Cenfdthy

80 The Open Health Services and Policy Journal, 2010, 3, 80-100
Open Access
Shelter from the Storm: Trauma-Informed Care in Homelessness Services
Settings
Elizabeth K. Hopper*,1, Ellen L. Bassuk2,3, and Jeffrey Olivet4
1
The Trauma Center at JRI 1269 Beacon Street Brookline, MA 02446, USA
2
The National Center on Family Homelessness, 181 Wells Avenue, Newton, MA 02459, USA
3
Department of Psychiatry, Harvard Medical School, USA
4
Centre 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. Although 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 definition 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; domestic violence; accidents; and disasters. Trauma

is widespread and affects people of every gender, age, race,
Trauma-Informed Care: A Paradigm Shift for Homeless sexual orientation, and background within homeless service
Services settings.
“Homelessness deprives individuals of…basic Early developmental trauma—including child abuse,
needs, exposing them to risky, unpredictable neglect, and disrupted attachment—provides a subtext for
environments. In short, homelessness is more the narrative of many people’s pathways to homelessness
than the absence of physical shelter, it is a [2]. Violence continues into adulthood for many people, with
stress-filled, dehumanizing, dangerous circums- abuse such as domestic violence often precipitating
tance in which individuals are at high risk of homelessness [3-5], and with homelessness leaving people
being witness to or victims of a wide range of vulnerable to further victimization. The impact of traumatic
violent events” [1]. stress often makes it difficult for people experiencing
Homelessness is a traumatic experience. Individuals and homelessness to cope with the innumerable obstacles they
families experiencing homelessness are under constant face in the process of exiting homelessness [6], and the
stress, unsure of whether they will be able to sleep in a safe victimization associated with repeated episodes of
environment or obtain a decent meal. They often lack a homelessness. Research has found that people who
stable home and also the financial resources, life skills, and experienced repeated homelessness were more likely than
social supports to change their circumstances. In addition to people with a single episode of homelessness to have been
the experience of being homeless, an overwhelming abused, often during childhood [6].
percentage of homeless individuals, families, and children Trauma refers to an experience that creates a sense of
have been exposed to additional forms of trauma, including: fear, helplessness, or horror, and overwhelms a person’s
neglect, psychological abuse, physical abuse, and sexual abuse resources for coping. The impact of traumatic stress can be
during childhood; community violence; combat-related 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
*Address correspondence to this author at the Trauma Center at JRI 1269,
Beacon Street Brookline, MA 02446, USA; Tel: (617) 232-1303, Ext.
relationships. Some people have minimal symptoms after
211; E-mail: [email protected] trauma exposure or recover quickly, while others may
1874-9240/10 2010 Bentham Open

Trauma-Informed Care in Homelessness The Open Health Services and Policy Journal, 2010, Volume 3 81
develop more significant and longer-lasting problems such • Describe models and case examples of what is being
as Posttraumatic Stress Disorder (PTSD) and Complex done in the field to implement TIC within homeless
Trauma. service settings
Trauma reactions are not the only psychiatric issue facing We conclude by summarizing implications of our current
people who are homeless; many people experiencing state of knowledge for practice, programming, policy, and
homelessness also suffer from depression, substance abuse [7- research and by highlighting next steps for developing
10], and severe mental illness [8, 10]. These issues leave evidence-based, trauma-informed homeless services.
individuals even more vulnerable to revictimization [11],
interfere with their ability to work, impair their social networks What is Trauma-Informed Care (TIC)?
[8], and further complicate their service needs. What is meant by TIC? Although there is agreement that
These findings suggest that we will be unable to solve the “trauma-informed” refers generally to a philosophical/ cultural
issue of homelessness without addressing the underlying trauma stance that integrates awareness and understanding of trauma,
that is so intricately interwoven with the experience of there is no consensus on a definition that clearly explains the
homelessness. Those working in homeless services have the nature of TIC.
opportunity to reach many trauma survivors who are otherwise TIC supports the delivery of Trauma-Specific Services
overlooked. Providers in these settings address the immediate (TSS). TSS refers to interventions that are designed to directly
crisis by offering food, shelter, and clothing; but they can also address the impact of trauma, with the goals of decreasing
contribute to longer-lasting changes by helping an individual or symptoms and facilitating recovery. TSS differs from TIC, in
family develop supportive connections in the community and that TSS are specific treatments for mental disorders resulting
begin to heal from past traumas. Despite this fact, few programs from trauma exposure, while TIC is an overarching framework
serving homeless individuals and families directly address the that emphasizes the impact of trauma and that guides the
specialized needs of trauma survivors. Homeless services have a general organization and behavior of an entire system. TSS may
long history of serving trauma survivors, without being aware be offered within a trauma-informed program or as stand-alone
of or addressing the impact of traumatic stress [12]. services [12].
Overwhelmed by the daily needs of their clients, providers in
Based on the literature review, we summarized the basic
these settings often have few resources to address issues of
principles of TIC proposed by various workgroups,
long-term recovery.
organizations, expert panels, and researchers. (see Table 1).
With increasing recognition of the pervasiveness of Each of these sources posited a unique definition of TIC. We
traumatic stress among people experiencing homelessness, identified and highlighted common cross-cutting themes and
awareness is growing of the importance of creating Trauma- then synthesized them into a single definition. Themes include:
Informed Care within homeless services settings. Trauma-
• Trauma awareness: Trauma-informed service
Informed Care (TIC) involves “understanding, anticipating, and
responding to the issues, expectations, and special needs that a providers incorporate an understanding of trauma into
their work. This may involve altering staff perspectives,
person who has been victimized may have in a particular setting
with providers understanding how various symptoms
or service. At a minimum, trauma-informed services endeavor
and behaviors represent adaptations to traumatic
to do no harm—to avoid retraumatizing or blaming [clients] for
experiences. Staff training, consultation, and supervision
their efforts to manage their traumatic reactions” [13].
are important aspects of organizational change towards
Implementing TIC requires a philosophical and cultural shift
within an agency, with an organizational commitment to TIC and organizational practices should be modified to
incorporate awareness of the potentially devastating
understanding traumatic stress and to developing strategies for
impact of trauma. For example, agencies may implement
responding to the complex needs of survivors.
routine screening for histories of traumatic exposure,
Despite its importance, the implementation of TIC within may conduct routine assessments of safety, and may
homelessness service settings is still in its infancy. Currently, develop strategies for increasing access to trauma-
the nature of TIC remains ill-defined. Strategies for specific services. Dealing with vicarious trauma and
implementation are obscure, few program models exist, and self-care is also an essential ingredient of trauma-
there is limited communication and collaboration among informed services. Many providers have experienced
programs implementing TIC. The descriptive and research trauma themselves and may be triggered by client
literature in this area is sparse, with only a handful of studies responses and behaviors.
examining the nature and impact of TIC. More clarification is
needed about what exactly defines TIC, what changes should be • Emphasis on safety: Because trauma survivors often
feel unsafe and may actually be in danger (e.g., victims
made within systems wishing to offer TIC, and how these
of domestic violence), TIC works towards building
changes should be implemented.
physical and emotional safety for consumers and
The purpose of this paper is to review the evidence base that providers. Precautions should be taken to ensure the
supports the use of TIC for individuals and families physical safety of all residents. In addition, the
experiencing homelessness. In this review, we have attempted organization should be aware of potential triggers for
to: consumers and strive to avoid retraumatization. Because
• Establish a consensus-based definition of TIC interpersonal trauma often involves boundary violations
and abuse of power, systems that are aware of trauma
• Discuss what is known about TIC based on our literature dynamics should establish clear roles and boundaries
review that are an outgrowth of collaborative decision-making.
82 The Open Health Services and Policy Journal, 2010, Volume 3 Hopper et al.
Privacy, confidentiality, and mutual respect are also literature (e.g., program evaluations and unpublished pilot
important aspects of developing an emotionally safe studies).
atmosphere. Additionally, cultural differences and
The literature on TIC is significantly greater in mental health
diversity (e.g., gender, ethnicity, sexual orientation) must
and substance use fields than within the homelessness field.
be addressed and respected within trauma-informed Thus, we also reviewed the current evidence base for trauma-
settings.
informed practices in these areas since there is a large overlap in
• Opportunities to rebuild control: Because control is the difficulties faced by many individuals with mental
often taken away in traumatic situations, and because health/substance use issues and those in homeless service
homelessness itself is disempowering, trauma- settings. In fact, in the Women, Co-Occurring Disorders, and
informed homeless services emphasize the Violence Study (WCDVS), a large multi-site study examining
importance of choice for consumers. They create trauma-informed services for women with co-occurring
predictable environments that allow consumers to re- disorders and trauma exposure, 70.4% of participants had been
build a sense of efficacy and personal control over homeless at some point in their lives [16]. We reviewed
their lives. This includes involving consumers in the evidence for trauma-informed services within all these settings,
design and evaluation of services. applying this broader knowledge base to our understanding of
• Strengths-based approach: Finally, TIC is TIC within homeless service settings.
strengths-based, rather than deficit-oriented. These We conducted our literature review by searching two
service settings assist consumers to identify their own databases, PsycInfo and Medline (PubMed), for peer-reviewed
strengths and develop coping skills. TIC service articles published in major journals. In addition, we used the
settings are focused on the future and utilize skills- Google search engine to locate web-based literature and
building to further develop resiliency. program information. Our search terms included: homeless,
homelessness, housing, shelters, trauma, trauma-informed,
These principles form a standard for programs wishing to
PTSD, services, abuse, violence, domestic violence,
develop TIC within homeless service settings. Based on
psychological, substance use, and mental health. We also
these combined principles, we developed a consensus-based
completed more specialized searches on unique populations
definition of TIC:
(using search terms such as youth, men, ethnicity, veterans),
Consensus-Based Definition authors of note (e.g., Harris, Fallot, Bassuk, and van der Kolk),
models (e.g., Attachment, Self-Regulation and Competency
“Trauma-Informed Care is a strengths-based
[ARC] and Sanctuary), programs (e.g., Community
framework that is grounded in an understanding of
Connections, the STAR program, and the Community Trauma
and responsiveness to the impact of trauma, that
Treatment Center for Runaway and Homeless Youth), and
emphasizes physical, psychological, and emotional
research studies (e.g., the Women, Co-Occurring Disorders, and
safety for both providers and survivors, and that
creates opportunities for survivors to rebuild a
Violence Study).
sense of control and empowerment.” In addition to reviewing the literature, we contacted various
programs directly, by telephone or email, including: the Natio-
Trauma-informed approaches are designed to respond to
nal Center on Family Homelessness (Moses, Guarino); Home-
the impact of trauma. The principles described above target
lessness Resource Center (Olivet); Community Connections
the specialized needs of trauma survivors and describe how
services can be delivered through the lens of trauma. (Fallot); the Institute for Health and Recovery (Markoff &
Dargon-Hart); CT State Department of Mental Health and
METHODS Addiction Services (Leal); the Domestic Violence & Mental
Health Policy Initiative (Brashler, Hall); the Community
This paper reviews the evidence base supporting the
Trauma Treatment Center for Runaway and Homeless Youth
effectiveness of TIC for people experiencing homelessness. To
(Schneir); the Trauma Center at JRI/ Youth on Fire, developers
date, most determinations of what constitutes evidence-based
of Phoenix Rising (Spinazzola); Kinniburgh and Blaustein,
practice have relied on outcome-based quantitative research. developers of ARC; Cincinnati Children's Hospital Medical
However, this approach neglects qualitative analyses that
Center, developers of CARE (Pearl); University of Connecticut
examine the nature and process of the intervention, as well as a
Department of Psychology and the CT Department of Mental
wealth of information that reflects what is occurring in practice.
Health and Addiction Services Research Division (Marra). Many
In fact, corroborative evidence, including clinical wisdom about
of these programs sent unpublished program evaluation reports,
“what works,” is often the starting point for developing both
manuals, or self-assessment tools, for inclusion in this review.
qualitative and quantitative studies. In the homelessness field,
corroborative evidence may be the primary body of knowledge RESULTS
we have about a particular intervention.
Organizational Needs Assessments: Do We Need
For this review, we utilized a comprehensive framework Trauma-Informed Care?
that was developed by the Homelessness Resource Center
(HRC) for assessing the level of evidence of an emerging, Needs assessments can be used to identify needs and to
promising or best practice [15]. The goal of this framework is detect gaps in service within a system. We began by
not to decide whether a practice qualifies as evidence-based, but reviewing results of needs assessments conducted by several
rather to synthesize all that we currently know about the agencies regarding the relevance of trauma within their
intervention. Thus, our review included peer-reviewed service system and the need for TIC. These needs
quantitative and qualitative studies, as well as corroborative
Table 1. Principles of Trauma-Informed Care
Example Definitions of Trauma-Informed Care
NCFH***: WCDVS****:
Operating Trauma-Informed
Community
NASMHPD*: Criteria NCTSN**: Principles for or Trauma-
Connections: Five
Common Principles Across for Building a Trauma- Principles of Trauma- Denied: Principles
Guiding Principles for
Definitions Informed Mental Trauma-Informed Informed & Implementation
Trauma-Informed
Health Service System Care for Children Organizational of Trauma-
Services [12]
Self- Informed Services
Assessment for Women [14].
Consensus-Based Principles
Theory-Based Expert Trauma Panel Experts Theory-Based Research-based
Across Definitions
Trauma function/ focus,

