Dalma Fabian
INTRODUCTION
Rates of homelessness are rising in almost all EU countries with a 150% increase in Germany from 2014 to 2016, a 20% rise in the number of people in emergency shelters in Spain over the same period, and an 8% increase in Denmark between 2015 and 2017. In the Netherlands 4,000 children in 2015 were registered with local authorities as homeless, up 60% on 2013. While the official number of people experiencing homelessness in Ireland is contested,1 the number has increased by 200% between July 2014 and November 2018, family homelessness having particularly contributed to this rise.2
Mortality rates among people experiencing homelessness are shockingly high. In England, the average age of death for men is 47 years old and for women it is even lower at just 43 years old. This is compared to 77 years old for the general population.3 Findings from a 2016 study of mortality among people experiencing homelessness in the Dublin region found that the average life expectancy was 44 for men and 38 for women.4 The impact of homelessness on the individual and society is profound, and it is therefore increasingly important to develop effective strategies to prevent and reduce the phenomenon.
UNDERSTANDING HOMELESSNESS
There is never a single cause of, or pathway to, homelessness. It is often described as an interaction of structural factors, system failures and individual variables. The predominant reasons are structural, including access to affordable housing, unemployment, failure to provide refuge in domestic abuse, and poverty. For others, relationship and individual factors, including traumatic experiences, contribute to them experiencing homelessness. Therefore, most people who become homeless due to housing shortage or job loss need little or no additional support beyond access to affordable and adequate housing. Those who become homeless for different reasons, often due to system failures, such as leaving state care or prison, usually stay homeless for a longer period and have greater and interrelated support needs. Those who are long-term (or chronically) homeless, and cycle between street, psychiatry, criminal justice services and temporary accommodation are the most likely to have been exposed to trauma, and as a result, have the greatest support needs.
UNDERSTANDING TRAUMA
Trauma is highly prevalent in the life of people who experience homelessness. Often starting early on in childhood through experiences of neglect, abuse, parental alcoholism, domestic violence and continuing later with experiences of violence, drugs, confrontation with police and experiences of prison.
In general, trauma refers to experiences or events that by definition are out of the ordinary in terms of their overwhelming nature. They are also more than stressful – they can be shocking, terrifying and devastating to the trauma survivor and often result in feelings of terror, shame, helplessness and powerlessness. These events are neither ordinary, nor uncommon. Destructive events, such as natural disasters, are easier to accept than atrocities committed by fellow human beings. Unfortunately, there is a lot of denial, and repression both at societal level and at the individual level about traumatic events.
There are two types of trauma. Type 1 trauma occurs at a particular time and place, and is short-lived, such as serious accident, sudden loss of parent or a single sexual assault. Type 2 refers to events which are typically chronic, begin in early childhood and occur within the family or social environment. They are usually repetitive and prolonged, involve direct or indirect harm or neglect by caregivers or other entrusted adults in an environment where escape is impossible. Many people experiencing homelessness have experience of both, which is referred to as “compound” or “complex” trauma.5
The earlier in life trauma occurs, the more damaging the consequences are likely to be. Extensive evidence demonstrates that traumatic experiences in childhood are strong predictors of poor mental and physical health in adulthood. Homelessness is one of the numerous negative effects that have been associated with Adverse Childhood Experience (ACE). ACEs refer to experiences during childhood that are considered maltreatment, for instance sexual, physical or emotional abuse or neglect. ACEs can also stem from living with an adult with mental illness, substance abuse problems or criminality or if domestic violence is committed in the household.
HOW ARE TRAUMA AND HOMELESSNESS INTERLINKED?
There is a strong link between these traumatic experiences and homelessness. A report by Theresa McDonagh for the Joseph Rowntree Foundation identified an overlap between experiencing homelessness and having other support needs. Nearly half of homeless service users have experience of institutional care, problem substance use, and street activities (begging).This report also detailed research which showed that 78% of respondents identified as experiencing “multiple exclusion homelessness”6 had also suffered childhood traumatic experiences.7
Trauma and Homelessness are Connected in at Least Three Ways
Firstly, trauma is prevalent in the narrative of many people’s pathway to homelessness. Research has shown that people who are homeless are likely to have experienced some form of trauma, often in childhood.8 There is a strong correlation between the extent of neglect and trauma suffered in childhood and the severity of disadvantage in adulthood.9 ACEs have long lasting impact, especially because they happen in a developmentally vulnerable period in one’s life. The earlier in life trauma occurs, the more damaging the consequences are likely to be. It can disrupt children’s basic biological regulatory systems and their normal attachment systems, especially if the perpetrator is a person whom they trusted and had strong emotional ties with. Insecure attachment strongly impacts upon the ability to have healthy social relationships in adulthood. Trauma experience has very strong implications for the person’s relationship to care and it often underpins ambivalence or dismissal of care.10
Secondly, trauma often happens during homelessness, for example by being a victim or witness of an attack, sexual assault or any other violent event. Services that do not recognise the impact that adverse experiences have had on their service users can cause further trauma and harm. People can be re-traumatised by services that leave them feeling powerless, for example, where there are unnecessary rules, compulsory engagement in services, or an atmosphere of control. This can recreate the cycle of rejection experienced in early life and can trigger emotional or psychological responses similar to the original trauma. In response many resort to negative coping strategies of drug use and self-harm to ease these symptoms.
