by EK Hopper · 2010 · Cited by 683 — traumatic stress among people experiencing homelessness, awareness is growing of the importance of creating Trauma-. Informed Care within homeless

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80 The Open Health Services and Policy Journal, 2010, 3, 80-100 Open Access 1874-9240/10 2010 Bentham Open Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings Elizabeth K. Hopper *,1 , Ellen L. Bassuk 2,3 , and Jeffrey Olivet 4 1The Trauma Center at JRI 1269 Beacon Street Brookline, MA 02446, USA 2The National Center on Family Homelessness, 181 Wells Avenue, Newton, MA 02459, USA 3Department of Psychiatry, Harvard Medical School, USA 4Centre for Social Innovation 215 Spadina Avenue, Suite 120 Toronto, Ontario M5T 2C7, Canada Abstract: It is reasonable to assume that individuals and families who are homeless have been exposed to trauma. Research has shown that individuals who are homeless are likely to have experienced some form of previous trauma; homelessness itself can be viewed as a traumatic experience; and being homeless increases the risk of further victimization and retraumatization. Historically, homeless service settings have provided care to traumatized people without directly acknowledging or addressing the impact of trauma. As the field advances, providers in homeless service settings are beginning to realize the opportunity that they have to not only respond to the immediate crisis of homelessness, but to also contribute to the longer-term healing of these individuals. Trauma-Informed Care (TIC) offers a framework for providing services to traumatized individuals within a variety of service settings, including homelessness service settings. Alt hough many providers have an emerging awareness of the potential importance of TIC in homeless services, the meaning of TIC remains murky, and the mechanisms for systems change using this framework are poorly defined. This paper explores the evidence base for TIC within homelessness service settings, including a review of quantitative and qualitative studies and other supporting literature. The authors clarify the defin ition of Trauma-Informed Care, discuss what is known about TIC based on an extensive literature review, review case examples of programs implementing TIC, and discuss implications for practice, programming, policy, and research. Keywords: Homelessness, trauma, trauma-informed, systems change. INTRODUCTION Trauma-Informed Care: A Paradigm Shift for Homeless Services fiHomelessness deprives individuals of–basic needs, exposing them to risky, unpredictable environments. In short, homelessness is more than the absence of physical shelter, it is a stress-filled, dehumanizing, dangerous circums- tance in which individuals are at high risk of being witness to or victims of a wide range of violent eventsfl [1]. Homelessness is a traumatic experience. Individuals and families experiencing homelessness are under constant stress, unsure of whether they will be able to sleep in a safe environment or obtain a decent meal. They often lack a stable home and also the financial resources, life skills, and social supports to change their circumstances. In addition to the experience of being homeless, an overwhelming percentage of homeless individuals, families, and children have been exposed to additional forms of trauma, including: neglect, psychological abuse, physical abuse, and sexual abuse during childhood; community violence; combat-related *Address correspondence to this author at the Trauma Center at JRI 1269, Beacon Street Brookline, MA 02446, USA; Tel: (617) 232-1303, Ext. 211; E-ma il: trauma; domestic violence; accidents; and disasters. Trauma is widespread and affects people of every gender, age, race, sexual orientation, and background within homeless service settings. Early developmental traumaŠincluding child abuse, neglect, and disrupted attachmentŠprovides a subtext for the narrative of many people™s pathways to homelessness [2]. Violence continues into adulthood for many people, with abuse such as domestic violence often precipitating homelessness [3-5], and with homelessness leaving people vulnerable to further victimization. The impact of traumatic stress often makes it difficult for people experiencing homelessness to cope with the innumerable obstacles they face in the process of exiting homelessness [6], and the victimization associated with repeated episodes of homelessness. Research has found that people who experienced repeated homelessness were more likely than people with a single episode of homelessness to have been abused, often during childhood [6]. Trauma refers to an experience that creates a sense of fear, helplessness, or horror, and overwhelms a person™s resources for coping. The impact of traumatic stress can be devastating and long-lasting, interfering with a person™s sense of safety, ability to self-regulate, sense of self, perception of control and self-efficacy, and interpersonal relationships. Some people have minimal symptoms after trauma exposure or recover quickly, while others may

