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Homelessness is inextricably linked to poverty, stress, violence, and a range of traumatic experiences. Trauma and victimization represent severe forms of stress that may have long-lasting consequences. While stress can be toxic to individuals, families, and communities, it does not generally engender the same intense feelings of betrayal, overwhelming powerlessness, helplessness, and terror that trauma and victimization do, or bring the threat of annihilation. Psychiatrist Judith Herman describes a traumatic event as one that is characterized by overwhelming powerlessness that devastates the human capacity for adaptation. She and Bessel van der Kolk, another psychiatrist, have pointed out that, unlike stress, trauma and victimization often result in severe psychological and biological harm in victims.
Unfortunately, our society has only recently begun to acknowledge the pervasive and harmful effects of violence on its victims.
Trauma, Victimization, And Homelessness
Trauma and victimization are omnipresent in the lives of homeless people. Their lives are typically characterized by extreme poverty, economic hardship, residential instability, and racism—all of which may lead to subtle and overt forms of victimization.
In addition to their exposure to these systemic forces in our society, which are intrinsically victimizing and traumatic, homeless people are faced with more frequent, intense, and unpredictable stressors compared to their housed counterparts. Many of these experiences, including homelessness itself, random violence, physical or sexual abuse, abrupt separations, and sudden catastrophic illness, may be traumatic.
Homelessness is a devastating and often traumatic event that is frequently compounded by violence and victimization. Losing a home also means losing one’s neighborhood, support system, daily routine, privacy, and feelings of safety, comfort, and familiarity. Many homeless people have lived in poor communities riddled with both random and interpersonal violence, and are already suffering from some of the invidious effects of these experiences. It is also not uncommon for women and their children to lose their homes because they are fleeing an abusive relationship or for teenagers to run away from abusive home environments. Once a person is living on the streets, the likelihood of victimization increases over time. Many homeless people living in the rough are physically abused and emotionally isolated. The street homeless may also be subject to incarceration by police for vagrancy, disorderly conduct, and offenses related to substance use. They may be further victimized in jail, setting the stage for severe posttraumatic responses to these experiences.
Abrupt separations, which are particularly common in homeless families, are another source of trauma. Interpersonal violence may lead to abrupt out-of-home placement of children. Family separations may also occur when shelter rules exclude men and teenage boys. These rules rob families of their strength and supportive qualities as a unit and may traumatize both children and parents.
Homeless people suffer from more acute and chronic medical illnesses than their housed counterparts. These illnesses tend to be exacerbated by their lack of a home (for example, from exposure to the elements) and by their compromised access to health care. Often they receive services only when these illnesses have progressed, which necessitates more intensive treatment or even hospitalization. Treating conditions such as cellulitis, hypertension, and diabetes is extremely challenging when patients are living on the streets or in shelters. Sudden catastrophic illness or severely debilitating chronic conditions are very stressful and often traumatic.
Homeless people’s experiences of trauma and victimization are not limited to the specific period of homelessness. Many are the victims of complex and repeated trauma that predates their first homeless episode.
Effects Of Interpersonal Violence
Experiences of trauma and victimization pervade the lives of homeless solitary adults both before and after they become homeless. Carol North, a psychiatrist, and her colleagues surveyed 900 homeless adults in St. Louis and found that 40 percent of both men and women in the sample had experienced at least one violent trauma, and for most of them, this had occurred before they became homeless. Thirty-three percent of the women and 20 percent of the men surveyed had posttraumatic stress disorder (PTSD); 75 percent of that group had developed PTSD prior to becoming homeless. Traumatic experiences for men were primarily assaults and for women rape. In addition, 92 percent of the men and 98 percent of the women reported one or more symptoms of PTSD in their lifetime, which indicates that they had been exposed to some type of trauma.
Nancy Jainchill, a psychologist, and her colleagues found that the relationship between abuse experiences and homelessness was similar for men and women. In her survey of homeless residents of therapeutic community shelters in New York City, she found high rates of abuse in both men and women, with the majority reporting the first episode prior to the age of fifteen years. Social worker Deborah Padgett and her colleagues found victimization rates as high as 56 percent in 1992 survey of 1,260 homeless adults in New York City.
Families and Children
A staggering number of homeless and extremely poor women and children have been exposed to violence and its far-reaching consequences. They have faced oppressive circumstances and endured unspeakable abuses, including being sexually or physically abused in childhood or adolescence, being a victim of crime, and witnessing violence.
A 1998 National Institute of Mental Health (NIMH)-supported study conducted by Ellen Bassuk, a psychiatrist, and her colleagues at the National Center on Family Homelessness (NCFH) reported that 92 percent of homeless mothers and 82 percent of low-income, housed mothers had been severely physically and/or sexually abused at some point in their lives. Approximately two-thirds of the women had histories of being in a battering relationship and about one-third were in such a relationship at the time of their admission to a shelter. These women were fleeing violent perpetrators. Many homeless women also report having experienced some form of violent victimization as children. Two-thirds of the women in the same study had been physically assaulted as children, and 43 percent had been sexually assaulted at least one time before the age of twelve years.
