Homelessness is a traumatic experience. People who experience homelessness also often have histories of trauma. Homeless service agencies can develop services and environments that are sensitive to clients’ trauma histories, triggers and reactions by becoming trauma-informed. This HRC brief summarizes what the literature tells us about implementing trauma-informed services.

Homelessness is a traumatic experience. Individuals and families who are homeless are under constant stress, often unsure of where they will sleep tonight or where they will eat their next meal. They may also have been exposed to neglect, psychological abuse, physical abuse, and sexual abuse during childhood; community violence; combat-related traumas; domestic violence; sexual assault; and accidents or disasters.

Definitions of trauma-informed care have remained murky, complicating the development of trauma-informed services. Trauma-informed care generally “involves understanding, 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 harm—to avoid retraumatizing or blaming [clients] for their efforts to manage their traumatic reactions” (Moses, Reed, Mazelis, and D’Ambrosio, 2003, p.19).

In 2007, HRC reviewed the evidence for trauma-informed services to determine what we know. Below are the common themes about implementation that emerged from this review. We encourage you to use these themes to educate program staff, funders and community members about implementing trauma-informed services.

• Training is a central component of implementing trauma-informed services.  Most programs building trauma-informed services included staff training to increase awareness of and sensitivity to trauma-related issues.  A large multi-site study of trauma-informed models found that “training on trauma for non-trauma providers was the first and most important step in making services more trauma-informed” (Moses et al., 2004, p. 23).
• Ongoing supervision, consultation, and support are needed to reinforce trauma-based concepts.  One lesson from the Women, Co-Occurring Disorders and Violence Study (WCDVS) was the importance of ongoing supervision and support to ensure trauma-informed services and staff self-care.  Many programs also used external trauma consultants and ongoing training (Moses et al., 2004).
• Assessment and screening are important aspects of trauma-informed services. Screening for trauma is important within homeless service settings (Christensen et al., 2005).  Although some providers express concern that this will lead to traumatic stress responses, findings indicate that most people benefit from this type of assessment (McHugo et al., 2005).
• Because individuals who are homeless often have multiple service needs, comprehensive and integrated services are essential.  Service settings that offered integrated counseling—addressing trauma, mental health, and substance use issues—had better results than other settings (Cocozza et al., 2005).
• Integrating trauma-informed services for children is also important. Children of parents who are dealing with trauma, mental illness, substance abuse, and/or homelessness may be at greater risk for adverse outcomes. In the WCDVS, a subset of sites offered specialized children’s programs, including assessment, groups, and resource coordination/advocacy for children to build coping skills, strengthen interpersonal relationships, and help develop positive identity and self-esteem (Finkelstein et al., 2005).
• There are many challenges to implementing trauma-informed services. Change, especially within larger systems, can be time-consuming and requires a great deal of commitment across all levels of an organization. Moses et al. (2003) highlighted challenges such as: philosophical differences between mental health and substance use treatment approaches, differences around issues of trauma, resistance at the service and administrative levels, limited resources, difficulties in achieving consistent participation in trauma groups, staff turnover, and the difficulty of change in general.
• Implementing a trauma-informed model can lead to changes in how an organization functions.  In a program implementing a trauma-informed model, staff reported a number of changes within their programs, including increased awareness and sensitivity about trauma, intake that incorporates questions about trauma, more freedom and choice given to consumers regarding their treatment, and environmental changes that led to increases in safety, confidentiality, and a more welcoming atmosphere (Marra, 2006).
• Including consumers in developing and evaluating trauma-informed services is important. The WCDVS found that integrating consumers into the design and evaluation of services had a profound impact on the systems involved (Moses et al., 2004), and that “integral to the… group's personal and professional growth was the development and expression of their individual and collective voices” (Mockus et al, 2005, p. 513).
• Cultural competence is important in developing trauma-informed services.  Because trauma may have different meanings in different cultures, and because traumatic stress may be expressed differently within different cultural frameworks, it is important for providers within a trauma-informed system to work towards developing cultural and linguistic competence (Moses et al., 2003).

References:

Christensen, R.C., Hodgkins, C.C., Garces, L.K., Estlund, K.L., Miller M.D., & Touchton, R. (2005). Homeless, mentally ill and addicted: The need for abuse and trauma services. Journal of Health Care for the Poor & Underserved, 16(4), 615-621. Available at: http://homeless.samhsa.gov/Resource/View.aspx?id=32749 

Cocozza, J.J., Jackson, E.W., Hennigan, K., Morrissey, J.B., Reed, B.G., & Fallot, R.
(2005). Outcomes for women with co-occurring disorders and trauma: Program
level effects. Journal of Substance Abuse Treatment, 28(2), 109-119. Available at:
http://homeless.samhsa.gov/Resource/View.aspx?id=22155

Finkelstein, N., Rechberger, E., Russell, L.A., VanDeMark, N.R., Noether, C.D.,
O’Keefe, M., et al.  (2005). Building resilience in children of mothers who have co
occurring disorders and histories of violence: intervention model and implementation
issues.  Journal of Behavioral Health Services Research, 32(2), 141-154. Available at:
http://homeless.samhsa.gov/Resource/View.aspx?id=32732

Marra, J.V.  (2006). Final Evaluation Report: Evaluation of the Trauma Center of
Excellence Initiative. Storrs, CT: University of Connecticut Department of Psychology
and the CT Department of Mental Health and Addiction Services Research Division.
Unpublished program evaluation.

McHugo, G.J., Caspi, Y., Kammerer, N., Mazelis, R., Jackson, E.W., Russell, L., et al.
(2005).  The assessment of trauma history in women with co-occurring substance abuse
and mental disorders and a history of interpersonal violence. The Journal of Behavioral
Health Services and Research, 32, 113-127. Available at:
http://homeless.samhsa.gov/Resource/View.aspx?id=22662

Mockus, S., Cinq Mars, L., Guazzo Ovard, D., Mazelis, R., Bjelajac, P., Grady, J., et al.
(2005). Developing consumer/ survivor/recovering voice and its impact on services and
research: Our experience with the SAMHSA Women, Co-Occurring Disorders and
Violence Study. Journal of Community Psychology, 33(4), 513-525.

Moses, D.J., Reed, B.G., Mazelis, R., and D’Ambrosio, B.  (2003). Creating Trauma
Services for Women with Co-Occurring Disorders:  Experiences from the SAMHSA
Women with Alcohol, Drug Abuse, and Mental Health Disorders who have Histories of
Violence Study.  Delmar, NY: Policy Research Associates.  Available at:
http://homeless.samhsa.gov/Resource/View.aspx?id=25663

Moses, D.J., Huntington, N., & D’Ambrosio, B. (2004).  Developing Integrated Services
for Women with Co-Occuring Disorders and Trauma Histories:  Lessons from the
SAMHSA Women with Alcohol, Drug Abuse and Mental Health Disorders who have
Histories of Violence Study.  Delmar, NY: Policy Research Associates.  Available at:
http://homeless.samhsa.gov/Resource/View.aspx?id=22873