trauma policy or
position, financing for
Trauma
best practices, trauma-
awareness;
informed services,
basic
clinical practice
understanding
guidelines for people
of trauma & Recognize the
a. Program with trauma histories,
1. Trauma triggers; impact of trauma on
philosophy and trauma-informed disaster
Awareness includes staff development and
mission planning, systems
training & coping
integration, research &
supervision,
data on trauma &
educating
evidence-based & best-
consumers
practice treatment
about trauma
models, access to
evidence-based & best-
practice trauma treatment
Workforce orientation,
training, support,
b. Staff
competencies and job Emphasize trauma
education,
standards related to recovery as a
training, and
trauma; promote primary goal
consultation
education of
professionals in trauma
Integration
Trauma screening and (symptoms
assessment; Trauma- such as
specific services, adaptive
c. Practices including evidence-based coping,
and emerging best- integrating
practice treatment services,
models trauma-specific
services)
d. Recognition of
vicarious trauma
and staff self-
care
Safety, basic
Create an
Maintaining clear needs,
a. Physical and Safety (physical and atmosphere of
2. Safety and consistent consistency,
emotional safety emotional) safety, respect, and
boundaries and
acceptance
predictability
Engagement: Utilize a relational

b. Relationships: Trustworthiness (clear respectful collaboration model.
authentic, tasks, consistent [see Delivering nonjudgmental Growth is fostered
respectful, clear practices, staff-consumer services below] relationships, by mutual,
boundaries boundaries) clear respectful, authentic
boundaries relationships
Procedures avoid
c. Avoid Minimize
retraumatization and
retraumatization retraumatization
reduce impacts of trauma
(Table 1) contd…..
Example Definitions of Trauma-Informed Care
NCFH***: WCDVS****:
Operating Trauma-Informed
Community Connections: NASMHPD*: Criteria NCTSN**: Principles for or Trauma-
Common Principles Across Five Guiding Principles for Building a Trauma- Principles of Trauma- Denied: Principles
Definitions for Trauma-Informed Informed Mental Trauma-Informed Informed & Implementation
Services [12] Health Service System Care for Children Organizational of Trauma-
Self- Informed Services
Assessment for Women [14].
Consensus-Based Principles
Theory-Based Expert Trauma Panel Experts Theory-Based Research-based
Across Definitions
Trauma policies and