Trauma and violence are also related to multiple episodes of homelessness. Based on longitudinal data, Bassuk and her colleagues reported higher baseline rates of interpersonal violence, especially during childhood, in women whose families had suffered multiple episodes of homelessness. The women in these families reported higher rates of childhood sexual abuse and violence from strangers than those who had not been homeless before. Sexual molestation during childhood was also an important predictor of recidivism. Prospectively, first-time-homeless mothers who experienced partner violence after being rehoused were more than three times as likely to experience a second homeless episode.
Trauma affects both victims and witnesses. Many children in homeless families have been exposed to terrifying scenes of domestic violence. Each year, an estimated 3.3 million children in the United States witness violent assaults against their mothers, usually at the hands of their father or their mother’s intimate partner. Mothers who have experienced violence or abuse frequently become emotionally numb and unaware of the connection between their violence/abuse experiences and the physical and mental health consequences of those experiences. Similarly, they are unlikely to recognize the impact that witnessing or experiencing violence has on their children, who are often the hidden victims in domestic violence. Whether or not the children are directly abused, witnessing the threats and assaults to their mothers has an emotional impact on them that is similar to the effect of direct victimization.
Many of the unaccompanied (runaway/homeless) youths living on the streets have experienced severe physical and sexual abuse. These children are often fleeing from chaotic, unsafe, disruptive home environments. A 1997 study from the U.S. Department of Health and Human Services reported that 46 percent of these youths had been physically abused and 17 percent had been forced into sexual activity by a member of their household. Researchers Marjorie J. Robertson and Paul A. Toro report that the rates of PTSD, conduct disorder, and major depression were three times as high in unaccompanied homeless youths as in a comparison sample of youths who had not left home. Once on the streets, many youths survive by exchanging sex for food and money, putting them at high risk of sexual and physical abuse and of contracting HIV. They are also more vulnerable to violent and abusive treatment.
Effects Of Trauma And Violence
The profound effects of trauma and violence are underacknowledged. Violence and trauma shape a person’s belief system, feelings, and self-perception. Herman and van der Kolk describe how trauma takes a toll on a person’s body, on mental and emotional responses, on relationships with others, and on society. Repeated violence and violence at the hands of a known perpetrator often have a stronger impact than a one-time occurrence. Van der Kolk, Diana Russell, a psychologist, and others have found that those who have been traumatized are at a higher risk of future victimization because of the psychobiological failures of natural protective mechanisms associated with the trauma response.
Effects on Relationships
Trauma and victimization disrupt critical attachments, especially when the perpetrators are trusted intimate family members or close friends. When individuals have been abused by someone they know, they may find it difficult to believe in the reality of the betrayal, and it may lead to a loss of trust in others. Traumatic experiences that occur at critical developmental junctures interfere with normal developmental processes and produce pervasive mistrust, decreased autonomy, and a debilitating fear that is not easily reversed. The lack of trust engendered by traumatic abuse is protective within the context of the abusive experience because it shields victims from developing expectations that others will protect and care for them. This protection, however, undermines their ability to form trusting relationships that might make a positive difference in their lives, which sometimes impedes the process of seeking help.
Mental and Emotional Responses
The mental and emotional effects of trauma on an individual are determined in part by the individual’s age, the nature and duration of the violence or trauma, the individual’s relationship to the perpetrator, and the response and availability of supports. Trauma arrests the normal course of development and has its most profound effect in the first decade of life. Herman points out that repeated trauma and violence in childhood both forms and deforms the personality, while repeated trauma in adulthood erodes the structure of the personality that has already been formed.
Chronic exposure to abuse and violence affects the normal integration of cognitive and emotional functions. This disruption in normal integrative processes has profound effects on an individual’s ability to interact with others, to cope with stresses, and to manage the demands of everyday life. For homeless people who are struggling to regain some stability in their lives, this can be catastrophic. Van der Kolk reports that chronic exposure to violent or traumatic experiences permanently alters an individual’s adaptive capacity and rigidifies certain mental processes.
A range of mental health issues can result from trauma and victimization. These include posttraumatic stress disorder (PTSD), anxiety, panic disorder, major depression, substance abuse and dependence, somatization, psychotic disorders, eating disorders, or any combination of these problems.
Psychobiological reactions generated by trauma and violence can easily overwhelm an individual’s capacity to bear feelings and to regulate affect. Emotions no longer alert individuals to possible danger— they immediately trigger a “fight or flight” response. When this happens, an individual may resort to seemingly inappropriate strategies to manage overwhelming feelings—strategies that may have helped and been adaptive during the traumatic event itself, but that now function maladaptively.
Posttraumatic Stress Disorder (PTSD)
Women, men, and children react to violence and abuse in complex ways. The trauma response involves both biological and psychological mechanisms that interact to produce an array of bio-behavioral changes in the individual. The effect of violence on a particular individual varies according to the extent, nature, and timing of the experience. Differences may be due to the developmental stage at the onset of the traumatic experience, the relationship between the perpetrator and the survivor, the frequency and duration of the abuse, the severity of the force used and the harm inflicted, the nature of the response by others to the traumatized individual, and the individual’s temperament and coping style.