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Trauma-Informed Care in Homelessness The Open Health Services and Policy Journal, 2010, Volume 3 81 develop more significant and longer-lasting problems such as Posttraumatic Stress Disorder (PTSD) and Complex Trauma. Trauma reactions are not the only psychiatric issue facing people who are homeless; many people experiencing homelessness also suffer from depression, substance abuse [7- 10], and severe mental illness [8, 10]. These issues leave individuals even more vulnerable to revictimization [11], interfere with their ability to work, impair their social networks [8], and further complicate their service needs. These findings suggest that we will be unable to solve the issue of homelessness without addressing the underlying trauma that is so intricately interwoven with the experience of homelessness. Those working in homeless services have the opportunity to reach many trauma survivors who are otherwise overlooked. Providers in these settings address the immediate crisis by offering food, shelter, and clothing; but they can also contribute to longer-lasting changes by helping an individual or family develop supportive connections in the community and begin to heal from past traumas. Despite this fact, few programs serving homeless individuals and families directly address the specialized needs of trauma survivors. Homeless services have a long history of serving trauma survivors, without being aware of or addressing the impact of traumatic stress [12]. Overwhelmed by the daily needs of their clients, providers in these settings often have few resources to address issues of long-term recovery. With increasing recognition of the pervasiveness of traumatic stress among people experiencing homelessness, awareness is growing of the importance of creating Trauma- Informed Care within homeless services settings. Trauma- Informed Care (TIC) involves fiunderstanding, anticipating, and responding to the issues, expectations, and special needs that a person who has been victimized may have in a particular setting or service. At a minimum, trauma-informed services endeavor to do no harmŠto avoid retraumatizing or blaming [clients] for their efforts to manage their traumatic reactionsfl [13]. Implementing TIC requires a philosophical and cultural shift within an agency, with an organizational commitment to understanding traumatic stress and to developing strategies for responding to the complex needs of survivors. Despite its importance, the implementation of TIC within homelessness service settings is still in its infancy. Currently, the nature of TIC remains ill-defined. Strategies for implementation are obscure, few program models exist, and there is limited communication and collaboration among programs implementing TIC. The descriptive and research literature in this area is sparse, with only a handful of studies examining the nature and impact of TIC. More clarification is needed about what exactly defines TIC, what changes should be made within systems wishing to offer TIC, and how these changes should be implemented. The purpose of this paper is to review the evidence base that supports the use of TIC for individuals and families experiencing homelessness. In this review, we have attempted to: Ł Establish a consensus-based definition of TIC Ł Discuss what is known about TIC based on our literature review Ł Describe models and case examples of what is being done in the field to implement TIC within homeless service settings We conclude by summarizing implications of our current state of knowledge for practice, programming, policy, and research and by highlighting next steps for developing evidence-based, trauma-informed homeless services. What is Trauma-Informed Care (TIC)? What is meant by TIC? Although there is agreement that fitrauma-informedfl refers generally to a philosophical/ cultural stance that integrates awareness and understanding of trauma, there is no consensus on a definition that clearly explains the nature of TIC. TIC supports the delivery of Trauma-Specific Services (TSS). TSS refers to interventions that are designed to directly address the impact of trauma, with the goals of decreasing symptoms and facilitating recovery. TSS differs from TIC, in that TSS are specific treatments for mental disorders resulting from trauma exposure, while TIC is an overarching framework that emphasizes the impact of trauma and that guides the general organization and behavior of an entire system. TSS may be offered within a trauma-informed program or as stand-alone services [12]. Based on the literature review, we summarized the basic principles of TIC proposed by various workgroups, organizations, expert panels, and researchers. (see Table 1). Each of these sources posited a unique definition of TIC. We identified and highlighted common cross-cutting themes and then synthesized them into a single definition. Themes include: Ł Trauma awareness : Trauma-informed service providers incorporate an understanding of trauma into their work. This may involve altering staff perspectives, with providers understanding how various symptoms and behaviors represent adaptations to traumatic experiences. Staff training, consultation, and supervision are important aspects of organizational change towards TIC and organizational practices should be modified to incorporate awareness of the potentially devastating impact of trauma. For example, agencies may implement routine screening for histories of traumatic exposure, may conduct routine assessments of safety, and may develop strategies for increasing access to trauma- specific services. Dealing with vicarious trauma and self-care is also an essential ingredient of trauma- informed services. Many providers have experienced trauma themselves and may be triggered by client responses and behaviors. Ł Emphasis on safety : Because trauma survivors often feel unsafe and may actually be in danger (e.g., victims of domestic violence), TIC works towards building physical and emotional safety for consumers and providers . Precautions should be taken to ensure the physical safety of all residents. In addition, the organization should be aware of potential triggers for consumers and strive to avoid retraumatization. Because interpersonal trauma often involves boundary violations and abuse of power, systems that are aware of trauma dynamics should establish clear roles and boundaries that are an outgrowth of collaborative decision-making.