services that respect
Delivering services Work towards
d. Acceptance culture, race, ethnicity,
in a nonjudgmental Cultural cultural competence,
of and respect gender, age, sexual
and respectful competence understand
for diversity orientation, disability,
manner contextual factors
and socio-economic
status
Consumer/Trauma Underscore
Choice: maximize Maximizing choice Consumer
3. Choice & a. Choice and Survivor/ Recovering consumers’ choice
consumer choice and and control for control, choice
Empowerment control person involvement and and control over
control participants and autonomy
trauma-informed rights recovery
Open
communication:
b. Empowerment: prioritize Avoiding Use an
provide
Empowermen consumer empowerment, provocation and empowerment
information
t model skill-building, and growth power assertion model
openly to
consumers
c. Consumers
involved in Collaboration: maximize Involve consumers
Sharing power in
service collaboration and sharing Shared power in design and
the running of
development of power between staff and and governance evaluation of
shelter activities
and consumers services
evaluation
Highlight
Focus on consumers’
4. Strengths- Healing,
strengths, [see Empowerment above] strengths,
based instilling hope
resiliency 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.
assessments were generally designed as a first step, prior to recovery, or how services might help or retraumatize
initiating a more formal organizational self-assessment or to survivors [19].
beginning programmatic shifts. Several findings emerged
• Many providers do not have systematic ways of
from a review of these needs assessments:
assessing for trauma-related issues. In a study
• Providers feel that they need to be better informed examining PTSD screening and referral practices in VA
about trauma and violence [17, 18]. Directors and staff addiction treatment programs, they found that although
within state domestic violence coalitions reported that one-half to two-thirds of clinicians did routinely screen
many shelters are unprepared to deal with the complex for trauma exposure and posttraumatic stress symptoms,
needs of the women they serve, many of whom have assessments were generally not conducted system-
few resources and have been victimized as children and atically and did not utilize validated measures [20].
as adults. Domestic violence advocates reported an
• Consumers want services that are empowering.
increasing awareness of the need for services appropriate
Qualitative research has suggested that homeless
for women with mental health issues, substance abuse
individuals and families need and want trauma-informed
problems, and histories of abuse. They also expressed a
services, including desire for autonomy, prevention of
need for guidance and resources in improving their
further victimization, and assistance in restoring their
responses to survivors of domestic violence who have devalued sense of identity [21]. A provider guidebook,
experienced multiple abuses throughout their lives [18].
written from a consumer perspective, notes the need
A multi-site program implementing trauma-informed
for accessible and effective programs for trauma
services found that prior to implementation, sites had
survivors [22].
little knowledge about trauma, how to facilitate
• Mental health services are an important need for • Because of these concerns, taking the time to build
many homeless families and individuals. In a multi- “buy-in” is particularly important. Recognizing the
site research study on trauma-informed services for importance of commitment in organizations, some
homeless families, researchers examined current service programs have developed committee structures
needs, including families’ need for social capital geared towards obtaining “buy-in” from
(educational or employment-related interventions), administration, program staff, and consumers.
physical health, and mental health/substance use Building strong relationships also aided buy-in and
treatment. Among the families, they found that “mental integration of services [19]. After building agency-
health needs were the most prevalent of all the wide commitment, programs have found strong
intervention needs components across sites (62%),” with support from staff members for implementing a
many facing multiple challenges, signaling the need for trauma-informed model [25].
comprehensive intervention [23].
• Consumers want providers who are empathic and
The results of these needs assessments supported the central caring, who provide validation, and who offer
importance of dealing with trauma within homelessness service emotional safety—characteristics of trauma-
settings and the perceived need for TIC. informed providers. Consumers have emphasized
the benefits of working with trauma-informed
Trauma-Informed Care within Homelessness Services providers. Some have suggested that programs could
Settings: Attitudes, Implementation, and Outcomes
benefit from having more trauma services, that
Once the perceived need for trauma services is established, practitioners need to remain patient, and that
we can begin to explore the development of a TIC framework consumers themselves need to be invested in actively
within homelessness service settings. We reviewed available addressing their own issues [26]. However, even
quantitative, qualitative, and corroborative evidence regarding within trauma-informed systems, consumers
trauma-informed services. sometimes struggle to feel empowered within a larger
service system [27].
Prochaska’s stages of change model [24] highlights the fact
that change is a process for individuals, who progress through 2. Implementation
precontemplation, contemplation, action, and maintenance of • Training is central to implementing TIC. The
change. Similarly, systems change is a multi-step process. Our majority of programs working to build TIC utilized
review of the literature highlighted three areas of evidence: staff training to increase awareness of and sensitivity
attitudes, implementation, and outcomes. “Attitudes” refers to to trauma-related issues. A large multi-site study of
the beliefs of consumers and providers (at all levels, from trauma-informed models found that “training on
management to front-line workers) of the need for a paradigm trauma for non-trauma providers was the first and
shift, confidence in ability to institute a paradigm shift, and most important step in making services more trauma-
belief that such a shift will lead to positive outcomes. informed” [19].
“Implementation” coincides with Prochaska’s action stage of
change. It is a process variable, and is concerned with how • Ongoing supervision, consultation, and support
changes are made. Implementation requires a clear definition of are needed to reinforce trauma-based concepts.
what is meant by Trauma-Informed Care, in order to translate One lesson from WCDVS was the importance of
these principles into concrete changes that will be instituted ongoing supervision and support to ensure that the
within the system. Finally, “outcomes” refers to the impact of a environment is trauma-informed and that staff
paradigm shift to TIC within homelessness service settings. members practice appropriate self-care. Many
Measurable objectives help to assess the efficacy of systems programs also used external trauma consultants and
change. Outcomes may include measurable quantitative ongoing training to reinforce knowledge and
outcomes, such as a decrease in recidivism in homelessness, or commitment to building trauma-informed services
qualitative outcomes, such as self-esteem or satisfaction with [19].
services. • Assessment and screening are important aspects of
Review of the Evidence: What Do We Know About TIC? trauma-informed services. Research documenting
high prevalence rates of trauma among people
In our review of the evidence for TIC, several salient points experiencing homelessness has led to the conclusion
emerged: that screening for trauma is important within
1. Attitudes homeless service settings [28]. Although providers
have at times expressed concern that inquiring about
• Programs attempting to implement TIC have trauma histories will lead to traumatic stress
encountered some concerns and resistance on the responses, findings indicate that there are few adverse
part of providers. Providers may be afraid that reactions to screening and assessment. Instead, most
addressing trauma will open a “Pandora’s box” of people benefit from this type of assessment [29].
reactions. They may lack confidence in their ability to Several pilot studies show that providers refined their
manage and address trauma reactions and may be intake processes to include screening for trauma
concerned that they will encounter triggers of their own exposure [28, 30]. Additionally, screening and
trauma histories [19]. They may also worry that they assessment tools should be revised and refined with
will not have the resources to adequately respond to the consumer and provider feedback [29].
complex needs of survivors.
• Because homeless individuals often have a impact on the systems involved [19], and that
multitude of service needs, comprehensive and “integral to the… group's personal and professional
integrated services are essential. Studies have found growth was the development and expression of their
that service settings offering integrated counseling— individual and collective voices” [27].
addressing trauma, mental health, and substance use • Cultural competence is important in developing
issues—had better results than settings that were not
TIC. Because trauma may have different meanings in
integrated [31].
different cultures, and because traumatic stress may
• Integrating trauma-informed services for children be expressed differently within different cultural
is also important. Children of parents who are frameworks, it is important for providers within a
dealing with trauma, mental illness, substance abuse, trauma-informed system to work towards developing
and/or homelessness may be at greater risk for cultural and linguistic competence [13].
adverse outcomes. A number of programs working to
3. Outcomes
integrate trauma-informed services have also
highlighted the importance of parallel services for • Trauma-informed service settings, with trauma-
children. In WCDVS, a subset of sites offered specific services available, have better outcomes
specialized children’s programs, including than “treatment as usual” for many symptoms. We
assessment, groups, and resource know from a variety of studies [31, 37] and pilot
coordination/advocacy for children to build coping programs [38] that setting that utilize a trauma-
skills, strengthen interpersonal relationships, and informed model report a decrease in psychiatric
develop positive identity and self-esteem [32]. symptoms and substance use. Some of these programs
have shown an improvement in consumers’ daily
• Many factors challenge implementation of functioning and a decrease in trauma symptoms,
trauma-informed services. Various reports
substance use, and mental health symptoms. These
highlighted the logistical difficulties of systems
findings suggest that integrating services for trau-
change. Change, especially within larger systems, can
matic stress, substance use, and mental health leads to
be time-consuming and requires a great deal of
better outcomes [16].
commitment across all levels of an organization.
Organizational resistance and stress can be a barrier • TIC for children lead to better outcomes, such as
to larger systems change [33]. Moses highlighted better self-esteem, improved relationships, and
challenges to systems change across a number of sites increased safety. A subset of programs within
working to implement integrated, trauma-informed WCDVS examined the impact of a standardized,
services for women with co-occurring disorders. trauma-informed intervention for children, consisting
These challenges included philosophical differences of a clinical assessment, coordination of resources
between mental health and substance use treatment and advocacy, and a psycho-educational skills-
approaches, differences around issues of trauma, building group. One year later, children in the
resistance at the service and administrative levels, intervention group had more positive self-identity,
limited resources, difficulties in achieving consistent increased tools for building healthy relationships, and
participation in trauma groups, staff turnover, and the improved safety. These changes were particularly
difficulty of change in general [13]. striking for children who had witnessed violence [32,
39].
• Implementing a trauma-informed model can lead
to changes in how an organization functions. In a • Early indications suggest that TIC may have a
program implementing a trauma-informed model, positive effect on housing stability. A multi-site
staff reported a number of changes within their study of TIC for homeless families found that, at 18
programs, including increased awareness and months, 88% of participants had either remained in
sensitivity about trauma, intake that incorporates Section 8 housing or moved to permanent housing
questions about trauma, more freedom and choice [23]. An outreach and care coordination program that
given to consumers regarding their treatment, and provided family-focused, integrated, trauma-informed
environmental changes that led to increases in safety, care to homeless mothers in Massachusetts found that
confidentiality, and a more welcoming atmosphere the program led to increased residential stability [38].
[30]. • TIC may lead to a decrease in crisis-based
• Including consumers in developing and evaluating services. Some studies have found decreases in the
trauma-informed services is important. Although use of intensive services such as hospitalization and
there has not yet been research that examines crisis intervention following the implementation of
differences in services that include or do not include trauma-informed care [40].
consumers in program development and evaluation, • Trauma-informed, integrated services are cost-
current wisdom in the field stresses the importance of effective. Because trauma-informed integrated
including consumers in all aspects of programming services have improved outcomes but do not cost
[34, 35]. This wisdom is consistent with theories on more than standard programming, they are judged to
empowerment, which suggest that survivors should be cost-effective [41].
be given agency in effecting their own outcomes [36].
The WCDVS found that integrating consumers into • Qualitative results find that providers report
the design and evaluation of services had a profound positive outcomes in their organizations from
implementing TIC. Providers report greater • We do not know how special populations respond
collaboration with consumers, enhanced skills, and a to trauma-informed homelessness services. Much
greater sense of self-efficacy among consumers, and of the evidence on trauma-informed homelessness
more support from their agencies. Supervisors report systems concerns women and children. We know less
more collaboration within and outside their agencies, about the response of other groups, such as men,
improved staff morale, fewer negative events, and veterans, individuals from ethnic/racial minorities or
more effective services [40]. other cultures, and lesbian, gay, bisexual and
transgendered (LGBT) individuals.
• Qualitative results indicate that consumers