Victims of physical or sexual abuse, domestic violence, and other traumas frequently develop PTSD. Dissociation is a hallmark of PTSD and helps survivors manage intense, overwhelming feelings. PTSD is also characterized by intrusive remembering (nightmares, flashbacks, or physiological reactivity), avoidance (emotional constriction, detachment, or difficulty remembering), and hyperarousal (disrupted sleep, poor concentration, or hypervigilance). Periods of agitation may alternate with emotional numbness. When victims dissociate at the moment of the traumatic event, they are more likely to develop PTSD. In contrast, those exposed to extreme stress may develop intrusive symptoms but not the dissociation, avoidance, and hyperarousal characteristic of trauma and PTSD.
The bio-behavioral changes related to PTSD may have serious health and mental health effects. People with PTSD suffer disproportionately from chronic medical conditions and nonspecific somatic complaints. They organize their lives around the trauma, seeking to avoid the intrusive and distressing recollections of the original abuse. Physiological arousal may trigger trauma-related memories, just as the memories may activate the physiological responses associated with the trauma.
Trauma produces psycho-biological changes in the individual and the resulting “physioneurosis” is ever present. The body has a lower threshold for stimulation and it experiences enduring hypersensitivity to physical stimuli—for example, touch and sound. Van der Kolk, his colleagues, and others report that bodies express what they cannot verbalize, that is, the “body keeps the score” of traumatic insults. Memories of the trauma are stored in the deepest, most inaccessible parts of the brain. Since survivors often cannot speak directly about the full effects of their traumatic experiences, their memories are often experienced as body pains, intense emotions or images, or as reenactments of the trauma.
“Body memories” often occur in the injured parts of the body (for example, the genitals and the stomach). In addition, traumatic memories can be transformed into physical symptoms not easily recognized as indicative of trauma or abuse. These include chronic pain, gynecological difficulties (in women), gastrointestinal problems, asthma, heart palpitations, headaches, and musculoskeletal problems. Chronic danger and anticipation of violence stress the immune and other bodily systems, leading to increased susceptibility to illness. Bassuk and others have found, not surprisingly, that trauma survivors report high rates of body pains and various medical conditions. Trauma survivors may also cope with overwhelming emotions by “somatizing” their feelings, expressing them as physical ailments or somatic complaints that are more easily described than overwhelming feelings.
A sense of helplessness and hopelessness is often a consequence of a traumatizing event. The erosion of the ability to trust and the sense that nothing can be done severely impede the use of services by homeless victims of violence. Overall, homeless persons’ use of services is low relative to their need, and this is especially true for those who have experienced trauma or violence. PTSD affects service use because providers may be viewed as untrustworthy and neither safe nor understanding. Early abuse and betrayal are related to a heightened negative perception of providers, fear, and a reluctance to enter into a relationship with a service provider who may not understand the individual’s experiences.
The lack of stable, affordable housing further reduces the accessibility of services, and the lack of coordination and integration among agencies that provide homeless services presents an additional barrier to access. The burden of integrating care may fall on the homeless person, and homeless people who have experienced trauma may not be able to summon sufficient organizing capacities to obtain proper care—especially in a system that is already extremely fragmented.
Access to appropriate services is often limited, and the services traumatized individuals may access may not be responsive to the impact of violence and victimization on their emotional, physical, and mental well-being.
Trauma-Informed and Trauma-Specific Services
Unfortunately, many service providers who have contact with homeless people do not recognize or understand the multiple complex and insidious impacts of violence. Trauma symptoms may not be readily apparent or may be misunderstood when masked by seemingly unrelated behavior or physical conditions. Standard approaches to medical and mental health problems may be retraumatizing to those who have experienced violence or trauma. This may compromise their recovery. Only recently have providers begun to understand that violence is normative in the lives of homeless people and that its effects are generally long-term and debilitating.
Trauma-informed services are based on an empowerment model that emphasizes the importance of reducing the power differential between client and provider. Negotiated, collaborative, respectful relationships of providers with clients minimize the possibility of revictimization within the service context. Implementing trauma-informed services requires a fundamental change in agency structure, culture, and practice. It requires an administrative commitment to developing standardized policies and procedures that facilitate recovery. Trauma-informed services and programs utilize staff who are well versed in the dynamics of trauma. Safety is a major priority and interventions are aimed at supporting client strengths.
Trauma-specific services consist of therapeutic interventions that directly and specifically target the effects of trauma. Although effective models of trauma-specific care have been developed, they are often not available in shelters and other service settings that assist homeless people. Trauma-specific services are often available only through referral to professionals who have been specifically trained in the methods. These services include Eye Movement Desensitization and Reprocessing (EMDR), hypnosis, and relational psychotherapy. Short-term psychoeducational group models have also been developed to provide trauma-specific treatment in structured settings. These groups have a clearly defined beginning and end and are oriented toward understanding the dynamics of trauma and PTSD, identifying and managing triggers, and developing coping strategies.
Effective group models include the Trauma Recovery and Empowerment Model (TREM), the Atrium model, and Seeking Safety.
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