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Engagement and Trauma: Building Safety and Trust in Populations with High-Acuity Needs

Mardoche Sidor, MD and Karen Dubin, PhD, LCSW — Sat, 24 Jan 2026 12:28:34 +0000

Authors Frederick Shack, LMSW1,4 Mardoche Sidor, MD1,2,3 Gary Jenkins, MPA1 Jose Cotto, LCSW1,5 Karen Dubin, PhD, LCSW2,4 Lesmore Willis Jr, MPA, MHA1 Affiliations 1Urban Pathways, New York, NY 2SWEET Institute, New York, NY 3Columbia University Center for Psychoanalytic Study and Research, New York, NY 4Columbia University, School of Social Work, New York, NY 5New York University, Department of Social Work, New York, NY Correspondence concerning this article should be addressed to Mardoche Sidor, MD, Urban Pathways, at msidor@urbanpathways.org Abstract Trauma profoundly shapes how individuals perceive safety, relationships, and systems of care. In supportive housing and community mental health, residents with trauma histories often present with mistrust, withdrawal, or conflict that can be misinterpreted as “non-engagement.” This article examines how the Four-Stage Engagement Model—Sitting, Listening, Empathizing, Collaborating—creates safety and trust for populations with high-acuity needs. Drawing on trauma theory, polyvagal science, and recovery research, we highlight how engagement restores relational security, counters retraumatization, and promotes healing. Composite case studies from Urban Pathways illustrate trauma-informed engagement in practice. Keywords Engagement, Trauma, Safety, Trust, Populations with High-Acuity Needs, Trauma-Informed Care, Polyvagal Theory, Supportive Housing Introduction Populations with high-acuity needs, including individuals experiencing homelessness, serious mental illness, and substance use disorders, are disproportionately impacted by trauma (Hopper et al., 2010). Trauma alters stress regulation, fosters hypervigilance, and erodes trust in relationships and systems (van der Kolk, 2014). Staff often misinterpret trauma-related behaviors as resistance or disinterest. The Four-Stage Engagement Model reframes these behaviors as protective adaptations and provides a relational framework for rebuilding safety and trust. Theoretical Framework Engagement and trauma-informed care intersect through: Polyvagal Theory: Safety and co-regulation restore autonomic balance (Porges, 2011). Trauma Theory: Trauma fragments trust and requires corrective relational experiences for repair (van der Kolk, 2014). SAMHSA’s Trauma-Informed Principles: Safety, trustworthiness, empowerment, and collaboration guide systemic care (SAMHSA, 2014). Attachment Theory: Consistent relational presence repairs disrupted attachment patterns (Siegel, 2012). Application/Analysis At Urban Pathways, staff are applying trauma-informed engagement by: Sitting: Learning to provide calm, non-demanding presence that reduces hyperarousal. Listening: Learning to validate traumatic narratives without rushing to problem-solving. Empathizing: Learning to offer unconditional positive regard to counter internalized stigma. Collaborating: Learning to co-create goals that respect trauma history and current level of preparedness. Composite Case Example: A resident with repeated violent outbursts was initially labeled “non-compliant.” Staff reframed the behavior as trauma-related hypervigilance. Through consistent sitting and empathic presence, the resident began to trust staff; and this is expected to be followed by reduced crises and increased participation in collaborative planning. Implications Practice: Engagement strategies are to be trauma-informed to avoid retraumatization. Supervision: Reflective supervision is to support staff in managing countertransference with trauma-affected residents. Policy: Programs ought to mandate trauma-informed engagement as a standard of care. Research: Studies need to measure the impact of engagement on trauma recovery outcomes. Systems: Trauma-informed engagement needs to extend across all staff roles, not only clinicians. Conclusion Trauma is not only a clinical diagnosis but a relational reality. The Four-Stage Engagement Model provides a roadmap for restoring safety and trust in populations with high-acuity needs, transforming engagement into a trauma-informed healing practice. References Hopper, Elizabeth K., et al. “Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings.” The Open Health Services and Policy Journal, vol. 3, no. 2, 2010, pp. 80–100. Porges, Stephen W. The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. Norton, 2011. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication, 2014. Siegel, Daniel J. The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. 2nd ed., Guilford Press, 2012. van der Kolk, Bessel A. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Viking, 2014. This article is part of a collaboration between SWEET Institute and Urban Pathways. Read the full scientific version HERE

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Engagement and Recovery: Relational Pathways to Healing and Growth

