# Presentation: 242085

## Trauma and Abuse in the Lives of Homeless Women and Men

-   Community Connections 2002

## Scope of the ProblemPrevalence Data

- Childhood sexual abuse

-  70% of non-psychotic women
-  55-63% of female psychiatric inpatients
-  40% of female outpatients
-  41% of HIV+ women

## Scope of the ProblemPrevalence Data (2)

- Lifetime exposure to sexual or physical violence

-  43-81% of patients diagnosed with serious mental illness
-  55-99% of substance addicted women
-  33% of women detainees
-  97% of homeless dually diagnosed women

## Scope of the ProblemPrevalence Data (3)

- Violence in the lives of Homeless Women

-  63% violently abused by an intimate partner
-  27% required medical attention due to injury caused by violence
-  25% physically or sexually assaulted during adulthood by non-intimate partner
-  66% violently abused by childhood caretaker or other adult in household
-  43% sexually molested as children

## Scope of the ProblemPrevalence Data (4)

**Sexual Abuse Among Men**

-  4 – 76% (differences based on population sampled and
-    definition used)
-  38% of male runaways
-  70% of rapists
-  Almost 100% of male/boy prostitutes
-  91% of males wait until adulthood to disclose

**Physical Abuse Among Men**

-  1/3 of males vs. 1/5 of females

## Trauma Philosophy

- Current problematic behaviors and symptoms may have originated as legitimate and even courageous attempts to cope with or defend against trauma.

## Symptoms are Adaptations

**People are adaptive. A trauma model frames survivors symptoms as adaptations, rather than as pathology.**
**Every symptom helped a survivor in the past and continues to help in the present – in some way.**
**An adaptation model emphasizes resiliency in human responses to stress.  It helps survivors recognize their own strengths and inner resources, rather than defining themselves by weakness and failure.**

## Behaviors and Symptoms Associated with Trauma

- Layers of clothes
- Hypervigilence
- Anonymity of large shelters
- Fear of shelters
- Not bathing
- Not willing to seek medical of dental attention

## Behaviors and Symptoms Associated with Trauma (2)

- Aggressiveness
- Not taking medications
- Use of drugs and alcohol
- Participation in the sex trade
- Self-destructive behavior
- Suicidality

## “Service As Usual”

- Treatment Tracks
**Sequential Treatment**
**Parallel Treatment**
**Integrated Treatment**

## Sequential Treatment

- Substance abuse and/or mental health treatment is initiated and well underway BEFORE trauma treatment begins
- detoxification, inpatient treatment programs
- residential programs
- day hospital and out patient programs
- AA/NA
- psychiatric medications

## Sequential Treatment (2)

**Assumptions**
- mental health and/or addiction problems are primary and must be addressed before trauma treatment can begin
- a clear, rational mind is a prerequisite for trauma treatment
**Disadvantages**
- trauma issues, if unrecognized, may be mislabeled as Axis II/character pathology and used to shame or stigmatize women
- trauma symptoms may emerge as a result of the removal of drugs and alcohol, and those symptoms may serve to trigger a relapse

## Parallel Treatment

- Substance abuse, mental health, and trauma treatment proceed concurrently but separately.  Separate providers or independent peer networks deliver services.

## Parallel Treatment (2)

- Assumptions
- trauma, mental health, and substance abuse are separate problems, requiring separate treatments
- Disadvantages
- a lack of coordination between providers
- conflicting messages delivered by different providers or peer supports
- trauma providers may support the use of prn medication for anxiety, while peers from an addictions network may urge total abstinence

## Integrated Treatment

- Trauma, addictions, and mental health problems, when they co-occur in a single individual, are addressed by a single system and at least in part by a single, unified intervention

## Integrated Treatment (2)

**Assumptions**
- the problems of trauma, substance abuse, and mental health interact complexly and casually within a single individual
- approaches to recovery must be whole person approaches
- value is placed on individual, family, and community empowerment
**Disadvantages**
- program costs
- need for specially trained staff
- availability of separate programs for women survivors

## An Integrated Treatment Approach

- Integrative Explanations
- Content Modules
- Cross-over Skills
- Program Milieu
- Ancillary Services
- Contraindicated Approaches

## Integrative Explanations

- Primary trauma is a stressor that may trigger substance use and the development of psychiatric symptoms
- Trauma sequelae (flashbacks, nightmares) are stressors that may trigger substance use. These sequelae may also result in a psychiatric diagnosis
- Substance use and certain psychiatric symptoms may have evolved as coping strategies at a time when options were limited

## Content Modules

- Drug and alcohol education
- How to recognize sexual, physical, emotional and institutional abuse
- Domestic violence
- Relapse prevention
- Parenting skills

## Cross-over Skills

- Interpersonal skills
- self knowledge
- self soothing
- self regulation
- self esteem
- self trust
- expression of needs and desires
- clear communication
- limit setting
- accurate perception of others and honest labeling
- establishment of safe boundaries
- mutuality and reciprocity

## Program Milieu

- Empowerment and strengths-based
- Relationship focused
- Nurturing peer environment
- Availability of female staff to provide services and to serve as role models
- Availability of same sexed groups

## Ancillary Services

- Health care
- HIV education and treatment
- Vocational/educational assessment and assistance with placement
- Housing opportunities and residential services
- Child care and services for children