respond well to TIC. Within the D.C. Trauma 3. Outcomes
Collaboration study, consumers reported an increased • We do not know whether differences in outcomes
sense of safety, better collaboration with staff, and a
are based on trauma-informed environments,
more significant “voice.” Eighty-four % of consumers
trauma-specific interventions, or both. Because
rated their overall experience with these trauma-
many service settings that provide TIC also offer
informed services using the highest rating available
trauma-specific services, the extent to which each
[42]. Survey results suggest that consumers were very
component contributes to change is difficult for
satisfied with trauma-informed changes in service research studies to determine.
delivery [25].
• We do not know whether trauma-informed
These results reinforce the need for TIC, assist in further
services are effective specifically within homeless
defining TIC, clarify the process of implementation, and
services. Although the research in other fields
suggest the efficacy of TIC for certain outcomes. However,
suggests that trauma-informed services may be
in our review, we found that various questions were not effective for homeless individuals, there have yet to
addressed by available evidence. These gaps in the available
be any rigorous, quantitative studies exploring
evidence are important in highlighting the additional work
outcomes within homelessness service settings. The
that remains to be done to implement TIC in homelessness
results of the Homeless Families Program, a current
service settings.
multi-site evaluation of trauma-informed
Review of the Evidence: What Do We Not Know About homelessness services, may begin to shed some light
TIC? on this issue.
Our review of the literature highlighted several directions Our review of the current evidence suggests that TIC is
for future exploration: an important area for further exploration. Initial feedback
appears to support the assertion that TIC has a positive
1. Attitudes
impact on both the process and outcome of service provision
• Although providers and consumers alike generally within homelessness service settings. However, the review
pay lip service to the idea of TIC, we do not know highlighted as many questions and gaps as it defined results
the extent to which their attitude is influenced by and conclusions.
demand. In much of the research to date, providers
Because the implementation of TIC within homelessness
and consumers were given brief questionnaires or
service settings is in its infancy, it is particularly important to
were interviewed—in many cases, by the individuals review lessons from the field, including self-assessments and
working to build trauma-informed services. Thus,
frameworks that are being developed to guide the paradigm
there may be a tendency to indicate support of
shift to TIC, as well as feed back from local, regional, and
implementation plans and strategies in the absence of
national programs and initiatives that are implementing TIC.
true commitment.
Lessons from the field highlight clinical insights, new
2. Implementation practice initiatives, and areas in need of further qualitative
and quantitative research.
• We do not know exactly what constitutes “trauma-
informed care.” Trauma has become a buzz-word Corroborative Evidence: Lessons from the Field on
recently, with many agencies and workgroups noting Building TIC in Homelessness Service Systems
the importance of becoming “trauma-informed.”
When we look to the field for best practices and clinical
However, definitions of “trauma-informed” and how
these ideas are implemented vary widely. There is wisdom, we find a wealth of information about current
theories, practices, programming, and policy initiatives. This
generally a lack of specificity in how agencies are
information tells us that although we do not yet have
defining “trauma-informed,” and how this relates to
substantial outcome-based research supporting the
actual practice.
effectiveness of TIC, there is considerable activity in the
• We do not have a clear method for measuring the field that is awaiting additional documentation. Many
degree to which a program is trauma-informed. homeless service systems are beginning to address this
Because of the lack of definitions and behaviorally- issue—administrators, providers, consultants, and consumers
defined changes signifying trauma-informed services, are working together to transform programs into
there is no consistent basis for identifying whether or environments that offer TIC.
not and to what degrees a program is trauma-
After recognizing the pervasiveness of traumatic stress
informed.
among people experiencing homelessness, various programs
are taking steps to become more trauma-informed. We have
selected several case examples to describe the ways in which Several trauma-informed organizational self-assessments
homeless service settings are striving to become more are currently available or/are in development. They include:
trauma-informed. This is not a comprehensive list of trauma-
• The Collaboration on Trauma-Surviving Homeless
informed resources and programs. Instead, it is intended to
Children, a partnership between the National Center
illustrate various creative ways that programs are on Family Homelessness and the Trauma Center at
implementing trauma-informed models within homeless
Justice Resource Institute (JRI), has developed the
service systems, and some of the tools that are available to
Trauma-Informed Organizational Self-Assessment
aid this transition.
for Programs Serving Homeless Families [50] to
Selected Promising Models help programs assess the degree to which their
services are trauma-informed and to highlight areas
To foster the development of trauma-informed homeless for change. The self-assessment addresses
service settings without reinventing the wheel within each
organizational issues such as delineating program
individual program, innovators have developed frameworks
mission, guidelines, and policies; reviewing services
and models that can serve as guides for implementing TIC.
and policies; establishing a safe and trauma-informed
Various models have been proposed that support
physical environment; respecting consumer needs and
organizational change towards a model of TIC and that guide
differences; protecting consumer privacy and
trauma-informed service delivery. Some of these models are: information; encouraging internal and external
• Attachment, Regulation, and Competency: A community-building; and involving consumers in
Comprehensive Framework for Intervention with program development and evaluation. The instrument
Complexly Traumatized Youth (ARC) [43] evaluates staff issues, including hiring practices, staff
training and education, and supervision and support.
• Child Adult Relationship Enhancement (CARE)
It also assesses consumer issues, including procedures
• A Long Journey Home [44] for arrival and intake; safety-planning and crisis
• Phoenix Rising [45] prevention; goal setting; and availability of services,
including trauma-specific interventions.
• Sanctuary Model [46]
• The Trauma Center at JRI has developed the
• Using Trauma Theory to Design Service Systems Trauma-Informed Facility Assessment [49], a brief
[12] instrument assessing the degree to which an
Table 2 describes each of these models, the applications organization’s physical space is trauma-informed.
of the models, and available evidence supporting their This assessment defines several characteristics that
effectiveness. These models of TIC emphasize staff are of primary importance for trauma-informed
education, involving consumers, and transforming systems to organizations, including physical safety, absence of
be responsive to the needs of trauma survivors. Several triggering material, privacy/ confidentiality, and
models, including ARC, CARE, and Sanctuary, have an structure and predictable/consistent response. Other
evidence base (e.g., outcomes-based quantitative research) in areas measured by the instrument include
the mental health field (including inpatient and outpatient accessibility; organization and hygiene; the ability to
settings) and are considered to be promising practices in meet the basic needs of consumers and provide links
trauma-informed care [46]. Others, such as A Long Journey to resources; the availability of personal/quiet space;
Home and Phoenix Rising, were developed specifically for the communication of positive messages; and the
homeless service settings. Most of these models have been creation of a sense of community, with consumer
implemented within homeless service settings, and process ownership of the space and the program.
and outcome evaluation data are currently being collected. • Community Connections has developed a Trauma-
HOW TRAUMA-INFORMED ARE WE? Informed Program Self-Assessment Scale and
ORGANIZATIONAL SELF-ASSESSMENTS Planning Protocol [51]. This tool allows
organizations to evaluate the degree to which
The models described above highlight the need for a program activities and settings are consistent with
framework that provides the foundation for a paradigm shift five guiding principles: safety, trustworthiness,
within homelessness service systems. Once a model for TIC choice, collaboration, and empowerment. Six major
has been identified, an organizational self-assessment can be domains are evaluated, including: program
utilized as a starting point for systems change. procedures and settings; formal services policies;
Self-assessment targets specific areas for change and trauma screening, assessment, and service planning;
indicates how a service delivery model might be adapted to administrative support for program-wide trauma-
an organization’s unique needs. As the model is informed services; staff trauma training and
implemented, a self-assessment is a useful reminder about education; and human-resource practices. Each
important aspects of trauma-informed care that facilitate self- domain is evaluated on the basis of review of
monitoring and program evaluation. Organizational self- program policies, standard program activities, review
assessments can also be conducted after implementation of a of physical space, staff ratings, and consumer ratings.
paradigm shift in order to evaluate the effectiveness of the • As part of a larger study examining integrated
systems change. trauma-informed treatment for women with
Table 2. Models of Trauma-Informed Care
Research
Model Developers Description Key Principles Applications Strengths Limitations
Evidence
The ARC Kinniburgh • ARC is a • 10 building blocks, Therapeutic • Pilot data: • Very strong • Although
Model and flexible based on three basic Procedures: ARC is theoretical basis. evaluated in
(Attachment, Blaustein [48] framework for principles: effective in • Addresses multiple
Self-Regulation, intervention Attachment, • Psycho- outpatient outpatient
education; developmental
and with Regulation, and settings. trauma. and milieu
Competency): A children/famil Competency. • Relationship • Quasi- settings, it
Comprehensive ies who have • Attachment: strengthening; • Offers a has yet to
experimental comprehensive
Framework for experienced Caregiver affect • Social skills; research be formally
Intervention complex framework for evaluated in
management, • Parent-education studies: milieu change;
with Complexly trauma. ARC attunement, consistent conducted in homeless
Traumatized has been training. provides a model settings.
responses, routines outpatient and for trauma-
Youth adapted for and rituals. • ARC principles milieu settings
use within adapted for use specific
• Regulation: Affect in MI, IL, CA, interventions.
various with homeless AL, & MA.
milieus. identification, adolescents. • Well-defined,
modulation, and Outcomes:
• It has been • ARC Agency decreased with an extensive
expression. manual and
applied within Inventory for trauma
homeless • Competency: homeless/ symptoms, comprehensive
settings for Executive functions, runaway youth PTSD, and training
runaway and self-development & has been internalizing/ • NCTSN calls it a
homeless identity, & developed. externalizing "promising
youth. developmental tasks. symptoms. practice"
• ARC Collecting
concepts- evidence on
adapted for effectiveness at
use in multiple sites.
homeless
settings but
not yet been
evaluated.
CARE Trauma • Trauma- CARE guides caregivers • Trauma • CARE is • Modified PCIT- • Limited
(Child Adult Treatment informed in child-directed and education empirically Strong scope in
Relationship Training modification parent-directed component. informed but theoretical & terms of
Enhancement) Center of Parent interactions: • Live coaching. has not yet research base systems
(TTTC). Child • Caretakers’ been • Effective for change.
Revised for Interaction • Practice of 3 P evaluated.
competence in Skills (Praise, building + • Does not
homeless Therapy managing child's • PCIT, the caregiver/child yet have an
populations by (PCIT). Paraphrase, and
problematic Point-Out foundation relationships & evidence
NCFH & the • Skill-based behaviors; for CARE, building base within
Trauma Behavior) to
model for use • Caretakers’ guide parent- has been caregiver homelessne
Center. in milieu empirically competence. ss.
competence child
settings. reinforcing + interactions. supported by • NCTSN calls it
• Being behaviors; numerous a promising
modified for studies. practice
• Reduce parent-child
homeless conflict; and • Piloted in
settings. shelters
• Enhance positive
parent-child
interactions.
A Long Prescott, L. A Guide for Offers guidance on: • Guide offers • In the final • Practical guide • Still in
Journey Home and NCFH Creating • Changing the concrete stages of for making developme
[44] Trauma- environment suggestions for developme concrete changes nt --does
Informed organizational nt; has not within systems. not yet
Services for • Trauma-informed shift towards been have a
policies and • Developed
Homeless TIC piloted in specifically for research or
Mothers and procedures homeless practice
• Includes concrete trauma-informed
Children • Trauma-informed examples, service systems change evidence
services & support exercises, & settings. within homeless base.
• Client representation suggestions for service settings.
& staff development staff training.
• Training and
supervision
• Developing
sustainability
(Table 2) contd…..
Research
Model Developers Description Key Principles Applications Strengths Limitations
Evidence
Phoenix Rising Youth on Fire Phoenix Rising Four main components: Designed for non- • Being • Practical • Manual
and the is an adaptation • Staff training & clinical staff in piloted at a guidebook for under
Trauma of ARC ongoing consultation shelters for drop-in concrete development
Center at JRI concepts for use homeless youth. program for systems and being
with homeless • Trauma-informed homeless change. piloted in a
milieu changes based Offers guidance on:
adolescents and adolescents • Modification of homeless
young adults. on the Trauma- • Training and and young service
Informed Facility philosophy-shift; a strong
adults in theoretical system.
Self-Assessment [49] • Self-assessment Cambridge, model (ARC)
• Comprehensive Risk • Organizational MA. for use at a
Counseling and and physical drop-in center
Services space issues for homeless
• Group activities • Staff issues youth.
(expressive art
therapies and • Consumer issues
community-building) (skill-building,
development of a
cohesive
environment)
The Sanctuary Bloom, S. [46] • Framework • Culture of • Program

