circumstance, and practitioners are keenly aware of how larger systems oppress their clients. Practitioners certainly think beyond the individual scope to consider other sources of systemic risk. Focusing on structural factors, one in-reach worker at a local jail noted how: “the issues that surround their circumstance are what really challenge us. Individuals that have mental health and addictions, they have quite complex needs sure, but the problem is that there are very limited resources in terms of getting them properly housed and getting them treatment.” (C009) Frustrated with social injustice, many of them participate in committee work, policy initiatives and advocacy. However, in their case management capacity, their impact is measured according to what can be done at the individual level.

Another prison in-reach worker explained how sometimes, “...all we can do is bear witness to people, so they don’t have to be alone through these things. We can’t change anything about their situation... we can just say “let me hold that with you”. “Let me check in on you.” (C027) This underscores the importance of recognizing moral injury as a reaction to social triage. Frontline service providers witness injustice and struggle with supporting people in a dramatically underfunded system. Recognizing their distress as being caused by organizational and structural problems, like punitive exclusionary systems, helps reframe understandings of burnout and trauma, moving away from pathologizing and blaming individuals (see also Dean, Talbot and Dean 2019).

The concept of “complex-needs” shines the spotlight on individual shortcomings and pathologies while obscuring organizational and structural failures. People with complex needs are not a distinct group of people with similar experiences. Rather, they are different types of people who present similar challenges to practitioners trying to work within structures of governance. A local ‘complex care subcommittee’ hired a consulting firm to make recommendations for service resolution aimed at meeting the needs of people with complex challenges (Newberry and Brown 2015). They found that rigid eligibility criteria, inflexibility in the system and lack of appropriate supportive housing were the most significant factors contributing to the difficulties people experience when trying to access services. Their interviews with practitioners confirmed they find it challenging to work with ‘complex’ clients. The most common challenges revolved around lack of housing and eligibility problems for people who have brain injuries, FASD or developmental problems, especially when combined with mental health or substance use issues. Altogether, they stressed how complexity “must be understood in relation to individual needs in interaction with the array of supports that a person is able – or unable – to access” (Taylor Newberry Consulting. 2015).

Participants in my study expressed system-focused critique, focusing on how police, courts, corrections and other social institutions contribute to keeping people oppressed, experiencing ongoing neglect, surveillance and punishment. This supports findings reported by Kerman et al. (2022a), who showed service providers working in Toronto’s homelessness sector experience “system trauma”, in that their work is made difficult by systemic factors, and this puts them “at risk of work-related mental health distress” (Kerman et al. 2022b: 11).

Social triage – as it relates to the triage and exclusion of marginalized and criminalized people who need supports - is directly related to system gaps and structural violence, like the racialized criminalization of poverty. Exasperated practitioners talked about clients who are expected to stay engaged, compliant, motivated and jumping through hoops in the absence of essentials:

Yeah, it’s extremely frustrating for us. You do a CASH application (for people with mental health, substance abuse, etc.), and we’re told it’ll take 3-4 years. How is that going to work!? With us, the whole point is that it’s a 30-day stay. If this doesn’t bridge you to housing, I don’t know, it’s bad, there is nothing.” (M032)

This highlights the effect of material deprivation on both criminalized individuals and on service providers trying to help them. There are so few culturally appropriate rehabilitation programs, affordable housing or specialized support for adults with acquired brain injuries that people who are waiting have to hold out until other clients die and free their spot. Even before COVID, the city’s more than 7,000 emergency and transitional shelter beds in 63 locations remained at capacity, and hundreds slept outside each night. These issues have been amplified by the pandemic, and by late 2022, reports indicate that 187 people are turned away from emergency shelters each night13. Another 81 042 people are waiting for subsidized housing14. Applicants with substance use challenges, criminal justice involvement, or greater support needs are disproportionately excluded from housing, and more than 17 000 people are waiting for mental health and addictions supportive housing15. Faced with monstrous waitlists, with average wait time of 12 years for a 1-bedroom in subsidized housing16 and 4 years for mental health and addiction supportive housing practitioners have to revise their strategies and focus their energies on productive interventions, often without housing.

Social workers have always had limited resources, and Milner and O’Byrne (2002) suggest, “it is not surprising they are lured into locating problems and solutions within the individual […] when faced with the miseries of poverty, inadequate housing and poor employment conditions, it is easier to seek psychological explanation for events than to explore complex interactions between social and psychological dimensions of the problem” (10). My findings echo this, suggesting risk logics can help keep focus on people who can be managed, and away from broader institutional or systemic issues that feel more out of reach.

Nonetheless, the most consistent complaints expressed were not about difficult clients, but the calamitous absence of appropriate housing options and the pressure to keep up with funding, partnerships and outcomes. These issues disproportionately affect clients who are justice-involved and multiply disadvantaged. Social supports are in crisis and there are not even enough resources to properly support clients who show recognizable potential, making it difficult to offer support to clients assessed as complex or difficult. Like others who have criticized the de-materialized nature of risk logics and governance (Hardy 2015; Lynch 2000), I draw attention to the impact resources gaps have on triage practices.

