1. Trauma-Informed Care Best-Practices for the homeless
Lewis “Rusty” Burger, LCSW
Family Preservation Services of VA
Providence Service Corporation

2. Quick Intro Who am I? Who are you? Goals of this session:
Develop a clear understanding of Trauma-Informed Care (TIC)
Review Evidenced-Based Practices that incorporate TIC standards for the homeless population.
Review Compassion Fatigue and Secondary Trauma for workers providing care to the homeless population.

3. Quick Exercise:
Everyone close your eyes – and point to Montana.
Open your eyes and look around.
Trauma-Informed Care is a “buzz” word right now – with many varying opinions…and with many definitions – let’s start with a clear context of what most experts believe TIC means.

4. What is Trauma?
a traumatic event, either witnessed or experienced, representing a fundamental threat to one’s physical integrity or survival
responses involve intense fear, helplessness or horror
the meaning of the event may be as important as the actual physical act/experience
what we want to emphasize is that it is an individual's subjective experience that determines whether an event is or is not traumatic

5. Trauma is the experience of great ____.
Answer – is loss!
Loss of:
boundaries
safety
trust
power and control
innocence
protection
attachment
possessions
consistency/predictability
sense of self/body image

6. U.S. Prevalence, cont'd
One in four children/adolescents experience at least one potentially traumatic event before the age of 16.1 In a 1995 study, 41% of middle school students in urban school systems reported witnessing a stabbing or shooting in the previous year.2 Four out of 10 U.S. children report witnessing violence; 8% report a lifetime prevalence of sexual assault, and 17% report having been physically assaulted.3
1. Costello et al. (2002). J Traum Stress;5(2):
2. Schwab-Stone et al. (1995). J Am Acad Child Adolesc Psychiatry;34(10):
3. Kilpatrick et al. (2003). US Dept. Of Justice. 27 27

7. Exposure to Violence in Childhood
46 million of 76 million children
are exposed to violence, crime and abuse each year
Finkelhor, D., et al. (2010). Trends in childhood violence and abuse exposure: evidence from 2 national surveys. Archives of Pediatric and Adolescent Medicine, 164(3), 238–242.

8. Exposure to Violence in Childhood
A national study of adult “foster care alumni” found higher rates of PTSD (21%) compared with the general population (4.5%). This was higher than rates of PTSD in American war veterans.1
Nearly 80% of abused children face at least one mental health challenge by age 21.2
1. Pecora, et al. (December 10, 2003). Early Results from the Casey National Alumni Study. Available at: 7ED1-440D-925A-E5BAF602294D/302/casey_alumni_studies_report.pdf.
2. ASTHO. (April 2005). Child Maltreatment, Abuse, and Neglect. Available at:

9. 1 year of violence= 124 billion dollars in recovery costs
The breakdown per child is: • $32,648 in childhood health care costs • $10,530 in adult medical costs • $144,360 in productivity losses • $7,728 in child welfare costs • $6,747 in criminal justice costs • $7,999 in special education costs

10. Statement on Homelessness
Traumatic Stress and Homelessness
“Homelessness 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 circumstance in which individuals are at high risk of being witness to or victims of a wide range of violent events”
Fitzpatrick KM, LaGory ME, Ritchey FJ. Dangerous places: Exposure to violence and its mental health consequences for the homeless. Am J Orthopsychiatry 1999; 69:

11. Powerful Statistics to Review
Men
• More than 2/3 of men in a dual-diagnosis treatment program for homeless people reported a history of trauma -- either physical or sexual abuse.
• More than 1/4 of homeless men were assaulted in the past year.
• Homeless men within substance treatment programs have a high prevalence of depression, family dysfunction, trauma, and multiple previous treatment experiences.
• Despite the fact that men comprise the majority of homeless people and are frequently exposed to trauma, homeless men are less likely to receive social services than homeless women, with less effort directed towards understanding the impact of trauma for this population.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.

12. Powerful Statistics to Review
Women/Mothers
• Although many people think of men when they consider the issue of homelessness, families—typically single mothers with young children—now comprise up to 40% of the overall homeless population.
• Trauma is extremely prevalent among homeless women: over 90% of homeless mothers report having experienced severe physical or sexual assault during their lifetimes.
• The majority of homeless mothers were abused during childhood, with nearly 2/3 reporting severe physical abuse and 42% reporting sexual abuse; 60% were abused before the age of twelve.
• More than 70% of homeless mothers have at least one childhood risk factor, including: severe physical abuse, unwanted sexual contact, having a parent who was mentally ill or who abused substances, running away for a week or more, or being in foster care.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.