Concrete tools for • Theoretical base. • Although
Model for nonviolence. intervention evaluation • Research evaluated
intervening • Emotional include: within evidence in within
with trauma intelligence. • Community inpatient multiple settings- multiple
survivors and meetings units: inpatient and outpatient
facilitating • Inquiry & social reduced and milieu
learning. • Red flag reviews outpatient
organizational PTSD settings, it
change. • Shared governance. • Psychoeducation symptoms • NCTSN calls it a has yet to be
& use of promising formally
• Originally • Open communication. • Self-care practice
developed for planning restraints/ evaluated in
• Social responsibility. seclusion, homeless
traumatized • Safety plans
adults in • Growth and change. improved settings.
inpatient Shared intervention • Team meetings patient
units, adapted language: SAGE (Safety, • Treatment satisfaction,
for DV Affect Management, planning improved
shelters. Grief, Emancipation) for conferences staff
adults, SELF (Safety, retention.
Emotions, Loss, Future) • Additional
for children. pilot trials
underway.
Using Trauma Harris and • Short edited • Systems change • Book describing • Piloted in • Theoretical • Evidence
Theory to Fallot [12] book approach. the model: DC, ME, & base. base comes
Design Service describes • Self-Assessment and Using Trauma CT. Most • Self- from
Systems trauma- Planning Protocol Theory to pilot projects Assessment and unpublished
informed ensures that all levels Design Service within Planning pilot studies.
systems & the of the organization Systems mental health protocol offers • Not yet
application of have an understanding • Trauma- & substance concrete steps evidence on
trauma theory of trauma, its Informed Self- abuse for this model
to systems sequelae, and the Assessment and settings. intervention. in homeless
change. impact of trauma in Planning • Initial pilot service
Applies • Training and
shaping a consumer’s Protocol. project data: consultation is settings.
concepts to responses. support for
various • Trauma- available.
Informed Self- this model
settings, such from
as shelters. Assessment
Scale organizations
Forms guide , staff, and
systems • Implementation consumers.
change. Form.
co-occurring disorders, the W.E.L.L. Project of the Although these self-assessment tools—like the service
Institute for Health and Recovery (IHR) developed a delivery models—are still in development and refinement
toolkit for developing trauma-informed organizations. stages, they reflect advances towards the development of
This self-assessment tool, entitled Developing TIC.
Trauma-informed Organizations: A Toolkit [52],
includes principles of trauma-informed treatment, a INNOVATIVE PROGRAMS AND INITIATIVES
self-assessment for provider organizations, and an UTILIZING TIC
organizational assessment for non-provider The development of these models and self-assessment
organizations. tools has facilitated the progress of a number of innovative
programs that are working to build TIC within homelessness Trauma-Informed Programs for Homeless Youth
service systems. We selected various programs that illustrate
• Youth on Fire is a drop-in center for homeless
lessons from the field with diverse populations experiencing
adolescents and young adults in Cambridge,
homelessness.
Massachusetts. This program utilizes the Phoenix
Trauma-Informed Family Shelters Rising model, an adaptation of ARC (Attachment,
Self-regulation, and Competency model) for homeless
• The Collaboration on Trauma-Surviving Homeless
and at-risk youth. Program staff members have
Children—a partnership among the National Center
received trauma training and continue to receive
on Family Homelessness, the Trauma Center at
trauma consultation from the Trauma Center at
Justice Resource Institute, and other agencies—has
Justice Resource Institute. They are working to
worked with various shelters within the Boston
modify their environment to become more trauma-
metropolitan area to build trauma-informed homeless informed. This program also offers trauma-specific
services. Experts in trauma and homelessness worked
group interventions.
jointly to develop trauma-based training and
consultation targeted specifically to the needs of • The Community Trauma Treatment for Runaway and
homeless families. Trauma training was offered to all Homeless Youth is a partnership among several
levels of program staff, from administrators to clinical agencies in the Los Angeles area that provides
case managers to family advocates. Staff participated outreach and services to homeless youth. This
in regular trauma team meetings that focused on both program has utilized the ARC model to institute a
trauma-informed organizational change and trauma- philosophical shift towards becoming trauma-
focused case consultation. Trauma-informed informed. They developed an ARC-based
programming was also instituted within shelter organizational self-assessment in order to target areas
settings. This included community-building activities, for change within participating agencies. They have
an expressive music program, and self-care activities also instituted trauma-informed case conference
for residents. The goal of this program was to meetings in which ARC concepts are used for case
increase the staff’s knowledge of traumatic stress, review. Trauma-specific interventions have also been
their skill level in responding to trauma-related issues, instituted within this program.
their self-efficacy about working with individuals and • The Homeless Children’s Network is a consortium of
families who have been traumatized, and their fifteen homeless and domestic violence programs in
awareness of issues related to vicarious trauma and San Francisco, California. This program provides
burnout, and self-care. Initial evaluation results therapy and case management to homeless children
indicated positive outcomes, with high levels of and their families. Their theoretical framework
support for the organizational shift to trauma- considers homelessness to be a traumatic stressor for
informed programming, increased staff confidence, children.
fewer resident conflicts, better relationships among
staff and residents, and fewer resident terminations. Trauma-Informed Treatment Programs for Homeless
People with Co-Occurring Mental Health and Substance
Trauma-Informed Domestic Violence Shelters Use Problems
• The Domestic Violence (DV) and Mental Health • The Seeking Treatment and Recovery (STAR)
Policy Initiative in Chicago is working with the Program in Florida provides treatment for homeless
Department of Public Health, the Mayors Office, and people who are suffering from co-occurring mental
several domestic violence shelters to create three illness and substance abuse. After determining that
“Centers of Excellence” for trauma and domestic 79.5% of the homeless individuals served by their
violence. This pilot program will evaluate changes program acknowledged a history of physical or sexual
among organizations, providers, and survivors. The abuse, this program began to make changes to
initiative is also developing a DV-Trauma Core become more trauma-informed. The program
Curriculum to assist providers in offering more instituted a formal process of screening for trauma
trauma-informed services within domestic violence exposure. Based on the high level of trauma exposure
programs. reported by men, they expanded the trauma-specific
Trauma-Informed Homeless Outreach Programs services to include treatment for male survivors. The
program also incorporated various training activities
• The Women’s Violence Prevention Project Alliance at to raise trauma awareness and to build trauma-
the Friends of the Shattuck shelter in Boston is an informed services [28].
outreach program for homeless men and women that
is working towards becoming more trauma-informed. Programs Utilizing a Trauma Framework for Veterans
This program developed a manual to help providers • Mary E. Walker House is a transitional-living
and outreach workers build their understanding of program for homeless women veterans in Coatesville,
trauma and learn how to respond appropriately to Pennsylvania, that focuses on recovery from trauma
survivors. The manual also includes a safety-planning and substance abuse. This program includes a trauma
guide for use with individuals who are living on the framework and also offers trauma-specific services.
streets.
• The Renew program is a V.A. program in Long importance of addressing the impact of trauma among
Beach, California, which serves both homeless and individuals experiencing homelessness, and several training
non-homeless women veterans who have experienced and technical assistance centers have emerged that are
military sexual trauma, and often pre-military sexual actively promoting trauma-informed homelessness services.
trauma. The Homelessness Resource Center (HRC), a
• New Directions is a V.A. program in Los Angeles, SAMHSA-funded program, provides resources, training, and
California, that offers substance abuse and mental technical assistance on issues affecting people who are
health treatment utilizing a trauma framework. Its homeless. Its mission is to improve the lives of people who
Women’s Program offers trauma counseling, with are homeless and have been impacted by trauma, substance
100% of clients reporting abuse. The Executive abuse, and mental health issues. One of HRC’s guiding
Director noted, “Most of our clients have experienced principles is to foster trauma-informed recovery systems.
multiple traumas, including physical trauma as a Through its website, the HRC disseminates tips, tools, and
child, military trauma and years of abuse on the knowledge-based products that can be used by programs
streets and in prisons. Since veterans are known to interested in implementing trauma-informed care. See
have a higher degree of trauma than the general www.homeless.samhsa.gov.
public, it would be most cost effective to begin to The National Center for Trauma-Informed Care,
treat trauma as the core disability rather than separate
funded by SAMHSA’s Center for Mental Health Services
and apart from all other symptoms” [53].
(CMHS), offers educational materials, technical assistance,
These program examples illustrate the beginning of a and training to social services systems to build an
paradigm shift in which homeless services sites are understanding of the impact of trauma and effective trauma-
recognizing the central role of trauma in the lives of based interventions. In collaboration with the Homelessness
consumers. These programs are being implemented in Resource Center, the National Center for Trauma-Informed
diverse settings including family-based shelters, domestic Care offers trauma-informed training to providers in the Gulf
violence programs, outreach programs, dual diagnosis Coast recovery area. In addition, training in trauma-informed
programs for homeless individuals, and programs for care has been offered to Projects for Assistance in Transition
homeless youth and veterans. However, this shift is only from Homelessness (PATH) programs.
beginning. Many programs do not yet recognize the central The National Child Traumatic Stress Network
role of trauma. Guidance from state and federal initiatives is
(NCTSN), another SAMHSA-supported program, has
likely to facilitate broader awareness of the need for TIC
focused on the impact of traumatic stress in the lives of
within behavioral health systems and, more specifically,
children. The Network has been active in promoting trauma-
within homelessness services settings.
informed care, including trauma awareness within homeless
SELECTED STATE AND FEDERAL INITIATIVES TO service settings for youth. The Homelessness and Extreme
ESTABLISH TIC Poverty Working Group is a branch of NCTSN that devotes
itself to the intersection of trauma, poverty, and
Over the past ten years, various state and federal policies homelessness in children.
have focused on the importance of establishing trauma-
informed services within mental health and substance abuse The Department of Veterans Affairs offers specialized
settings. In 1998, the National Association of State Mental services to homeless veterans, and is increasingly addressing
Health Program Directors (NASMHPD) issued a position sexual trauma among female veterans. However, the
statement on services and supports for trauma survivors, National Coalition for Homeless Veterans noted that “with
recognizing that “the psychological effects of violence and greater numbers of women in combat operations, along with
trauma in our society are pervasive, highly disabling, yet increased identification of and a greater emphasis on care for
largely ignored.” The statement articulated a commitment to victims of sexual assault and trauma, new and more
address the issue of trauma. The report, Models for comprehensive services are needed.” The Coalition’s 2007
Developing Trauma-Informed Behavioral Health Systems public policy priorities include increasing homeless veterans’
and Trauma-Specific Services, defined “trauma-informed” access to comprehensive, high-quality and affordable health
and described programs that have implemented trauma- care, including substance abuse and mental health care.
informed models on a statewide or local level [54]. Limitations still exist in the VA’s policy on trauma-informed
NASMHPD also developed a Trauma Services care for homeless veterans, particularly around the treatment
Implementation Toolkit for State Mental Health Agencies of trauma (not necessarily combat-related) among male
[42] that describes products being used by various state veterans.
agencies to work towards building trauma-informed systems. The work of these initiatives has been integral to raising
Although these policy documents are not directed towards awareness of the need for trauma-informed homeless service
homeless service systems, they provided momentum in the systems. However, a large gap still remains between the
social-services fields towards incorporating knowledge of recognition of trauma and the implementation of programs
trauma into service systems. and policies that ensure available and accessible trauma-
Regional and national initiatives regarding the need for informed care for homeless individuals and families. Further
TIC within the homelessness field are even more recent. advances in practice, programming, policy, and research are
Within the past ten years, a number of homeless service needed to develop evidence-based, trauma-informed care
organizations and coalitions have begun to emphasize the within homeless services across the country.
DISCUSSION practices and clinical wisdom in developing and