Mardoche Sidor, MD and Karen Dubin, PhD, LCSW — Sat, 17 Jan 2026 12:16:57 +0000

Authors Frederick Shack, LMSW1,4 Mardoche Sidor, MD1,2,3 Gary Jenkins, MPA1 Jose Cotto, LCSW1,5 Karen Dubin, PhD, LCSW2,4 Lesmore Willis Jr, MPA, MHA1 Affiliations 1Urban Pathways, New York, NY 2SWEET Institute, New York, NY 3Columbia University Center for Psychoanalytic Study and Research, New York, NY 4Columbia University, Department of Social Work, New York, NY 5New York University, Department of Social Work, New York, NY Correspondence concerning this article should be addressed to Mardoche Sidor, MD, Urban Pathways, at msidor@urbanpathways.org Abstract Recovery in mental health and supportive housing is often framed as symptom reduction or service utilization. Yet recovery is fundamentally relational, rooted in trust, safety, and empowerment. This article explores how the Four-Stage Engagement Model—Sitting, Listening, Empathizing, Collaborating—provides relational pathways to healing and growth. Drawing on recovery-oriented care, trauma-informed practice, and positive psychology, we examine how engagement fosters meaning, hope, and agency. Composite case examples from Urban Pathways illustrate how relational engagement has the potential to support resident resilience, reduce hospitalizations, and promote long-term stability. Keywords Engagement, Recovery, Healing, Growth, Resilience, Trauma-Informed Care, Recovery-Oriented Practice, Supportive Housing Introduction Recovery is increasingly recognized as more than clinical improvement; it is about living a meaningful life despite adversity (Anthony, 1993). Research highlights the importance of hope, empowerment, and relationships in the recovery process (Davidson et al., 2006). Yet many systems still emphasize compliance and risk management over relational healing. The Four-Stage Engagement Model re-centers recovery on relationships, ensuring that every staff interaction fosters healing, safety, and growth. Theoretical Framework Engagement and recovery are linked through: Recovery-Oriented Care: Emphasizes personhood, meaning, and community participation (Anthony, 1993). Trauma-Informed Practice: Recognizes recovery as relational repair and empowerment (SAMHSA, 2014). Positive Psychology: Growth is fueled by strengths, meaning, and relationships (Seligman, 2011). Common Factors Theory: Alliance and empathy are central predictors of positive outcomes (Wampold & Imel, 2015). Application/Analysis At Urban Pathways, recovery is being facilitated through engagement by: Sitting: Staff are learning to use presence to reduce isolation and model relational safety. Listening: Staff are learning to attune to resident goals to reinforce agency and meaning. Empathizing: Staff are learning to use Corrective emotional experiences to help heal relational wounds and support resilience. Collaborating: Staff are learning to co-create goals to foster empowerment, community integration, and long-term stability. Composite Case Example: A resident with repeated psychiatric hospitalizations redefined recovery not as “medication compliance” but as reconnecting with family and pursuing creative interests. Through empathic engagement and collaborative planning, staff is supporting these goals; and this in turn, is expected to lead to reduced hospitalizations and increased well-being. Implications Practice: Recovery is to be measured by meaning, hope, and empowerment, not only compliance. Supervision: Supervisors are to emphasize recovery-oriented engagement in case reviews. Policy: Funders need to support recovery-based outcomes such as resident-reported hope and empowerment. Research: Studies need to examine how engagement predicts recovery outcomes over time. Systems: Embedding engagement into all levels of care ensures recovery-oriented transformation. Conclusion Recovery is not a destination but a relational journey. The Four-Stage Engagement Model provides pathways for healing and growth by centering presence, empathy, and collaboration. In doing so, it transforms supportive housing and mental health systems into environments where recovery is not just possible, but expected. References Anthony, William A. “Recovery from Mental Illness: The Guiding Vision of the Mental Health Service System in the 1990s.” Psychosocial Rehabilitation Journal, vol. 16, no. 4, 1993, pp. 11–23. Davidson, Larry, et al. “Creating a Recovery-Oriented System of Behavioral Health Care: Moving from Concept to Reality.” Psychiatric Rehabilitation Journal, vol. 29, no. 4, 2006, pp. 315–321. Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. U.S. Department of Health and Human Services, 2014. Seligman, Martin E. P. Flourish: A Visionary New Understanding of Happiness and Well-Being. Free Press, 2011. Wampold, Bruce E., and Zac E. Imel. The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work. 2nd ed., Routledge, 2015. This article is part of a collaboration between SWEET Institute and Urban Pathways. Read the full scientific version HERE

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Engagement and Motivation: Applying the Stages of Changes in Practice