13. Powerful Statistics to Review
Women/Mothers
• Homeless mothers are also frequently the victims of abuse during adulthood, with 61% reporting a history of domestic violence and 32% acknowledging recent domestic violence.
• Homelessness puts women at risk for assault; being homeless was associated with more than three times the risk of sexual assault for women.
• Homelessness and victimization are associated with adverse mental health outcomes: more than 50% of homeless mothers reported depression, and more than 40% reported posttraumatic stress disorder (PTSD), and were three times as likely as housed women to suffer from PTSD.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.

14. Powerful Statistics to Review
Children and Youth
• Child abuse is associated with high-risk behaviors in adolescents, such as truancy and running away, that may lead to homelessness. Almost 3/4 of girls on the streets report that they were forced to run away from violence at home.
• Homeless children and youth are at risk for further victimization, such as repeated abuse, exposure to violence, and forced prostitution.
• 86% of homeless youth report exposure to trauma, with almost 2/3 reporting exposure to multiple traumatic events; physical assaults are prevalent for young men, while sexual/physical abuse is common among young women.
• Homeless children are at increased risk for medical, emotional, behavioral, and academic problems, including post-trauma responses, insecure attachments, and difficulty learning.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.

15. Powerful Statistics to Review
Elderly
• The elderly make up a relatively lower percentage of the homeless population, only 2%,however, elderly homeless persons are more vulnerable to victimization, have more health problems, and may be less likely to receive needed social services and protection from law enforcement.
• In 2006, 27% of the homeless victims of violent crimes were between years of age.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.

16. Powerful Statistics to Review
Veterans
• Veterans are disproportionately represented in the homeless population, with veterans making up 23% of all homeless people in the U.S.
• The majority of women in homeless veteran programs have serious trauma histories, including being physically harassed, sexually harassed, or raped while in the military.
• One-quarter or more of homeless veterans manifest symptoms of PTSD; 76% experience alcohol, drug, or mental health problems.
• Trauma and related distress are related to relapse and re- hospitalization of homeless veterans who have substance abuse problems, particularly for female veterans.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.

17. Powerful Statistics to Review
Minorities
• Minorities are over-represented among the homeless population, with almost half being African-American.
• Families of color also disproportionately experience trauma.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.

18. Powerful Statistics to Review
Lesbian, Gay, Bisexual, & Transgendered (LGBT)Individuals
• 40% of homeless youth identify as LGBT.
• One-third of LGBT youth are assaulted after disclosing their sexual orientation; 40% to 60% of homeless youth cited physical abuse as a reason for leaving home.
• Thirty-three percent of transgendered individuals reported that they had been physically or sexually assaulted in the past year.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.

19. Discussion
Thoughts regarding these statistics? Discussion on how Traumatic Events increase the likelihood of someone becoming homeless. Patterns of Violence – Review Cycle of Violence that leads to Homelessness.

20. Have No fear – TIC Is Here!
Definition of TIC:
“Trauma-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.”
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.

21. Have No fear – TIC Is Here!
Key Components a TIC Worker will Display:
Trauma Awareness:
Will display an understanding of Trauma
Staff supervision and polices will embody TIC Standards
Self-care and vicarious trauma is processed
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.

22. Have No fear – TIC Is Here!
Key Components a TIC Worker will Display:
Emphasis on Safety:
Will build emotional and physical safety for your consumers.
Establish clear roles and boundaries.
Privacy, confidentiality, and mutual respect are practiced.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.

23. Have No fear – TIC Is Here!
Key Components a TIC Worker will Display:
Opportunities to rebuild control:
Importance of Choice
Predictable Environments
Efficacy and Personal Control
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.

24. Have No fear – TIC Is Here!
Key Components a TIC Worker will Display:
Strengths-based approach:
Not Deficit - Oriented
Focus on the Future
Utilization of Skill-Building (not tearing one down).
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.

25. Time to Be Real
What is the culture like at your organization toward the homeless? How would you improve on practices of 1) Trauma Awareness; 2) Emphasis on Safety; 3) Opportunities to Rebuild Control; 4) Strengths- Based Approach?

26. Promising Models of Care for Homelessness Organizations
Attachment, Regulation, and Competency: A Comprehensive Framework for Intervention with Complexly Traumatized Youth (ARC)
Child Adult Relationship Enhancement (CARE)
A Long Journey Home
Phoenix Rising
Sanctuary Model
Using Trauma Theory to Design Service Systems
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.

27. Trauma Present … Key Elements of TIC
Five Core Values (Fallot, 2009)
Safety
Trustworthiness
Choice
Collaboration
Empowerment

28. Not react to the behavior
We must ……
Respond to the need ….
Not react to the behavior

29. Trauma and Professionals
Bride (2007) did a study of master’s level social workers licensed in a southern state. The study found that…
70.2% of workers experienced at least one symptom of STS in the previous week
55 % met the criteria for at least one of the core symptom clusters
15 .2% met the core criteria for a diagnosis of PTSD.
The intrusion criterion was endorsed by nearly half of the respondents.
The most often reported symptoms were intrusive thoughts, avoidance of reminders of clients, and numbing responses.