implementing trauma-informed theories and practices.
Our review of the current evidence suggested that, while
there are challenges to implementing trauma-informed RECOMMENDATIONS
services, Trauma-Informed Care appears to be effective. We
This review documents the high rates of traumatic stress
can conclude from research in other fields that, with
necessary buy-in, TIC is well-received by consumers and among people who experience homelessness and supports
the need for developing trauma-informed services. While
providers, most likely leads to better outcomes, and does not
considerable progress has been made in increasing awareness
cost significantly more than treatment as usual. Despite these
of the impact of traumatic stress, the implementation of a
promising findings, this review also highlighted what we do
widespread system of trauma-informed homeless services is
not yet know about TIC within homelessness services
in its early stages. Although this review highlights various
settings. There is a dearth of research on trauma-informed
approaches specifically within homeless service settings. innovative practices and programs that have been created in
a wide array of settings for various subgroups of homeless
Most organizations that are working towards building
people, they are relatively limited given the enormous need.
trauma-informed homelessness service settings are collecting
Many program strategies and models are still being
minimal or no information for evaluation purposes. The
developed and piloted. Preliminary feedback from the
Homeless Families Program, a large quasi-experimental
homelessness arena and other service settings suggests that
study examining trauma-informed services within homeless
services, is an exception. these approaches may be effective in producing better
outcomes and promoting systems change. However, the
Initiated by the Substance Abuse and Mental Health evidence base supporting the effectiveness of these practices
Services Administration (SAMSHA) in 1999, the Homeless and programs is largely drawn from the corroborative
Families Program is the first large research study to examine literature.
integrated, trauma-informed care for homeless families with
psychiatric disorders, substance use problems, and trauma The research base supporting the effectiveness of trauma-
informed services within homeless settings is limited. Over
histories. Each of the eight sites focuses on helping
the past decade, trauma-informed services have begun to be
consumers understand the connection between their own
implemented in other fields, including mental health and
trauma histories and their current issues; this education lays
substance use programs. With this implementation has come
the groundwork for assisting consumers in developing new
some robust quantitative and qualitative research.
coping strategies and working to improve their parenting
skills and relationships. The program also focuses on staff Quantitative research from these fields indicates that trauma-
informed services are associated with improved outcomes,
issues, including team-building, staff support, and self-care.
such as decreased mental health, trauma-related, and
Although evaluation of the Homeless Families Program substance abuse symptoms and behaviors. Qualitative
is still in progress, and final results are not yet available, research from these fields has better described the meaning
preliminary findings have identified several factors that seem of trauma-informed care and has found that its
to be important for implementing trauma-informed services: implementation can be a challenging process, but that it can
1) the trauma intervention approach should fit into the lead to systems changes that have positive impacts on both
overall model and philosophy of the program; 2) programs providers and consumers. Findings from these studies can
should utilize strengths-based approaches in working with inform best practices within the homelessness field.
trauma survivors; 3) programs should encourage mutual
Even with significant limitations in the research
respect and trustworthy behavior (e.g., following through on
commitments); 4) programs should avoid punitive literature, we have learned important lessons about how we
can best move ahead to make the homelessness service
approaches, limiting rules and regulations to those ensuring
system more trauma-informed.
safety; 5) staff should be encouraged to have realistic
expectations about the progress that can be expected; 6) Practice
programs should engage survivors in the process of helping
others (e.g., normalizing, empathizing, assisting, allowing Despite the prevalence of trauma among individuals
transformative experiences); and 7) programs should experiencing homelessness, many homeless service systems
maintain a nonjudgmental approach, while encouraging are not yet adequately addressing this issue. Greater
personal responsibility and the possibility of making better uniformity and consistency of trauma-informed services for
choices [55]. homeless individuals will aid in our understanding of the
effectiveness of those practices.
Clearly, although initial investigations are promising, the
research to date is inadequate for evaluating the effectiveness Practice recommendations for building trauma-informed
of trauma-informed models within homeless service settings. homeless services include the following:
Additional quantitative and qualitative research is needed to 1. Although a number of homeless services settings may
further explore trauma-informed practices specifically within be beginning to implement trauma-informed services,
homeless service settings. This research can be used to there is great variability in how these services are
establish empirically-based best practices and will be the implemented. Utilization of a theory-based model or
springboard for policy that can drive systems change in framework would help to ensure consistency across
programs nationwide. Because the field is only beginning to sites and help to begin to build evidence-based
generate research-based evidence on trauma-informed practices.
homelessness services, we have looked to the field for best
2. Programs should strive to avoid any practices that Beyond offering services that have a trauma-based
may be retraumatizing. This applies to all levels of framework, programming efforts are needed to establish
the system, including administrative, provider, and agency-wide commitment to building trauma-informed
consumer levels. services. Programming builds continuity among providers to
3. Homeless service systems should implement establish the overall shift in program philosophy necessary
for building trauma-informed services.
universal systematic screening for trauma histories,
using standardized measures. 1. Homeless programs should integrate trauma
awareness and responsiveness into their program
4. Program intake and evaluation should include an
missions.
assessment of consumer strengths and resources. This
contributes to the development of a strengths-based 2. There is a need to operationalize the principles of
model and supports the further development of trauma-informed services, and to link these principles
coping resources. to quantitative, measurable changes that can be
tracked and evaluated.
5. Because research has found that integration of
services is a key factor in improving outcomes, it is 3. Guidelines should be developed for implementing a
recommended that substance abuse, mental health, trauma-informed model or framework in homeless
and trauma services be integrated. service settings.
6. Programs implementing integrated trauma-informed 4. Programs working for larger systems change towards
treatment approaches should also include trauma- a trauma-informed model should start with an
informed services for children, in order to increase organizational self-assessment in order to identify
resiliency in children and youth. strengths and target areas for change.
7. Because the majority of consumers in homeless 5. Organizations should institute regular internal and/or
service settings are trauma survivors, additional external reviews to assess the degree to which their
trauma-specific services should be made available for programs are trauma-informed.
consumers who wish to receive targeted treatment. 6. Despite the fact that they work with trauma survivors
8. Building on empowerment-based trauma theories on a daily basis, most staff members within homeless
emphasizing the importance of actively participating services are not trained about the impact of trauma or
in service programs and rebuilding a sense of control, strategies for working with trauma survivors.
programs should support and encourage consumer Homeless services should implement standardized
involvement. Examples of consumer involvement training on understanding traumatic stress and
include active goal-setting and crisis planning, peer- working with trauma survivors. Because these
led services, leadership roles for consumers, and concepts are complex and cannot be adequately
involvement in program design, evaluation, and covered in one training, regular follow-up trainings
refinement. should be offered.
9. All trauma-informed services should be culturally 7. A consultation model that is ongoing and responsive
and linguistically competent. to specific needs should be utilized to reinforce
concepts learned in trainings, as well as to help
Programming providers apply what they have learned to actual
Our review of the theory, study, and practice of trauma- situations in their service settings.
informed services underscored six steps that are essential 8. Regular supervision should be offered in order to
when implementing a trauma-informed model, including: assist staff members in understanding the impact of
1. Obtaining “buy-in” at multiple levels within the trauma in particular situations, and to aid staff in
system recognizing and managing their own reactions.
2. Conducting a needs assessment to identify areas for 9. Homeless services should design trauma-informed
change environments, including attention to issues of
physical space, triggering materials, privacy/
3. Reviewing the organization’s environment,
confidentiality, and structure/ predictability.
procedures, and services and revising them to become
more aligned with the principles of trauma-informed 10. Policies and protocols should be reviewed to ensure
care that they are consistent with a trauma-informed model
and are not inadvertently retraumatizing.
4. Providing training on trauma
11. Homeless service organizations should be aware of
5. Offering ongoing trauma-based consultation and
and responsive to issues of job stress, burnout, and
supervision
vicarious trauma in providers. Programs need to have
6. Providing access to trauma-specific interventions structures in place for prevention of, and early
These principles and implementation strategies are a intervention for, vicarious trauma. In terms of