Thirdly, homelessness itself can be traumatic in multiple ways. Often the loss of a home coincides with other losses, for instance loss of family connections and social roles. This is because “like other traumas, becoming homeless frequently renders people unable to control their daily lives.”11 Social exclusion activates the same neurological systems as physical trauma, with a similar impact on people.12 Added to this, homelessness can be such an additional stress in the life of a person that it can erode the person’s coping mechanisms. Life on the streets can be so stressful that it induces trauma.
If trauma is a very common experience for people who are experiencing homelessness and if we know that trauma and homelessness are so deeply interlinked, what can we do about it? How can we support those with traumatic experiences and at risk of homelessness? And what about those who are entrenched in long-term homelessness?
WHY IS IT IMPORTANT FOR THE HOMELESSNESS SECTOR TO BE TRAUMA INFORMED?
What we have learnt about trauma and its long-lasting effects allows us to better understand how trauma impacts on emotions and behaviours, and it opens up new opportunities to work with people who are often rejected by services because of their complex needs or behaviour. We can now understand behaviour as a response to the effects of trauma and consider it as a “normal responses to abnormal stress,” rather than as deviances or failures.13
This recognition, that exposure to violence and trauma has resulted in the problems and behaviours, brings validation to those who have suffered, in silence, the impact of traumatic experiences. If homelessness services are equipped with the right resources to help people with trauma histories, the shame and stigma that often prevents people from seeking help in the first place will be removed.
An important dimension is the gender impact of harm in critiquing homelessness. Women experiencing homelessness are extremely likely to experience violence and abuse.14 It is violence against women and children which drives women away from abusive partners and often into homelessness with violence sometimes continuing during homelessness. Homeless services are likely to be mixed-gender and not equipped to respond to the trauma-related needs of women, including the need for safety. The way trauma is experienced is specific to gender and services should be both trauma and gender-informed.
WHAT STRATEGIES CAN BREAK THE CYCLE BETWEEN TRAUMA AND HOMELESSNESS?
There is a vicious circle between trauma and homelessness. Trauma drives homelessness and homelessness can increase traumatic exposure. Trauma drives relationship difficulties and mental health problems which can cause homelessness. To break the cycle between trauma and homelessness an important step is to ensure permanent, stable and supportive housing. Trauma resulting from the experience of homelessness reflects a failure of services to provide housing and support, and at worst it reflects re-traumatisation within homelessness services. The bigger the delay in getting the person into housing, the more psychological barriers are created by the experience of homelessness. To prevent this vicious cycle, housing should be obtained as quickly as possible to minimize the potential of additional traumatic experiences. Redesigning homelessness services to better meet the needs of people affected by trauma is crucial. Two approaches to delivering homelessness services which take effect the impact of trauma, have been developed: Trauma Informed Care (TIC) and Psychologically Informed Environments (PIE).
TIC is an approach to engaging with service users which considers behaviours from a trauma perspective, and creates an environment for recovery. Hopper, Bassuk and Oliver define TIC as:
… a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.
A Psychologically Informed Environment (PIE) takes into account the psychological makeup of each individual, their thinking, emotions, personalities and past experiences.16 It is an approach to supporting people out of homelessness, in particular those with complex trauma-related needs. It also works with the psychological needs of staff by providing training, increasing motivation and job satisfaction and building resilience to avoid burn-out and vicarious (or secondary) trauma.
Relationships are essential to healing from trauma and recovery. According to both approaches, staff are encouraged to develop relationships with clients that are supportive and encourage self-development and recovery. The emphasis is on enabling clients to lead their own recovery. This is only possible if staff are also given time to reflect together, on a regular basis, with the aim of developing an understanding of their own, and their clients’ psychological needs, and the relationship between both.
The evidence of the link between adverse childhood experiences and the risk of homelessness is clear. The overrepresentation of ACEs amongst those experiencing homelessness strongly points to the need for effective prevention and early intervention and for strategies across the life course to be developed that aim to reduce the long-term effects of ACE on health and wellbeing. Such intervention has the potential to decrease rates of homelessness, in particular cyclical homelessness. It is also critical to embed trauma considerations across the whole range of services across different sectors so that whichever service the person accesses they will get a service that is trauma sensitive.
CONCLUSION
The cost of ignoring trauma is high. It can take a huge toll on people’s lives and result in a cycle of being in and out of prisons, hospitals and homeless services, and rough sleeping. Developing trauma-sensitive services does not require significant new resources but requires change in the way organisations work, and first and foremost a recognition of the impact of trauma in the lives of people experiencing homelessness.
While it is important to recognise the link between trauma and homelessness, it should not be done at the expense of the recognition of homelessness as a structural problem and the structural inequalities and poverty as the main causes of homelesness.