Karen Dubin, PhD, LCSW — Thu, 08 Jan 2026 10:28:03 +0000

Authors Frederick Shack, LMSW1,4 Mardoche Sidor, MD1,2,3 Gary Jenkins, MPA1 Jose Cotto, LCSW1,5 Karen Dubin, PhD, LCSW2,4 Lesmore Willis Jr, MPA, MHA1 Affiliations 1Urban Pathways, New York, NY 2SWEET Institute, New York, NY 3Columbia University Center for Psychoanalytic Study and Research, New York, NY 4Columbia University, School of Social Work, New York, NY 5New York University, Department of Social Work, New York, NY Correspondence concerning this article should be addressed to Mardoche Sidor, MD, Urban Pathways, at msidor@urbanpathways.org Abstract The Stages of Change model offers a critical framework for understanding motivation, yet staff often struggle to align interventions with residents’ level of preparedness. The Four-Stage Engagement Model—Sitting, Listening, Empathizing, Collaborating—integrates seamlessly with motivational science, providing staff with tools to meet residents where they are. This article explores how engagement and the Transtheoretical Model (TTM) together guide stage-matched interventions, prevent staff frustration, and support sustainable behavior change. Composite case studies from Urban Pathways illustrate how aligning engagement with level of preparedness, has the potential to reduce reluctance and enhance collaboration in supportive housing. Keywords Engagement, Motivation, Stages of Change, Transtheoretical Model, Motivational Interviewing, Supportive Housing, Behavior Change, Trauma-Informed Care, Level of Preparedness Introduction Motivation for change is not static but dynamic, shifting across stages of preparedness (Prochaska & DiClemente, 1984). Staff often become frustrated when residents appear “unmotivated,” but such perceptions typically reflect mismatched interventions (Miller & Rollnick, 2013). The Four-Stage Engagement Model provides relational practices that align with stages of change, transforming staff perspective from blame to partnership. By embedding motivational science into engagement, Urban Pathways ensures interventions are resident-centered, trauma-informed, and sustainable. Theoretical Framework The integration of engagement and motivation is supported by: Transtheoretical Model (TTM): Identifies stages of change—precontemplation, contemplation, preparation, action, maintenance (Prochaska & DiClemente, 1984). Motivational Interviewing (MI): Enhances motivation by evoking residents’ own reasons for change (Miller & Rollnick, 2013). Self-Determination Theory: Collaboration supports autonomy, competence, and relatedness, fueling intrinsic motivation (Deci & Ryan, 2000). Trauma-Informed Care: Recognizes that level of preparedness may be impacted by trauma, requiring relational safety first (SAMHSA, 2014). Application/Analysis At Urban Pathways, engagement is being aligned with stages of change through: Sitting (Precontemplation): Presence without pressure communicates acceptance, reducing defensiveness. Listening (Contemplation): Open-ended questions evokes ambivalence and surfaces resident goals. Empathizing (Preparation): Corrective emotional experiences strengthens trust and preparedness. Collaborating (Action & Maintenance): Shared goal setting and accountability sustains motivation. Composite Case Example: A resident reluctant to substance use treatment was initially met with empathic presence (sitting). Over time, listening revealed ambivalence (“I hate how it makes me feel”). Staff empathized with his struggle, and collaboration eventually supported harm-reduction goals, aligning with his level of preparedness. Implications Practice: Staff ought to view “lack of motivation” as an engagement challenge, not resident failure. Supervision: Supervisors can help staff identify mismatches between engagement strategies and stages of change. Policy: Programs are to embed motivational and engagement training as core competencies. Research: Studies need to test combined engagement + stage-matched interventions for long-term housing and health outcomes. Systems: Aligning engagement with stages of change provides a replicable framework for diverse human service settings. Conclusion Motivation emerges from alignment, not coercion. The Four-Stage Engagement Model provides staff with a relational roadmap for applying the Stages of Change, ensuring interventions match readiness, reduce resistance, and foster sustainable transformation. References Deci, E. L., & Ryan, R. M. (2000). The “what” and “why” of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11(4), 227–268. https://doi.org/10.1207/S15327965PLI1104_01 Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press. Prochaska, J. O., & DiClemente, C. C. (1984). The transtheoretical approach: Crossing traditional boundaries of therapy. Dow Jones-Irwin. Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. U.S. Department of Health and Human Services. This article is part of a collaboration between SWEET Institute and Urban Pathways. Read the full scientific version HERE

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Engagement and Neuroscience: The Brain Basis of Presence, Empathy, and Collaboration