prevention, it is recommended that organizations
starting point for any program wishing to implement trauma-
institute policies, programs, or activities that
informed services.
encourage staff self-care and support.
12. Consumer involvement is an integral part of a trauma- Human Services, the U.S. Department of Veterans
informed system. It is recommended that consumers Affairs, the U.S. Departments of Housing and Urban
of homeless services participate as active members in Development, the U.S. Interagency Council on
program development, operation, and evaluation. Homelessness, state-level councils to end
Some possibilities for this involvement include: Town homelessness, the National Alliance to End
Hall meetings, consumer advisory boards, and peer- Homelessness, the National Health Care for the
led groups. Prescott [22] offers guidelines for Homeless Council, the National Law Center on
integrating consumers into trauma-informed Homelessness and Poverty, the National Center on
programs. Family Homelessness, and the Homelessness
Resource Center.
13. Services and programs should promote cultural
diversity and competency. Research
Policy There is a paucity of research examining the
effectiveness of trauma-informed services for homeless
The evidence on trauma-informed services in homeless
individuals and families. Most programs that have begun to
settings is limited and there is a lack of clearly defined
institute trauma-informed practices have not tested their
principles, definitions, and methods for establishing trauma-
models for effectiveness. This may be due to financial
informed services. More research is needed to evaluate the
process of developing trauma-informed services and to constraints and to the fact that many programs are focused
on direct service, as opposed to research.
evaluate the effectiveness of trauma-informed services for
homeless individuals. State and federal funding should be 1. Although research on trauma-informed services in the
appropriated for examining evidence for trauma-informed mental health and substance use fields is promising,
interventions. The National Association of State Mental further research is needed on developing trauma-
Health Program Directors (NASMHPD) has taken a first step informed services within homeless service settings.
in this direction by recommending that states establish
2. Researchers and providers need to establish a greater
financing criteria and mechanisms for funding best-practice
consensus about what constitutes a “trauma-informed
trauma treatment models and services. However, these policy
service system.” Clearly defining what is meant by a
efforts should be expanded to include federal and local
“trauma-informed system” will create greater
funding, and to include a focus on homeless service settings.
uniformity in research, increasing the ability to
The current review of trauma-informed homeless compare strategies for implementing trauma-informed
services suggests a number of policies whose adoption is systems.
necessary to move the field further:
3. Methods to achieve trauma-informed systems also
1. Policies should support homeless services that need to be more clearly established. The conceptual
employ strategies to prevent trauma exposure, framework established by a set of guiding principles
including the elimination of practices that are should be behaviorally defined within a system. This
retraumatizing. allows fidelity measurements, indicating the degree to
which a program is meeting the general standards for
2. Policies should support increased capacity for early
a trauma-informed program. Clearly defining
detection of trauma within homeless service settings.
methods will also lead to the possibility of a
3. Mainstream services should be available and classification system delineating varying levels of
accessible to individuals experiencing homelessness trauma-informed systems.
and should be responsive to the needs of trauma
4. Although a number of models or frameworks for
survivors.
building trauma-informed services have been
4. Policies should guide the development and offering of developed, more evidence is needed to evaluate and
comprehensive, integrated, trauma-informed refine these approaches. Thus, additional research is
treatment within homeless service settings. needed to evaluate trauma-informed models within
5. Policies should prescribe and define consumer homeless settings. It is recommended that additional
involvement in developing and evaluating homeless research within the homelessness arena be conducted
services. using models such as ARC, CARE, A Long Journey
Home, Sanctuary, and Using Trauma Theory to
6. Policies should ensure that funding is available to Design Service Systems.
develop and sustain trauma-informed care.
5. The corroborative evidence that is available offers a
7. Policies should ensure that services are designed to be clear starting point for future research on trauma-
developmentally-appropriate, and culturally and informed homeless services. Additional qualitative
linguistically competent. research is needed to more clearly define the process
8. Trauma-informed homeless service policies need to of offering trauma-informed services, while
be supported by larger systems guiding services for quantitative studies should follow after models have
homeless individuals and families, including national, been clearly defined and described. These should
state, and local governmental, community-based examine the outcomes of trauma-informed
groups, and non-profit organizations. Some of these interventions.
systems include: the U.S. Department of Health and
6. Additional research is needed to distinguish the childhood; community violence; sexual assault; combat-
relative contribution of trauma-informed care, versus related traumas; domestic violence; and accidents or
trauma-specific services. The majority of the research disasters. A literature review found consistent and well-
to date on trauma-informed care has also included documented evidence of high levels of multiple forms of
trauma-specific services. While clinically this makes traumatic stress within individuals and families who are
intuitive sense, research is needed to evaluate what homeless. It is clear that trauma affects people of every
specific factors are leading to change within these gender, age, race, sexual orientation, and background within
systems. homeless service settings. No one is immune. The following
data highlight this point:
7. Additional research is required on the needs of
special populations who are homeless. For instance, Men
additional research is needed to determine how
trauma-informed care should be adapted to meet the • More than 2/3 of men in a dual-diagnosis treatment
unique issues faced by youth, veterans, individuals program for homeless people reported a history of
from other countries, individuals of different ethnic trauma -- either physical or sexual abuse [28].
backgrounds, and LGBT individuals who are • More than 1/4 of homeless men were assaulted in the
experiencing homelessness. past year [56].
Trauma-informed homeless services offer a promising • Homeless men within substance treatment programs
new area for increasingly effective and sensitive service have a high prevalence of depression, family
approaches for highly vulnerable people. Because many, if dysfunction, trauma, and multiple previous treatment
not all, homeless individuals have been exposed to high experiences [57].
levels of traumatic stress, it is essential that homeless service
systems develop sensitivity and responsiveness to post- • Despite the fact that men comprise the majority of
homeless people and are frequently exposed to
trauma responses among the people they serve. More efforts
trauma, homeless men are less likely to receive social
are needed in terms of practice, programming, policy, and
services than homeless women [58], with less effort
research to continue to build empirically-based, effective
directed towards understanding the impact of trauma
models of trauma-informed care for people who are
for this population.
struggling daily to exit homelessness.
Women/Mothers
ACKNOWLEDGEMENTS
• Although many people think of men when they
Special thanks to Dawn Jahn-Moses of the National
consider the issue of homelessness, families—
Center on Family Homelessness, and the team at the Center
typically single mothers with young children—now
for Social Innovation.
comprise up to 40% of the overall homeless
CONFLICT OF INTEREST population [59].
Authors work within organizations that developed some • Trauma is extremely prevalent among homeless
of the models reviewed (e.g. organizational assessments, women: over 90% of homeless mothers report having
ARC model, Phoenix Rising). experienced severe physical or sexual assault during
their lifetimes [60].
This document was developed under Contract No.
HHSS280200600029C from the Substance Abuse and • The majority of homeless mothers were abused
Mental Health Services Administration (SAMHSA), U.S during childhood, with nearly 2/3 reporting severe
Department of Health and Human Services (HHS). The physical abuse and 42% reporting sexual abuse; 60%
views, policies, and opinions expressed are those of the were abused before the age of twelve [2].
authors and do not necessarily reflect those of SAMHSA or • More than 70% of homeless mothers have at least one
HHS. childhood risk factor, including: severe physical
APPENDIX 1 abuse, unwanted sexual contact, having a parent who
was mentally ill or who abused substances, running
Traumatic Stress and Homelessness away for a week or more, or being in foster care [61].
“Homelessness deprives individuals of…basic • Homeless mothers are also frequently the victims of
needs, exposing them to risky, unpredictable abuse during adulthood, with 61% reporting a history
environments. In short, homelessness is more of domestic violence and 32% acknowledging recent
than the absence of physical shelter, it is a domestic violence [2].
stress-filled, dehumanizing, dangerous
circumstance in which individuals are at high • Homelessness puts women at risk for assault; being
risk of being witness to or victims of a wide homeless was associated with more than three times
range of violent events” [1]. the risk of sexual assault for women [56].
Researchers have documented that the rates of traumatic • Homelessness and victimization are associated with
stress are extremely high, and may even be normative, adverse mental health outcomes: more than 50% of
among those experiencing homelessness. Individuals who homeless mothers reported depression, and more than
are homeless may have been exposed to neglect, 40% reported posttraumatic stress disorder (PTSD)
psychological abuse, physical abuse, or sexual abuse during
[62], and were three times as likely as housed women • One-third of LGBT youth are assaulted after