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82 The Open Health Services and Policy Journal, 2010, Volume 3 Hopper et al. Privacy, confidentiality , and mutual respect are also important aspects of developing an emotionally safe atmosphere. Additionally, cultural differences and diversity (e.g., gender, ethnicity, sexual orientation) must be addressed and respected within trauma-informed settings. Ł Opportunities to rebuild control: Because control is often taken away in traumatic situations, and because homelessness itself is disempowering, trauma- informed homeless services emphasize the importance of choice for consumers. They create predictable environments that allow consumers to re- build a sense of efficacy and personal control over their lives. This includes involving consumers in the design and evaluation of services. Ł Strengths-based approach : Finally, TIC is strengths-based , rather than deficit-oriented. These service settings assist consumers to identify their own strengths and develop coping skills. TIC service settings are focused on the future and utilize skills- building to further develop resiliency. These principles form a standard for programs wishing to develop TIC within homeless service settings. Based on these combined principles, we developed a consensus-based definition of TIC: Consensus-Based Definition fiTrauma-Informed Care is a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.fl Trauma-informed approaches are designed to respond to the impact of trauma. The principles described above target the specialized needs of trauma survivors and describe how services can be delivered through the lens of trauma. METHODS This paper reviews the evidence base supporting the effectiveness of TIC for people experiencing homelessness. To date, most determinations of what constitutes evidence-based practice have relied on outcome-based quantitative research. However, this approach neglects qualitative analyses that examine the nature and process of the intervention, as well as a wealth of information that reflects what is occurring in practice. In fact, corroborative evidence, including clinical wisdom about fiwhat works,fl is often the starting point for developing both qualitative and quantitative studies. In the homelessness field, corroborative evidence may be the primary body of knowledge we have about a particular intervention. For this review, we utilized a comprehensive framework that was developed by the Homelessness Resource Center (HRC) for assessing the level of evidence of an emerging, promising or best practice [15]. The goal of this framework is not to decide whether a practice qualifies as evidence-based, but rather to synthesize all that we currently know about the intervention. Thus, our review included peer-reviewed quantitative and qualitative studies, as well as corroborative literature (e.g., program evaluations and unpublished pilot studies). The literature on TIC is significantly greater in mental health and substance use fields than within the homelessness field. Thus, we also reviewed the current evidence base for trauma- informed practices in these areas since there is a large overlap in the difficulties faced by many individuals with mental health/substance use issues and those in homeless service settings. In fact, in the Women, Co-Occurring Disorders, and Violence Study (WCDVS), a large multi-site study examining trauma-informed services for women with co-occurring disorders and trauma exposure, 70.4% of participants had been homeless at some point in their lives [16]. We reviewed evidence for trauma-informed services within all these settings, applying this broader knowledge base to our understanding of TIC within homeless service settings. We conducted our literature review by searching two databases, PsycInfo and Medline (PubMed), for peer-reviewed articles published in major journals. In addition, we used the Google search engine to locate web-based literature and program information. Our search terms included: homeless, homelessness, housing, shelters, trauma, trauma-informed, PTSD, services, abuse, violence, domestic violence, psychological, substance use, and mental health. We also completed more specialized searches on unique populations (using search terms such as youth, men, ethnicity, veterans), authors