Notes.
1. In March 2018 the definition of homelessness used to compile national statistics changed, resulting in a drop in overall numbers recorded as homeless, see: Focus Ireland, “Latest Figures on Homelessness in Ireland” (Focus Ireland, 2018), https://www.focusireland.ie/resource-hub/latest-figures-homelessness-ireland/.
2. FEANTSA, “The Third Overview of Housing Exclusion in Europe 2018” (Brussels: FEANTSA, 2019), https://www.feantsa.org/en/report/2018/03/21/the-second-overview-of-housing-exclusion-in-europe-2017; Department of Housing, Planning and Local Government, “Homelessness Report November 2018” (Department of Housing, 2018), https://www.housing.gov.ie/sites/default/files/publications/files/homeless_report_-_november_2018_0.pdf.
3. Robert W. Aldridge et al., “Morbidity and Mortality in Homeless Individuals, Prisoners, Sex Workers, and Individuals with Substance Use Disorders in High-income Countries: a Systematic Review and Meta-analysis,” Lancet 391, no. 10117 (2018): 241–250.
4. Joe Barry, Jo-Hanna Ivers, and Bernie O’Donoghue-Hayes, “Mortality Amongst the Homeless Population in the Dublin Region,” Irish Street Medicine Symposium (Dublin: Institute of Public Health Trinity College Dublin and the Dublin Region Homeless Executive, September 24, 2016),https://www.homelessdublin.ie/content/files/2017-BODH-JI-Mortality-Amongst-the-Homeless-ISM-Dublin.pdf
5. Nick J. Maguire, R. Johnson, P. Vostanis, H. Keats, and R.E. Remington, “Homelessness and Complex Trauma: a Review of the Literature” (Southampton: University of Southampton, 2009), http://eprints.soton.ac.uk/69749/.
6. Multiple exclusion homelessness is defined as, “People have experienced MEH if they have been ‘homeless’ (including experience of temporary/unsuitable accommodation as well as sleeping rough) and have also experienced one or more of the following other domains of ‘deep social exclusion’: ‘institutional care’ (prison, local authority care, mental health hospitals or wards); ‘substance misuse’ (drug, alcohol, solvent or gas misuse); or participation in ‘street culture activities’ (begging, street drinking, ‘survival’ shoplifting or sex work).” Suzanne Fitzpatrick, “Multiple Exclusion Homelessness Across the UK : A Quantitative Survey ESRC End of Award Report” (Swindon : ESRC, 2011), 2.
7. Theresa McDonagh, “Tackling homelessness and exclusion: Understanding complex lives,“ in Round-ups, ed. Joseph Roundtree Foundation (York: Joseph Rowntree Foundation, 2011), 3,
https://www.jrf.org.uk/sites/default/files/jrf/migrated/files/homelessness-exclusion-services-summary.pdf.
8. Eva C. Sundin and Thom Baguley, “Prevalence of Childhood Abuse among People who are Homeless in Western Countries: a Systematic Review and Meta-analysis,” Social Psychiatry and Psychiatric Epidemiology 50, no. 2 (2015): 183–194.
9. The LankellyChase Foundation, “Hard Edges: Mapping Severe and Multiple Disadvantage” (London: The LankellyChase Foundation, 2015),http://lankellychase.org.uk/wp-content/uploads/2015/07/Hard-Edges-Mapping-SMD-2015.pdf.
10. Bessel A. van der Kolk, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma (New York, NY: Viking Books, 2014).
11. Lisa, Goodman, Leonard Saxe, and Mary, Harvey, “Homelessness as Psychological Trauma. Broadening Perspectives,” American Psychologist 46, no. 11(1991): 1219–1225.
12. N.I. Eisenberger, M.D. Lieberman, and K.D. Williams, “Does Rejection Hurt? An FMRI Study of Social Exclusion,” Science 302 (2003): 290–292; Ethan Kross, Marc G. Berman, Walter Mischel, Edward E. Smith, and Tor D. Wager, “Social Rejection Shares Somatosensory Responses with Physical Pain” Proceedings of the National Academy of Sciences 108, no. 15 (2011): 6270–6275.
13. Sandra L. Bloom, “Creating Sanctuary: Healing from Systematic Abuses of Power,” Therapeutic Communities; The International Journal for Therapeutic and Supportive Organisations 21, no. 2 (2000): 67–91.
14. St Mungo’s, “Rebuilding Shattered Lives: The Final Report” (2013c), https://www.mungos.org/publication/rebuilding-shattered-lives-final-report/.
15. Elizabeth K. Hopper, Ellen L. Bassuk, and Jeffrey Olivet, “Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings,” The Open Health Services and Policy Journal 2 (2009), 133., 133.
16. Helen Keats, Nick Maguire, Robin Johnson, and Peter Cockersell, “Psychologically Informed Services for Homeless People: Good Practice Guide” (2012),www.rjaconsultancy.org.uk/6454%20CLG%20PIE%20operational%20document%20AW-1.pdf