Mardoche Sidor, MD and Karen Dubin, PhD, LCSW — Thu, 01 Jan 2026 02:05:27 +0000

Authors Frederick Shack, LMSW1,4 Mardoche Sidor, MD1,2,3 Gary Jenkins, MPA1 Jose Cotto, LCSW1,5 Karen Dubin, PhD, LCSW2,4 Lesmore Willis Jr, MPA, MHA1 Affiliations 1Urban Pathways, New York, NY 2SWEET Institute, New York, NY 3Columbia University Center for Psychoanalytic Study and Research, New York, NY 4Columbia University, School of Social Work, New York, NY 5New York University, Department of Social Work, New York, NY Correspondence concerning this article should be addressed to Mardoche Sidor, MD, Urban Pathways, at msidor@urbanpathways.org Abstract Neuroscience increasingly validates what practitioners in supportive housing and mental health have long observed: presence, empathy, and collaboration change the brain. This article explores the neurobiological basis of the Four-Stage Engagement Model—Sitting, Listening, Empathizing, Collaborating—highlighting how relational practices activate neural circuits for safety, trust, and motivation. Drawing on interpersonal neurobiology, affective neuroscience, and research on therapeutic alliance, we demonstrate how engagement supports neuroplasticity, emotion regulation, and recovery. Composite case examples from Urban Pathways illustrate how engagement practices have the potential to reshape resident behavior and staff resilience at the neural level. Keywords Engagement, Neuroscience, Interpersonal Neurobiology, Empathy, Collaboration, Neuroplasticity, Trauma-Informed Care, Supportive Housing Introduction While engagement is often framed as a “soft skill,” neuroscience confirms its biological impact. Presence regulates the autonomic nervous system, empathy activates mirror neuron systems, and collaboration engages reward circuits (Porges, 2011; Decety & Jackson, 2004). Residents in supportive housing often experience chronic dysregulation from trauma and homelessness; engagement practices restore regulation through relational neuroplasticity (Siegel, 2012). The Four-Stage Engagement Model can thus be understood as not only relational but neurobiological intervention. Theoretical Framework Neuroscience of engagement builds upon: Polyvagal Theory: Safety and co-regulation calm the autonomic nervous system, fostering trust (Porges, 2011). Mirror Neuron Research: Empathy is underpinned by neural resonance with others’ emotions and actions (Decety & Jackson, 2004). Interpersonal Neurobiology: Relationships shape the architecture of the brain across the lifespan (Siegel, 2012). Reward Circuitry: Collaboration activates dopaminergic pathways linked to motivation and sustained change (Murray et al., 2022). Application/Analysis At Urban Pathways, neuroscience-informed engagement is being demonstrated in: Sitting: Staff are learning to use Calm presence to reduce resident hyperarousal and improve regulation. Listening: Staff are learning to use Active listening to increase resident feelings of safety, reducing defensive reactivity. Empathizing: Validating residents’ emotions to activate mirror systems and foster social bonding. Collaborating: Staff are learning to use shared goal setting to engage reward pathways, reinforcing motivation for change. Composite Case Example: A resident with trauma-related hypervigilance initially avoided contact. Through consistent calm presence and empathic listening, staff is working on facilitating nervous system regulation, which, in turn, will gradually enable collaboration on housing and health goals. Implications Practice: Staff ought to understand that engagement changes brain function, not just behavior. Training: Neuroscience education can deepen staff appreciation of relational practices. Policy: Investment in engagement practices is to be recognized as neurobiological interventions. Research: Studies need to measure neural and physiological outcomes of engagement (e.g., HRV, cortisol, fMRI). Systems: Neuroscience bridges clinical and organizational buy-in for engagement models. Conclusion Engagement is not only relational but neurobiological. By activating circuits for safety, empathy, and reward, the Four-Stage Engagement Model has the potential to foster healing at the level of the brain, reinforcing its central role in supportive housing and systemic transformation. References Decety, Jean, and Philip L. Jackson. “The Functional Architecture of Human Empathy.” Behavioral and Cognitive Neuroscience Reviews, vol. 3, no. 2, 2004, pp. 71–100. Murray, Elisabeth A., Steven P. Wise, and Wayne C. Drevets. “Role of Dopamine in Motivation, Reward, and Learning.” Nature Reviews Neuroscience, vol. 23, no. 1, 2022, pp. 43–60. Porges, Stephen W. The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. Norton, 2011. Siegel, Daniel J. The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. 2nd ed., Guilford Press, 2012. This article is part of a collaboration between SWEET Institute and Urban Pathways. Read the full scientific version HERE