## Contraindicated Approaches

- Shaming techniques
- Intrusive monitoring
- Excessive confrontation
- Stripping away all defenses in order to make a women more vulnerable
- Moral inventories that encourage survivors to assume more than their share of responsibility for past abuses

## Contraindicated Approaches (2)

- Exclusive emphasis on surrender to a higher power with no recognition of personal power
- Premature self-disclosure
- Forced treatment

## Trauma Screening & Assessment

- The interviewer:

-  Should have skills in general assessment/interviewing and should have specific training in trauma concerns
-  Should be someone who has, or will have, an ongoing relationship with the consumer/survivor
-  Should pay attention to the overall assessment process and avoid repeating violence and trauma- related questions that have already been answered

## Trauma Screening & Assessment (2)

- Timing

-  Use as early as possible in the intake and assessment process
-  Ask these questions earlier rather than later in the day in order to have time for following up on the consumer’s responses
-  Repeat the questionnaire periodically in the event of a negative screen

## Trauma Screening & Assessment (3)

- Suggestions for Agencies:

-  Provide training for staff who will use the screening instrument
- Identify specific staff members who will be involved in the screening
-  Identify the timing of the screening in the overall intake and assessment process
-  Specify time guidelines for repeating the screening

## Trauma Screening & Assessment (4)

- Maximizing Consumer/Survivor Choice and Control

-  If consumers become uncomfortable during the screening, they should be given the option of continuing when they feel more comfortable
-  The choice of self-administering the questionnaire should be offered for consumers who feel uncomfortable with one-on-one interviews

## Trauma Screening & Assessment (5)

- Ending the Interview: Referral and Planning

- If the consumer reports no history of abuse or violence on the screening

-  thank the consumer for responding to the questions
-  let consumers know they are welcome to return at any time to discuss violence, trauma, or related issues

## Trauma Screening & Assessment (6)

- If the consumer answers yes to any of the questions:

-  assess current danger
-  establish procedure for safety planning
-  establish procedure for providing necessary and appropriate support, including crisis intervention options
-  have resources available for referral
-  match the referral to the specific and immediate needs and preferences of the consumer/survivor

## D.C. Trauma Collaboration StudyViolence and Trauma Screening

**1. At any time in your life, have you witnessed someone seriously injured or killed due to an unnatural event such as a shooting,stabbing, or hit–and-run accident?**
**2. At any time in your life have you witnessed a physical or sexual assault against a family member, friend, or other significant person?**
**3. At any time in your life, touched**
** ****you sexually when you did not **
**want them to?**

- _Lifetime_        _Past 12 Months_

## D.C. Trauma Collaboration StudyViolence and Trauma Screening (2)

**4. At any time in your life, has **
**anyone forced you to have sex **
**when you did not want to?**
**5. At any time in your life, has**
** ****anyone slapped, pushed, grabbed,or shoved you?**
**6. At any time in your life, has**
** ****anyone choked, kicked, bit, or**
** ****punched you? **

- _Lifetime_        _Past 12 Months_

## D.C. Trauma Collaboration StudyViolence and Trauma Screening (3)

**7. At any time in you life, has **
**anyone threatened you with, or**
**actually used, a knife gun or other**
**weapon to scare or hurt you?**
**8. At any time in your life, have**
** ****you been afraid that a specific**
** ****person (whether it was someone**
** ****you knew well or not) would hurt**
** ****you physically?**

- _Lifetime_        _Past 12 Months_

## An Introduction to Trauma Issues for Women on Inpatient or Short-Stay Units

-     Community Connections 2001

## Session 1  An Introduction to Trauma & Psychiatric  Symptoms

**Session Rationale:** Often women are unclear about the relevance of discussing trauma issues.  If a woman has been hospitalized for depression, anxiety or substance use, she may not see the connection between those symptoms and behaviors and a history of abuse. By using readily accessible prevalence data, leaders begin to draw connections between abuse and current symptomatic behaviors.

## Session 2   Coping with Feelings of Being Out of Control

**Session Rationale**: Hospitalizations are often initiated when a woman feels out of control. Being unable to manage your own responses can be terrifying in general and for a trauma survivor can be reminiscent of experiences of abuse. Powerful feelings are one of the on-going aftermaths of having been traumatized.   Women may find that such overwhelming feelings leave them frightened and confused.  Not knowing where the feelings come from or having a plan for how to manage them can make matters worse.

## Session 3  Self-Soothing

**Session Rationale**: The need to gain comfort and to self-soothe is a universal human need; yet many survivors of trauma find themselves unable to utilize healthy soothing strategies.
- Often survivors have had to rely on strategies that may bring comfort, but that have great down-side risk, drugs and alcohol being prime examples.  Learning to first identify and then make use of strategies for gaining comfort is an important step in the recovery process.

## Session 4  Where Do You Go from Here?

**Session Rationale**: An introduction to trauma issues is just that---an introduction.  Leaders and group members should be clear that the four introductory sessions are not a substitute for more in depth recovery work. Some women may decide that they are not ready to go forward and that decision should always be respected.  Others, however, will feel intrigued and validated by the trauma-first perspective and will want to do more work.  The question for each woman is “What approach would be best for me?”  Since so many trauma survivors learn not to trust their own judgments, answering that question might be difficult. Consequently, survivors need a set of categories they can use to help make the decision about their future recovery work.