of note (e.g., Harris, Fallot, Bassuk, and van der Kolk), models (e.g., Attachment, Self-Regulation and Competency [ARC] and Sanctuary), programs (e.g., Community Connections, the STAR program, and the Community Trauma Treatment Center for Runaway and Homeless Youth), and research studies (e.g., the Women, Co-Occurring Disorders, and Violence Study). In addition to reviewing the literature, we contacted various programs directly, by telephone or email, including: the Natio- nal Center on Family Homelessness (Moses, Guarino); Home- lessness Resource Center (Olivet); Community Connections (Fallot); the Institute for Health and Recovery (Markoff & Dargon-Hart); CT State Department of Mental Health and Addiction Services (Leal); the Domestic Violence & Mental Health Policy Initiative (Brashler, Hall); the Community Trauma Treatment Center for Runaway and Homeless Youth (Schneir); the Trauma Center at JRI/ Youth on Fire, developers of Phoenix Rising (Spinazzola); Kinniburgh and Blaustein, developers of ARC; Cincinnati Children’s Hospital Medical Center, developers of CARE (Pearl); University of Connecticut Department of Psychology and the CT Department of Mental Health and Addiction Services Research Division (Marra). Many of these programs sent unpublished program evaluation reports, manuals, or self-assessment tools, for inclusion in this review. RESULTS Organizational Needs Assessments: Do We Need Trauma-Informed Care? Needs assessments can be used to identify needs and to detect gaps in service within a system. We began by reviewing results of needs assessments conducted by several agencies regarding the relevance of trauma within their service system and the need for TIC. These needs

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Trauma-Informed Care in Homelessness The Open Health Services and Policy Journal, 2010, Volume 3 83 Table 1. Principles of Trauma-Informed Care Example Definitions of Trauma-Informed Care Common Principles Across Definitions Community Connections: Five Guiding Principles for Trauma-Informed Services [12] NASMHPD*: Criteria for Building a Trauma- Informed Mental Health Service System NCTSN**: Principles of Trauma-Informed Care for Children NCFH***: Operating Principles for Trauma- Informed Organizational Self- Assessment WCDVS ****: Trauma-Informed or Trauma- Denied: Principles & Implementation of Trauma- Informed Services for Women [14] . Consensus-Based Principles Across Definitions Theory-Based Expert Trauma Panel Experts Theory-Based Research-based 1. Trauma Awareness a. Program philosophy and mission Trauma function/ focus, trauma policy or position, financing for best practices, trauma- informed services, clinical practice guidelines for people with trauma histories, trauma-informed disaster planning, systems integration, research & data on trauma & evidence-based & best- practice treatment models, access to evidence-based & best- practice trauma treatment Trauma awareness; basic understanding of trauma & triggers; includes staff training & supervision, educating consumers about trauma Recognize the impact of trauma on development and coping b. Staff education, training, and consultation Workforce orientation, training, support, competencies and job standards related to trauma; promote education of professionals in trauma Emphasize trauma recovery as a primary goal c. Practices Trauma screening and assessment; Trauma- specific services, including evidence-based and emerging best- practice treatment models Integration (symptoms such as adaptive coping, integrating services, trauma-specific services) d. Recognition of vicarious trauma and staff self- care 2. Safety a. Physical and emotional safety Safety (physical and emotional) Maintaining clear and consistent boundaries Safety, basic needs, consistency, and predictability Create an atmosphere of safety, respect, and acceptance b. Relationships: authentic, respectful, clear boundaries Trustworthiness (clear tasks, consistent practices, staff-consumer boundaries) [see Delivering services below] Engagement: respectful nonjudgmental relationships, clear boundaries Utilize a relational collaboration model. Growth is fostered by mutual, respectful, authentic relationships c. Avoid retraumatization Procedures avoid retraumatization and reduce impacts of trauma Minimize retraumatization