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Engagement Across Roles: From Security to Leadership

Mardoche Sidor, MD and Karen Dubin, PhD, LCSW — Thu, 25 Dec 2025 12:04:22 +0000

Authors Frederick Shack, LMSW1,4 Mardoche Sidor, MD1,2,3 Jose Cotto, LCSW1,5 Karen Dubin, PhD, LCSW2,4 Ann Hanford, MPH1 Gary Jenkins, MPA1 Lesmore Willis Jr, MPA, MHA1 Gary Jenkins, MPA1 Affiliations 1Urban Pathways, New York, NY 2SWEET Institute, New York, NY 3Columbia University Center for Psychoanalytic Study and Research, New York, NY 4Columbia University, School of Social Work, New York, NY 5New York University, Department of Social Work, New York, NY Correspondence concerning this article should be addressed to Mardoche Sidor, MD, Urban Pathways, at msidor@urbanpathways.org Abstract Engagement is often considered the responsibility of clinicians or case managers, or social services staff, yet every staff role, from security to leadership, shapes the relational climate of supportive housing. This article examines how the Four-Stage Engagement Model—Sitting, Listening, Empathizing, Collaborating—can be operationalized across diverse roles in Urban Pathways programs. Drawing on trauma-informed care, organizational psychology, and social role theory, we highlight how security staff, administrators, and executives each contribute uniquely to engagement. Case studies demonstrate how aligning all roles around engagement creates coherence, enhances trust, and fosters resident stability. Keywords Engagement, Trauma-Informed Care, Organizational Culture, Security, Leadership, Supportive Housing, Relational Climate, Systems Integration Introduction Too often, engagement is siloed within clinical teams, leaving other roles excluded from relational practices. Yet research demonstrates that residents’ trust and healing are influenced by every interaction (Hopper et al., 2010). Security staff, housing specialists, administrators, and leaders all contribute to the relational environment. Embedding engagement system-wide ensures consistency, coherence, and trust, particularly for residents with histories of trauma and systemic mistrust (Bloom, 2013). Theoretical Framework Engagement across roles is supported by: Trauma-Informed Systems: Safety and trust require organization-wide consistency, not just clinician practice (SAMHSA, 2014). Organizational Psychology: Culture is shaped by shared behaviors and leadership modeling (Schein, 2010). Role Theory: Each staff role carries expectations that influence relational dynamics (Biddle, 1986). Common Factors Research: Relational qualities (empathy, respect, trust) predict outcomes across roles, not only in therapy (Norcross & Wampold, 2019). Application/Analysis At Urban Pathways, engagement is being embedded across roles by: Security Staff: Trained in Motivational Interviewing and to greet residents respectfully and de-escalate with empathy, conveying unconditional regard. Housing Specialists: Practiced listening and collaboration in daily problem-solving. Program Managers: Modeled empathic leadership in supervision, reinforcing engagement as a value. Executives: Communicated the centrality of engagement in all-staff meetings and policies. Composite Case Example: A resident with a history of incarceration initially distrusted security personnel. Through repeated respectful greetings and calm presence at entry points, security staff provided corrective emotional experiences, which built trust and paved the way for clinical collaboration. Implications: Practice: Engagement is be framed as everyone’s responsibility, not just clinicians’. Training: All staff, including security and administrative roles, are to receive engagement training. Policy: Job descriptions and evaluations need to include engagement responsibilities. Research: Studies need to explore how non-clinical staff influence resident outcomes through relational practices. Systems: Cross-role alignment strengthens coherence, reduces retraumatization, and improves outcomes. Conclusion Engagement is not a task reserved for clinicians but a responsibility of all staff, from security to leadership. By embedding the Four-Stage Engagement Model across roles, Urban Pathways is demonstrating that coherence in relational practices fosters trust, safety, and transformation. References Biddle, Bruce J. “Recent Developments in Role Theory.” Annual Review of Sociology, vol. 12, no. 1, 1986, pp. 67–92. Bloom, Sandra L. Creating Sanctuary: Toward the Evolution of Sane Societies. 2nd ed., Routledge, 2013. Hopper, Elizabeth K., Ellen L. Bassuk, and Jeffrey Olivet. “Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings.” The Open Health Services and Policy Journal, vol. 3, no. 2, 2010, pp. 80–100. Norcross, John C., and Bruce E. Wampold. “Evidence-Based Therapy Relationships: Research Conclusions and Clinical Practices.” Psychotherapy, vol. 56, no. 3, 2019, pp. 419–430. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. U.S. Department of Health and Human Services, 2014. Schein, Edgar H. Organizational Culture and Leadership. 4th ed., Jossey-Bass, 2010. This article is part of a collaboration between SWEET Institute and Urban Pathways. Read the full scientific version HERE