CONCLUSION

This paper has highlighted the effect of material deprivation on both criminalized individuals and on service providers trying to help them. The situation is dire. There are so few culturally appropriate or accessible rehabilitation programs, affordable housing or specialized long-term support for adults with complex needs or acquired brain injuries that people who are waiting have to hold out until other clients die and free their spot. In the meantime, people are dying in shelters and on the street. Even before COVID, the city’s more than 7,000 emergency and transitional shelter beds remained at capacity, and hundreds slept outside each night. The worst year for homeless deaths in recent memory was 2021, when Toronto set a despairing record of 223 deaths. These issues have been amplified by the pandemic. By late 2022, reports indicate that 187 people are turned away from emergency shelters each night.17 Another 81,042 people are waiting for subsidized housing.18 Applicants with substance use challenges, criminal justice involvement, or greater support needs are disproportionately excluded from housing, and more than 17,000 people are waiting for mental health and addictions supportive housing.14 Faced with monstrous waitlists, with an average wait time of 12 years for a 1-bedroom in subsidized housing15 and four years for mental health and addiction supportive housing, practitioners have to revise their strategies and focus their energies on productive interventions, often without housing.

Social workers have always had limited resources, and Milner and O’Byrne (2002:10) suggest, “it is not surprising they are lured into locating problems and solutions within the individual […] when faced with the miseries of poverty, inadequate housing and poor employment conditions, it is easier to seek psychological explanation for events than to explore complex interactions between social and psychological dimensions of the problem.” My findings echo this, suggesting risk logics can help keep focus on people who can be managed, and away from broader institutional or systemic issues that feel more out of reach. Nonetheless, the most consistent complaints expressed were not about difficult clients, but the calamitous absence of appropriate housing options and the pressure to keep up with funding, partnerships and outcomes. These issues disproportionately affect clients who are justice-involved and multiply disadvantaged. Social supports are in crisis and there are not even enough resources to properly support clients who show recognizable potential, making it difficult to offer support to clients assessed as complex or difficult. Like others who have criticized the de-materialized nature of risk logics and governance (Hardy 2015; Lynch 2000), I draw attention to the impact resources gaps have on triage practices.

My analysis of practitioner narratives and practices focused on issues of client triage and exclusions. First, I considered the individualization of social problems and the responsibilization of marginalized people. Client triage and exclusion are often driven by a pathologizing focus on individual characteristics. Some are pushed out more often than others, like those with records of sexual offense, fire setting, drugs, violence, self-harm or so-called non-compliance. Second, I considered how triage and exclusion are also driven or amplified by organizational demands for risk management related to liability, funding, partnerships and staffing – or by the lack of resources available to meet client’s basic needs like shelter or housing. I argue that triage is linked to consideration of individuals and related risks to the organization. Triage strategies prioritize cases with the potential for outcomes that align with measurable goals (ex.: clients rehoused; recidivism lowered). This managerial focus is disadvantageous for people who want services but have histories of not complying or being labelled “complex.” Given the impact of structural problems like lack of housing combined with systemic pressures to generate and share risk data, assessment mandates can have unintended consequences for clients and practitioners.

Indeed, organizational risk aversion and systemic failures amplify individualized interpretations of risk, driving social exclusion, risk of harm and criminalization of excluded people. I have described how community-based practitioners struggle to navigate overlapping demands to respond to client needs and to anticipate multiple dimensions of risk. Participants talked about experiencing distress and frustration because they are asked to solve complex problems with limited resources and unreasonable expectations. They are pushed to screen who can be served successfully and often have limited ability to improve social justice or to expand resources to better serve all. Like others who have studied triage practices, I note how crises, and social and systemic issues, complicate and drive the utilitarian logics that motivate excluding people who are beyond rehabilitation (see also Glumm and Johnson 2001; Meredith 1992). Social triage, in the form of service and housing exclusions, exacerbates problems by promoting criminalization, instability and suffering for the most marginalized.

This predominantly critical account of triage practices should be read as a partial examination, which has set aside the numerous creative, impressive and valuable strategies practitioners develop to work around standards that push them to exclude certain clients. It is also important to note that some organizations are dedicated to client - or member - led services, adopting low-barrier, outreach and drop-in models. Supporting people as they are without imposing conditions, low-barrier initiatives are valued for promoting health, safety and trust, yet they are overwhelmingly underfunded and stretched beyond capacity (see Cook and Crowe. 2022). Those services are often designed to meet the needs of vulnerable and underserved clients, complying with harm reduction principles and embracing the idea that to manage risk effectively, it should not be avoided, amplified or bumped off to others (see also Hardy 2015). Some have described these as examples of “tolerant containment” (Gong 2019) or “palliative governance” (Di Mario 2022), which raises interesting and critical questions about how we can best care for people without (over)controlling them. Hannah-Moffat (2016) proposed we could and should transfer the notion of dynamic risk, and the focus on “transformation potential,” towards systemic factors that drive criminogenic factors and contribute to cyclical problems. Relatedly, Manikis (2022) proposed we consider more formally the significance of state blame and state misconduct when thinking about these issues. Similarly, I conclude we should focus on how processes of social triage are counterproductive and deadly, and on how practitioners, organizations and societies can do better. Shifting our responsibilizing gaze to institutions and agencies – not to individual clients or practitioners – would open different conversations about who can be helped and how.

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