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84 The Open Health Services and Policy Journal, 2010, Volume 3 Hopper et al. assessments were generally designed as a first step, prior to initiating a more formal organizational self-assessment or to beginning programmatic shifts. Several findings emerged from a review of these needs assessments: Ł Providers feel that they need to be better informed about trauma and violence [17, 18]. Directors and staff within state domestic violence coalitions reported that many shelters are unprepared to deal with the complex needs of the women they serve, many of whom have few resources and have been victimized as children and as adults. Domestic violence advocates reported an increasing awareness of the need for services appropriate for women with mental health issues, substance abuse problems, and histories of abuse. They also expressed a need for guidance and resources in improving their responses to survivors of domestic violence who have experienced multiple abuses throughout their lives [18]. A multi-site program implementing trauma-informed services found that prior to implementation, sites had little knowledge about trauma, how to facilitate recovery, or how services might help or retraumatize survivors [19]. Ł Many providers do not have systematic ways of assessing for trauma-related issues. In a study examining PTSD screening and referral practices in VA addiction treatment programs, they found that although one-half to two-thirds of clinicians did routinely screen for trauma exposure and posttraumatic stress symptoms, assessments were generally not conducted system- atically and did not utilize validated measures [20]. Ł Consumers want services that are empowering. Qualitative research has suggested that homeless individuals and families need and want trauma-informed services, including desire for autonomy, prevention of further victimization, and assistance in restoring their devalued sense of identity [21]. A provider guidebook, written from a consumer perspective, notes the need for accessible and effective programs for trauma survivors [22]. (Table 1) contd–.. Examp le Definitions of Trauma-Informed Care Common Principles Across Definitions Community Connections: Five Guiding Principles for Trauma-Informed Services [12] NASMHPD*: Criteria for Building a Trauma- Informed Mental Health Service System NCTSN**: Principles of Trauma-Informed Care for Children NCFH***: Operating Principles for Trauma- Informed Organizational Self- Assessment WCDVS ****: Trauma-Informed or Trauma- Denied: Principles & Implementation of Trauma- Informed Services for Women [14] . Consensus-Based Principles Across Definitions Theory-Based Expert Trauma Panel Experts Theory-Based Research-based d. Acceptance of and respect for diversity Trau ma policies and services that respect culture, race, ethnicity, gender, age, sexual orientation, disability, and socio-economic status Delivering services in a nonjudgmental and respectful manner Cultural competence Work towards cultural competence, understand contextual factors 3. Choice & Empowerment a. Choice and control Choice: maximize consumer choice and control Consumer/Trauma Survivor/ Recovering person involvement and trauma-informed rights Maximizing choice and control for participants Consumer control, choice and autonomy Underscore consumers™ choice and control over recovery b. Emp owermen t model Empowerment: prioritize consumer empowerment, skill-building, and growth Avoidi ng provocation and power assertion Open communication: provide information openly to consumers Use an empowerment model c. Consumers involved in service development and evaluation Collaboration: maximize collaboration and sharing of power between staff and consumers Shar ing power in the running of shelter activities Shared power and governance Involve consumers in design and evaluation of services 4. Strengths- based Focus on strengths, resiliency [see Empowerment above] Hea ling, instilling hope Highlight consumers™ strengths, adaptations, and resiliencies * NASMHPD= National Association of State Mental Health Program Directors. ** NCTSN = National Child Traumatic Stress Network. *** NCFH = National Center on Family Homelessness. **** WCDVS = Women, Co-Occurring Disorders and Violence Study.