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Measuring Engagement: Developing Metrics for Relational Outcomes in Supportive Housing

Karen Dubin, PhD, LCSW — Thu, 18 Dec 2025 14:42:56 +0000

Authors Frederick Shack, LMSW1,4 Mardoche Sidor, MD1,2,3 Jose Cotto, LCSW1,5 Karen Dubin, PhD, LCSW2,4 Lesmore Willis Jr, MPA, MHA1 Gary Jenkins, MPA1 Affiliations 1Urban Pathways, New York, NY 2SWEET Institute, New York, NY 3Columbia University Center for Psychoanalytic Study and Research, New York, NY 4Columbia University, School of Social Work, New York, NY 5New York University, Department of Social Work, New York, NY Correspondence concerning this article should be addressed to Mardoche Sidor, MD, Urban Pathways, at msidor@urbanpathways.org Abstract Traditional metrics in supportive housing and community mental health emphasize compliance (appointments kept, medications taken, housing retention). Yet these measures fail to capture the relational core of engagement. This article proposes a framework for measuring engagement through relational outcomes such as trust, safety, collaboration, and resident-reported experience. Drawing from implementation science, alliance research, and trauma-informed care, we present the Engagement Stage Self-Assessment Checklist as both a fidelity and outcome measure. Composite case studies from Urban Pathways are starting to demonstrate how shifting measurement priorities has the potential to support systemic accountability to relational practice. Keywords Engagement, Measurement, Metrics, Relational Outcomes, Therapeutic Alliance, Fidelity, Trauma-Informed Care, Supportive Housing Introduction “You can’t improve what you don’t measure.” In mental health and housing, metrics drive funding, policy, and practice priorities. Historically, systems have measured compliance behaviors (e.g., medication adherence) rather than relational outcomes (Stanhope & Dunn, 2011). However, research across psychotherapy and health services shows that alliance and trust predict long-term outcomes more strongly than compliance (Flückiger et al., 2018; Wampold & Imel, 2015). The Four-Stage Engagement Model requires metrics that reflect its relational foundation. Theoretical Framework Relational metrics are supported by: Therapeutic Alliance Research: Alliance predicts outcomes across modalities (Horvath et al., 2011). Trauma-Informed Care: Safety and trustworthiness ought to be measured to ensure trauma-informed fidelity (SAMHSA, 2014). Implementation Science: Fidelity tools are essential for sustaining practice change (Fixsen et al., 2005). Recovery-Oriented Care: Outcomes need to include empowerment, choice, and satisfaction (Davidson et al., 2006). Application/Analysis At Urban Pathways, engagement metrics will include: Resident-Reported Trust: Surveys asking residents if they feel listened to, respected, and safe. Staff Fidelity Assessments: Use of the Engagement Stage Self-Assessment Checklist during supervision. Collaborative Goal Setting: Tracking how many goals were resident-led vs. staff-driven. Composite Case Example: A site with high rates of incidents would improve outcomes after adding resident trust surveys. Staff would shift from compliance focus to listening and empathizing, resulting in fewer conflicts and higher stability. Implications Practice: Staff need to be accountable not only for tasks completed but for relationships built. Supervision: Supervisors can use fidelity tools to identify staff growth areas. Policy: Funders need to incentivize relational metrics alongside compliance outcomes. Research: Studies need to compare relational metrics with traditional metrics in predicting long-term outcomes. Systems: Measuring engagement reframes accountability around dignity, trust, and empowerment. Conclusion Measuring engagement through relational outcomes ensures accountability to what matters most: trust, safety, and collaboration. By expanding metrics beyond compliance, supportive housing and community mental health systems can realign practice with recovery-oriented, trauma-informed principles. References Davidson, Larry, et al. “Creating a Recovery-Oriented System of Behavioral Health Care: Moving from Concept to Reality.” Psychiatric Rehabilitation Journal, vol. 29, no. 4, 2006, pp. 315–321. Fixsen, Dean L., et al. Implementation Research: A Synthesis of the Literature. University of South Florida, 2005. Flückiger, Christoph, et al. “The Alliance in Adult Psychotherapy: A Meta-Analytic Synthesis.” Psychotherapy, vol. 55, no. 4, 2018, pp. 316–340. Horvath, Adam O., et al. “Alliance in Individual Psychotherapy.” Psychotherapy, vol. 48, no. 1, 2011, pp. 9–16. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. U.S. Department of Health and Human Services, 2014. Stanhope, Victoria, and Kathleen Dunn. “The Curious Case of the ‘Working Alliance’ in Assertive Community Treatment: A Review of the Literature.” Administration and Policy in Mental Health, vol. 38, no. 5, 2011, pp. 301–310. Wampold, Bruce E., and Zac E. Imel. The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work. 2nd ed., Routledge, 2015. This article is part of a collaboration between SWEET Institute and Urban Pathways. Read the full scientific version HERE