30. Trauma and Human Service Systems
Who saves the hero ??
Within and between human service organizations we witness fight flight and freeze …
When we think about where this comes from … it is very similar to the experience of our clients
We bring in our own ACE scores
Our environments are stressful, demanding and sometimes abusive
Budget Cuts
Higher Caseloads
Increase paperwork demands
Higher expectations for outcomes and evidence informed practices
Constantly changing regulations
Vicarious Trauma with and through our clients

31. Cross System Challenges can also be because of …
Lack of Knowledge
Lack of Awareness
Lack of True Collaboration
Lack of Resources

32. Becoming a trauma informed organization …

33. Preparing Our Workforce to offer Trauma Informed Phase Oriented Care
Phase I: Safety and Stabilization
Phase 2: Trauma Reprocessing
Phase 3: Reintegration
Courtois, C., Ford, J., & M. Cloitre (2009), pp

34. Who is taking care of you ??
Compassion Fatigue
Who is taking care of you ??

35. Mirror Neurons

36. Impact of Working with Victims of Trauma
Trauma experienced while working in the role of helper has been described as:
Compassion fatigue
Countertransference
Secondary traumatic stress (STS)
Vicarious traumatization
Unlike other forms of job “burnout,” STS is precipitated not by work load and institutional stress but by exposure to clients’ trauma.
STS can disrupt staff’s lives, feelings, personal relationships, and overall view of the world.
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37. Impact of Chronic Stress http://www.helpguide.org/mental/stress_signs.htm
raise blood pressure
suppress immune system
increase the risk of heart attack and stroke
contribute to infertility
speed up the aging process (life expectancy)
create vulnerability for anxiety and depression
obesity
skin conditions (ex: eczema)
sleep problems
digestive problems

38. Managing Stress when working youth
Request and expect regular supervision and supportive consultation.
Utilize peer support.
Consider therapy for unresolved trauma, which the child welfare work may be activating.
Practice stress management through meditation, prayer, conscious relaxation, deep breathing, and exercise.
Develop a written plan focused on maintaining work–life balance.
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39. Perry and Cost of Caring http://childtraumaacademy
Information and slide part of Dr. Allison Sampson's Trauma Presentation

40. Self-Care
“Whether you and I and a few others will renew the world some day remains to be seen. But within ourselves we must renew it each day.” —Hermann Hesse

41. Self-care Strategies http://www. compassionfatigue
The best strategy to address compassion fatigue is to develop excellent self care strategies, as well as an early warning system that lets you know that you are moving into the caution zone of Compassion Fatigue.

42. Self Care: Need Options
Time and Connection:
10 second exercises
2 minute exercises
5-10 minute exercises
20-30 minute GI, Walking Meditation

43. Caring For Yourself

44. Self Care Apps Provider Resilience GPS for the Soul
Mediation Oasis Apps
Mindfulness Training System
IChill App (Peter Levine)
Narrative Therapy Questions (Narrative Q’s)
Brain Wave
Flipagram (example)
NCTSN Self Care Inventory

45. Provider Resilence

46. GPS for the Soul

52. “Dig where the ground is soft” Chinese proverb
Conclusion: “Dig where the ground is soft” Chinese proverb Instead of picking your trickiest area, pick the issue that you can most easily visualize improving on. (e.g.: “making a commitment to going for a walk every lunch time vs. getting rid of my difficult supervisor”). You may not notice it right away, but making one small change to your daily routine can have tremendous results in the long term. Imagine if you started walking up two flights a stairs per day instead of using the elevator, what might happen after three months?

53. Questions….
“…We are stewards not just of those who allow us into their lives but of our own capacity to be helpful...”

54. 10 percent of the work done 90 percent to go What will you do ?
Understanding what we can do even better …
Acknowledging what we are doing now
TIC SUPPORT IN VA

55. What is next for your organization?
Trauma Informed approaches are a lens you can use to define the way you …
- Screen and Assess children and families
- Gather information from youth and families about the services they need and are receiving from you
- Educate your workforce
- Make decisions about referrals to trauma informed and evidence informed programs
-Create safe and secure environments (physically and emotionally)
- Engage in Community Outreach and Partnership Building
- Make decisions about ongoing performance of your work, your agency and the quality of the work you offer

56. “If our aim is to nurture healthy children within safe communities, we need to change our approach and the values that drive our responses to violence. The reliance on highly punitive approaches [is] not working — they make people more alienated and angry, they feed cycles of revenge, and, as if that is not enough, they are costly.”
Dr. Lauren Abramson, Executive Director, Community Conferencing Center, Baltimore

57. Together we can make a difference
Becoming Trauma Informed is a process …
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58. Trauma-Informed Care Best-Practices for the homeless
Lewis “Rusty” Burger, LCSW
Family Preservation Services of VA
Providence Service Corporation