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Trauma-Informed Care in Homelessness The Open Health Services and Policy Journal, 2010, Volume 3 85 Ł Mental health services are an important need for many homeless families and individuals. In a multi- site research study on trauma-informed services for homeless families, researchers examined current service needs, including families™ need for social capital (educational or employment-related interventions), physical health, and mental health/substance use treatment. Among the families, they found that fimental health needs were the most prevalent of all the intervention needs components across sites (62%),fl with many facing multiple challenges, signaling the need for comprehensive intervention [23]. The results of these needs assessments supported the central importance of dealing with trauma within homelessness service settings and the perceived need for TIC. Trauma-Informed Care within Homelessness Services Settings: Attitudes, Implementation, and Outcomes Once the perceived need for trauma services is established, we can begin to explore the development of a TIC framework within homelessness service settings. We reviewed available quantitative, qualitative, and corroborative evidence regarding trauma-informed services. Prochaska™s stages of change model [24] highlights the fact that change is a process for individuals, who progress through precontemplation, contemplation, action, and maintenance of change. Similarly, systems change is a multi-step process. Our review of the literature highlighted three areas of evidence: attitudes, implementation, and outcomes. fiAttitudesfl refers to the beliefs of consumers and providers (at all levels, from management to front-line workers) of the need for a paradigm shift, confidence in ability to institute a paradigm shift, and belief that such a shift will lead to positive outcomes. fiImplementationfl coincides with Prochaska™s action stage of change. It is a process variable, and is concerned with how changes are made. Implementation requires a clear definition of what is meant by Trauma-Informed Care, in order to translate these principles into concrete changes that will be instituted within the system. Finally, fioutcomesfl refers to the impact of a paradigm shift to TIC within homelessness service settings. Measurable objectives help to assess the efficacy of systems change. Outcomes may include measurable quantitative outcomes, such as a decrease in recidivism in homelessness, or qualitative outcomes, such as self-esteem or satisfaction with services. Review of the Evidence: What Do We Know About TIC? In our review of the evidence for TIC, several salient points emerged: 1. Attitudes Ł Programs attempting to implement TIC have encountered some concerns and resistance on the part of providers. Providers may be afraid that addressing trauma will open a fiPandora™s boxfl of reactions. They may lack confidence in their ability to manage and address trauma reactions and may be concerned that they will encounter triggers of their own trauma histories [19]. They may also worry that they will not have the resources to adequately respond to the complex needs of survivors. Ł Because of these concerns, taking the time to build fibuy -infl is particularly important. Recognizing the importance of commitment in organizations, some programs have developed committee structures geared towards obtaining fibuy-infl from administration, program staff, and consumers. Building strong relationships also aided buy-in and integration of services [19]. After building agency- wide commitment, programs have found strong support from staff members for implementing a trauma-informed model [25]. Ł Consumers want providers who are empathic and caring, who provide validation, and who offer emotional safetyŠcharacteristics of trauma- informed providers. Consumers have emphasized the benefits of working with trauma-informed providers. Some have suggested that programs could benefit from having more trauma services, that practitioners need to remain patient, and that consumers themselves need to be invested in actively addressing their own issues [26]. However, even within trauma-informed systems, consumers sometimes struggle to feel empowered within a larger service system [27]. 2. Implementation Ł Training is central to implementing TIC. The majority of programs working to build TIC utilized staff training to increase awareness of and sensitivity to trauma-related issues. A large multi-site study of trauma-informed models found that fitraining on trauma for non-trauma providers was the first and most important step in making services more trauma- informedfl [19]. Ł Ongoing supervision, consultation, and support are needed to reinforce trauma-based concepts. One lesson from WCDVS was the importance of ongoing supervision and support to ensure that the environment is trauma-informed and that staff members practice appropriate self-care. Many programs also used external trauma consultants and ongoing training to reinforce knowledge and commitment to building trauma-informed services [19]. Ł Assessment and screening are important aspects of trauma-informed services. Research documenting high prevalence rates of trauma among people experiencing homelessness has led to the conclusion that screening for trauma is important within homeless service settings [28]. Although providers have at times expressed concern that inquiring about trauma histories will lead to traumatic stress responses, findings indicate that there are few adverse reactions to screening and assessment. Instead, most people benefit from this type of assessment [29]. Several pilot studies show that providers refined their intake processes to include screening for trauma exposure [28, 30]. Add itionally, screening and assessment tools should be revised and refined with consumer and provider feedback [29].

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