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The SWEET Model and the Future of Mental Health: From Symptom Management to Human Flourishing

Mardoche Sidor, MD and Karen Dubin, PhD, LCSW — Fri, 12 Dec 2025 01:36:15 +0000

Abstract Mental health care is at a crossroads. While advances in neuroscience, trauma-informed care, and psychopharmacology have deepened our understanding of suffering, the field still largely prioritizes symptom reduction over full human development. The SWEET Model offers a paradigm shift—from managing dysfunction to cultivating transformation, meaning, and integration. In this article, we explore how the model responds to the unmet potential of mental health care and provides a vision for a future centered not just on surviving, but thriving. Keywords SWEET Model, SWEET Institute, mental health future, transformation, human flourishing, trauma-informed, integration, holistic care Introduction For decades, mental health systems have operated from a pathology paradigm, emphasizing diagnosis, symptom management, and compliance. While these tools can be necessary, they often miss the full story—and the full potential—of those they aim to serve (Sederer, 2015). The SWEET Model responds by expanding the goals of care from mere stabilization to transformation, integration, and flourishing. It places the individual not within a diagnostic box, but in a layered, evolving journey toward selfhood and purpose. Theoretical Framework The SWEET Model is built on the premise that healing occurs in four dimensions: Conscious Layer – observable behavior, skill-building, awareness Preconscious Layer – adaptive beliefs, emotional patterns, socialized roles Unconscious Layer – core wounds, trauma imprints, protective structures Existential Layer – purpose, identity, mortality, meaning Rather than viewing treatment as a one-dimensional fix, the model facilitates an iterative, layered process of becoming. It integrates psychodynamic theory (Freud, 1915/1957), existential psychology (Frankl, 1985; Yalom, 1980), trauma science (Van der Kolk, 2014), and adult development frameworks (Kegan & Lahey, 2009). Application and Analysis In current mental health systems, patients may be stabilized without ever exploring: The deeper meanings of their suffering The internal logic of their symptoms The existential questions that might free them The SWEET Model challenges clinicians to go beyond treatment compliance and into transformational engagement. This includes: Treating depression not just with medication, but by exploring suppressed grief, lost meaning, and identity confusion Addressing anxiety not only with regulation strategies, but with inquiry into existential fear, ancestral trauma, and disconnection Supporting clients in defining what flourishing looks like to them, rather than imposing external norms Implications The SWEET Model contributes to a redefined mental health future in which: Flourishing, not functioning, is the ultimate goal Clients are seen as whole people across multiple layers of experience Cultural, existential, and neurobiological realities are integrated Transformation is available not just to clients, but to clinicians, systems, and societies This approach calls for a new kind of clinician—one who is not just a technician of change, but a midwife of transformation. Conclusion The future of mental health lies not in tighter diagnostic precision, but in deeper human understanding. The SWEET Model offers a blueprint for this future—one rooted in layered integration, compassion, and the radical belief that people are not just problems to be solved but beings to be supported in becoming. References Frankl, V. E. (1985). Man’s search for meaning. Beacon Press. Freud, S. (1957). The unconscious. In J. Strachey (Ed. & Trans.), The Standard Edition of the Complete Psychological Works of Sigmund Freud (Vol. 14, pp. 159–204). (Original work published 1915) Kegan, R., & Lahey, L. L. (2009). Immunity to change: How to overcome it and unlock potential in yourself and your organization. Harvard Business Press. Sederer, L. I. (2015). The prevention of mental illness: Can it be done?. Columbia University Press. Van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Yalom, I. D. (1980). Existential psychotherapy. Basic Books. Download the scholarly version of this article by clicking HERE

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Collaboration in Practice: Aligning Engagement with Resident-Led Goals