to suffer from PTSD [63]. disclosing their sexual orientation; 40% to 60% of
homeless youth cited physical abuse as a reason for
Children and Youth leaving home [76].
• Child abuse is associated with high-risk behaviors in • Thirty-three percent of transgendered individuals
adolescents, such as truancy and running away, that reported that they had been physically or sexually
may lead to homelessness [64]. Almost 3/4 of girls on assaulted in the past year [56].
the streets report that they were forced to run away
from violence at home [65]. These statistics suggest that it is reasonable to assume
that the majority of homeless individuals have been exposed
• Homeless children and youth are at risk for further to traumatic stress. Most people experiencing homelessness
victimization, such as repeated abuse, exposure to have been victimized one or more times in their lives. For
violence, and forced prostitution [66]. many people, abuse began during childhood; in fact,
• 86% of homeless youth report exposure to trauma, developmental trauma with disrupted attachments may
with almost 2/3 reporting exposure to multiple provide the subtext for the stories of many people’s
traumatic events; physical assaults are prevalent for pathways towards homelessness [2]. Violence continues into
young men, while sexual/physical abuse is common adulthood for many people, with abuse such as domestic
among young women [67]. violence often precipitating homelessness [3-5], and with
homelessness leaving people vulnerable to further
• Homeless children are at increased risk for medical,
victimization. In fact, homelessness has been suggested to be
emotional, behavioral, and academic problems,
a traumatic event in and of it, compounding the
including post-trauma responses, insecure
psychological impact of the myriad risk factors often
attachments, and difficulty learning [60, 68, 69]. experienced by people who are homeless [77]. Based on this
Elderly assumption, we can conclude that individuals experiencing
homelessness are, by definition, trauma survivors,
• The elderly make up a relatively lower percentage of demonstrating the urgency of addressing trauma within this
the homeless population, only 2% [70]; however, population.
elderly homeless persons are more vulnerable to
victimization, have more health problems, and may be Another reason that it is important to address trauma
less likely to receive needed social services and within homelessness service settings is that victimization is
protection from law enforcement [71]. associated with repeated episodes of homelessness. Research
has found that people who experienced repeated
• In 2006, 27% of the homeless victims of violent homelessness were more likely than people with a single
crimes were between 50-59 years of age [9]. episode of homelessness to have been abused, often during
Veterans childhood. First-time homeless mothers who experienced
domestic violence were more than three times as likely to
• Veterans are disproportionately represented in the become homeless again [6]. These findings suggest that we
homeless population, with veterans making up 23% will be unable to solve the issue of homelessness without
of all homeless people in the U.S. [72]. addressing the underlying trauma that is so intricately
• The majority of women in homeless veteran programs interwoven with the experience of homelessness.
have serious trauma histories, including being As can be seen from this description, the relationship
physically harassed, sexually harassed, or raped while between trauma and homelessness is complex, with
in the military [73]. traumatic stress being a possible core factor increasing
• One-quarter or more of homeless veterans manifest vulnerability to homelessness, and with homelessness
symptoms of PTSD; 76% experience alcohol, drug, or leaving individuals more vulnerable to further victimization.
mental health problems [74]. There is also a complex and multi-directional relationship
between trauma, substance abuse, mental illness, and
• Trauma and related distress are related to relapse homelessness. All these factors need to be addressed in
and rehospitalization of homeless veterans who have services for homeless men, women, children and youth, the
substance abuse problems, particularly for female elderly, minorities, veterans, LGBT individuals, and other
veterans [75]. people.
Minorities APPENDIX 2
• Minorities are over-represented among the homeless The Impact of Trauma
population, with almost half being African-American
[4]. Traumatic stress can be devastating and long-lasting. To
develop an understanding about how to build trauma-
• Families of color also disproportionately experience sensitive services, we need to first clearly understand that the
trauma [50]. impact of traumatic stress can be devastating and long-
Lesbian, Gay, Bisexual, & Transgendered (LGBT) lasting, interfering with a person’s sense of self, and sense of
Individuals safety, leading to feelings of helplessness, terror, and
disempowerment. Traumatic exposure may lead to responses
• 40% of homeless youth identify as LGBT.
Table 3. How Common Trauma Reactions May Explain Some “Difficult” Behaviors or Reactions Within Homeless Service
Settings
"Difficult" Behaviors or Reactions within Homeless Service Settings Common Trauma Reactions
Has difficulty getting motivated to get job training, pursue education, locate a job, or find housing Depression and diminished interest in everyday activities
Complains that the setting is not comfortable or not safe, appears tired and poorly rested. Is up
Nightmares and insomnia
roaming around at night.
Perceives others as being abusive, loses touch with current-day reality and feels like the trauma is
Flashbacks, triggered responses
happening over again
Avoids meetings with counselors or other support staff, emotionally shuts down when faced with
Avoidance of traumatic memories or reminders
traumatic reminders
Isolates within the shelter, stays away from other residents and staff Feeling detached from others
Lacks awareness of emotional responses, does not emotionally respond to others Emotional numbing or restricted range of feelings
Is alert for signs of danger, appears to be tense and nervous Hyper-alertness or hypervigilance
Has interpersonal conflicts within the shelter, appears agitated Irritability, restlessness, outbursts of anger or rage
Has difficulty keeping up in educational settings or job training programs Difficulty concentrating or remembering
Becomes agitated within the shelter. Is triggered by rules and consequences. Has difficulty setting
Feeling unsafe, helpless, and out of control
limits with children.
Has difficulty following rules and guidelines within the shelter or in other settings. Is triggered
Increased need for control
when dealing with authorities. Will not accept help from others.
Feels emotionally "out of control." Staff and other residents become frustrated by not being able to Affect dysregulation (emotional swings – like crying and
predict how he or she will respond emotionally then laughing)
Seems spacey or "out of it." Has difficulty remembering whether or not they have done something.
Dissociation
Is not responsive to external situations.
Complains of aches and pains like headaches, stomachaches, backaches. Becomes ill frequently. Psychosomatic symptoms, impaired immune system
Cuts off from family, friends, and other sources of support Feelings of shame and self-blame
Has difficulty trusting staff members; feels targeted by others. Does not form close relationships in
Difficulty trusting and/or feelings of betrayal
the service setting.
Complains that the system is unfair, that they are being targeted or unfairly blamed Loss of a sense of order or fairness in the world
Puts less effort into trying--does not follow through on appointments, does not respond to
Learned helplessness
assistance
Invades others' personal space or lacks awareness of when others are invading their personal space Boundary issues
Has ongoing substance abuse problems Use of alcohol or drugs to manage emotional responses
Remains in an abusive relationship or is victimized again and again Revictimization (impaired ability to identify danger signs)
including Posttraumatic Stress Disorder (PTSD) and including their emotional states and their physiological
Complex Trauma. reactions. Their emotions sometimes shift rapidly, leaving
Posttraumatic Stress Disorder (PTSD) refers to a group them feeling helpless in the face of overwhelming emotion.
Their bodies are easily activated, resulting in anxiety, panic,
of symptoms that some individuals experience after
or terror. At other times, they have dissociative responses in
overwhelming, frightening, or horrifying life experiences
which their bodies or emotions shut down and they become
that exceed their capacity to cope. PTSD includes intrusive
numb. Triggered responses, reactions to reminders of the
symptoms such as triggered memories or nightmares,
trauma, are also common. In Complex PTSD, the traumatic
avoidance symptoms such as social withdrawal, constriction,
and emotional numbing, and symptoms of hyperarousal such experiences impact the survivor’s sense of self; survivors
often blame themselves for their abuse, feeling damaged and
as concentration problems, irritability, and constant alertness
ashamed. Individuals who have experienced chronic
for danger.
interpersonal trauma often have problems sustaining
Exposure to chronic interpersonal trauma such as child supportive relationships, such as difficulty trusting others or
abuse or domestic violence may have an even more problems establishing clear boundaries and setting limits
extensive impact on the survivor, sometimes referred to as with others. This increases their vulnerability to
“Complex PTSD,” or “Disorders of Extreme Stress, Not retraumatization, and interferes with the development of
Otherwise Specified” (DES-NOS). Survivors with Complex adequate social networks for support in times of crisis.
PTSD have difficulty regulating their internal states, Individuals with Complex PTSD may have impaired
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Received: August 20, 2009 Revised: September 20, 2009 Accepted: September 28, 2009
© Hopper et al.; Licensee Bentham Open.

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80 The Open Health Services and Policy Journal, 2010, 3, 80-100

INTRODUCTION trauma; domestic violence; accidents; and disasters. Trauma

1874-9240/10 2010 Bentham Open

Table 1. Principles of Trauma-Informed Care

Example Definitions of Trauma-Informed Care

Trauma function/ focus,

Engagement: Utilize a relational

Example Definitions of Trauma-Informed Care

Trauma policies and

Table 2. Models of Trauma-Informed Care

The Sanctuary Bloom, S. [46] • Framework • Culture of • Program

DISCUSSION practices and clinical wisdom in developing and

© Hopper et al.; Licensee Bentham Open.

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