Mardoche Sidor, MD and Karen Dubin, PhD, LCSW — Wed, 10 Dec 2025 22:41:37 +0000

Authors Frederick Shack, LMSW1,4 Mardoche Sidor, MD1,2,3 Jose Cotto, LCSW1,5 Karen Dubin, PhD, LCSW2,4 Lesmore Willis Jr, MPA, MHA1 Gary Jenkins, MPA1 Affiliations 1Urban Pathways, New York, NY 2SWEET Institute, New York, NY 3Columbia University Center for Psychoanalytic Study and Research, New York, NY 4Columbia University, School of Social Work, New York, NY 5New York University, Department of Social Work, New York, NY Correspondence concerning this article should be addressed to Mardoche Sidor, MD, Urban Pathways, at msidor@urbanpathways.org Abstract Collaboration is the culmination of the Four-Stage Engagement Model, where staff and residents co-create meaningful goals and actionable steps. In supportive housing and community mental health, collaboration is often undermined when staff impose organizational or clinical priorities over resident preferences. This article explores how Urban Pathways is applying stage-matched collaboration rooted in motivational interviewing, the Stages of Change, and trauma-informed care. Composite case examples illustrate how aligning interventions with resident-led goals has the potential to enhance trust, reduce reluctance, and foster sustainable outcomes. We propose a framework for embedding collaborative practice across housing programs and beyond. Keywords Collaboration, Resident-Led Goals, Engagement, Motivational Interviewing, Stages of Change, Trauma-Informed Care, Supportive Housing, Co-creation Introduction Collaboration is widely cited as a principle of recovery-oriented practice, yet in practice, staff often unintentionally dominate goal-setting processes (Topor et al., 2011). For residents with histories of trauma, coercion, or homelessness, true collaboration requires a shift in power: residents are to be seen as experts in their own lives (SAMHSA, 2014). The Four-Stage Engagement Model situates collaboration as the final stage, building upon presence, listening, and empathizing. This stage integrates motivational and behavioral science to ensure actions align with both level of preparedness and resident-defined priorities. Theoretical Framework Collaboration is informed by: Motivational Interviewing (MI): Emphasizes partnership, evocation, and autonomy support (Miller & Rollnick, 2013). Stages of Change: Collaboration strategies need to be tailored to level of preparedness for change (Prochaska & DiClemente, 1984). Trauma-Informed Care: Collaboration restores choice and empowerment—key antidotes to trauma (SAMHSA, 2014). Self-Determination Theory: Autonomy, competence, and relatedness drive sustained motivation (Deci & Ryan, 2000). Application/Analysis At Urban Pathways, collaborative practice is operationalized by: Resident-Led Goal Setting: Staff ask residents what matters most (“Tell me what you would like to work on together this month?”). Stage-Matched Collaboration: Staff align supports with level of preparedness (e.g., information in precontemplation; action planning in preparation). Shared Accountability: Staff follow through on commitments and review progress jointly with residents. Composite Case Example: A resident labeled “non-adherent” with medical appointments reframed collaboration by setting his own initial goal: reconnecting with his sister. Once staff supported that, trust grew, and he later initiated medical care on his own. Implications Practice: Collaboration requires shifting from compliance to co-creation, validating resident expertise. Supervision: Supervisors can review case notes for evidence of resident-led goals and collaborative summaries. Policy: Funding structures need to incentivize shared decision-making and resident-reported satisfaction. Research: Studies need to measure the impact of resident-led collaboration on long-term housing stability and recovery outcomes. Systems: Collaborative practice needs to extend beyond housing into healthcare, education, and justice systems. Conclusion Collaboration is not merely the final step of engagement; rather, it is the embodiment of recovery-oriented practice. By aligning supports with resident-led goals, staff foster trust, autonomy, and sustainability. The Urban Pathways experience is demonstrating that collaboration, when stage-matched and resident-driven, has the potential to transform both relationships and outcomes. References Deci, Edward L., and Richard M. Ryan. “The ‘What’ and ‘Why’ of Goal Pursuits: Human Needs and the Self-Determination of Behavior.” Psychological Inquiry, vol. 11, no. 4, 2000, pp. 227–268. Miller, William R., and Stephen Rollnick. Motivational Interviewing: Helping People Change. 3rd ed., Guilford Press, 2013. Prochaska, James O., and Carlo C. DiClemente. The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy. Dow Jones-Irwin, 1984. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication, 2014. Topor, Alain, et al. “Not Just an Individual Journey: Social Aspects of Recovery.” International Journal of Social Psychiatry, vol. 57, no. 1, 2011, pp. 90–99. This article is part of a collaboration between SWEET Institute and Urban Pathways. Read the full scientific version HERE

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