Healing from Within: Homelessness, Trauma and the Role of Evidence-

Based PracticeKatharine Wenocur & Meghan Parkinson-Sidorski

Jane Addams Place/ Lutheran Settlement HousePhiladelphia, PA

Jane Addams Place

Image Credit: OCF Realty

• Lutheran Settlement House• BDVP, Senior Center, Afterschool

program, Urban Farm• Family Shelter in West

Philadelphia• Daily Census: 29 mothers and

~65 children• Trauma-Informed Approach

• “Sanctuary Inspired”• Onsite behavioral health

services to address traumatic exposure

2014 Point in Time Count 19.4% of Philadelphia’s homeless

population is comprised of families with children under the age of 18

511 Families living in Emergency shelter 969 children 543 Adults

2015Point in time count 670 unsheltered persons (86% increase

from previous year)

Philadelphia: A Snap Shot

Source: The 2014 Annual Homeless Assessment Report to Congress: Point-in-Time Estimates of Homelessness; The 2015 Office of Supportive Housing: Philadelphia's Continuum of Care 2015 PIT count

Image Credit: visitphilly.com

Homelessness & TraumaExploring the Link

What Is Trauma?

“Trauma is personal. It does not disappear if it is not validated. When it is ignored or invalidated the silent screams continue internally heard only by the one held captive. When someone enters the pain and hears the screams healing can begin.” 

Source: Danielle Bernock, Emerging with Wings: A True Story of Pain, Lies and a Love That Heals

Image Credit: apa.org

Adverse Childhood Events (ACEs)

Abuse & Neglect Physical Abuse Emotional Abuse Sexual Abuse Emotional Neglect Physical Neglect

Household Dysfunction Substance Abuse in home Mentally Ill household

member Domestic Violence Incarcerated Relative

Additional Urban ACEs Witnessed Neighborhood

Violence Bullied Lived in Foster Care Felt Discrimination

The Philadelphia Urban ACE study. (2013, September 18). Retrieved November 23, 2015 from www.instituteforsafefamilies.org/philadelphia-urban-ace-study

Adverse Childhood Events (ACEs)

At least 4 ACEs More likely to smoke Higher rates of substance use Higher rates of depression

~20% attempt suicde Physical Health

Athsma Severe Obesity Diabetes Cancer

The Philadelphia Urban ACE study. (2013, September 18). Retrieved November 23, 2015 from www.instituteforsafefamilies.org/philadelphia-urban-ace-study

When Does an Adverse Event Become Traumatic?

Source: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V)

After directly experiencing, witnessing or hearing about an adverse event, exhibiting symptoms in four categories; Re-Experiencing

Spontaneous memories, flashbacks, recurrent flashbacks Negative Cognitions

Sense of blame, diminished interest in previously enjoyable activities Mood

Estrangement from others, diminished ability to remember key aspects of the event

Arousal Aggressive, reckless or self-destructive behavior, sleep disturbances, hyper-

vigilance

Childhood PTSD

Nightmares Toileting Accidents

Bed-wetting Mastery/ Re-enactment

play Batman

Image Credit: mom-psych.com

Homelessness-Trauma Link

Herbers, J., Cutuli, J., Monn, A., Naryan, A. & Masten, A. (2014). Trauma, adversity and parent-child relationships among children experiencing homelessness. Journal of Abnormal Clinical Psychology, 42, 1167-1174.

Increased risk of experiencing ACEs

Recent Philadelphia Study Average 3.05 ACEs

reported >10 reported

Complex Trauma

Common ACEs Domestic Violence Incarcerated Parent Divorce/Separation Community Violence Medical Trauma D&A in family

Homelessness-Trauma Link

Bassuk, E.L., DeCandia, C.J., Beach, C.A., & Berman, F. (2014, Nov.) America’s youngest outcasts: A report card on child homelessness. Retrieved from www.homelesschildrenamerica.org

Complex Trauma is a “prolonged, persistent traumatic stress that often originates within the caregiving system during critical developmental stages.”

Image Credit: hcpl.net

Barriers to Service Access

The Young family consisted of mom,  daughter Maya ( 7 years old) and two sons John (9 years old) and Frank (13 years old). The Young family entered shelter after mom lost her job and unemployment funds ran out. Mom had a bipolar diagnosis but had not received treatment in many years. During their residency Mom became symptomatic and soon the children distributed disruptive behaviors. John and Frank would often become physically aggressive with mom, each other and staff. There were incidents of them damaging property, breaking a window, hitting staff and running away. Staff had little immediate resources as intake appointments for local mental health providers had a 30-60 day wait. 

Trauma-Focused & Trauma Informed

Evidence-Based Practice

A Quick Note on Language

Trauma-Informed Practices that are

sensitive to past trauma, but do not directly treat trauma.

“Universal Precautions” Appropriate for staff

members across disciplines

Trauma-Focused Clinical models developed

specifically to treat post-traumatic symptoms

Implemented by licensed clinicians

“The conscientious use of current best evidence in making decisions about patient care”

Evidence-Based Practice

Process vs. Treatment Supported by Scientific

Research Adaptations made for

specific client or population

Continually evolving

Source:

The Sanctuary Model

The Sanctuary model is a trauma informed theory based approach to change organizational culture. An organization that has adopted the Sanctuary Model allows for a more effective environment for healing from traumatic experiences. 

Sanctuary Mission: " To teach individuals and organizations the necessary skills for creating and sustaining nonviolent lives and nonviolent systems and to keep believing in the unexplored possibilities of peace." 

Source: The Sanctuary Institute

The Sanctuary Model

Key Components S.E.L.F Group

(Safety, Emotions, Loss, Future)

The Seven Sanctuary Commitments

Red Flag Meeting Safety Plans

Growth & ChangeNon-ViolenceEmotional IntelligenceSocial ResponsibilityOpen CommunicationDemocracySocial Learning

Source: The Sanctuary Institute

Child and Family Traumatic Stress Intervention (CFTSI)

Peri-traumatic period 30-45 days following

traumatic event or disclosure of abuse

Short term Completed in 4 to 6

sessions Parent-Child sessions

Target Audience: 7-18 years old + parent/caregiver

Early Intervention/ Prevention

Tools to manage symptoms as they arise

Berkowitz, S.J., Stover, C.S. & Marans, S.R. (2011). The child and family traumatic stress intervention: Secondary prevention for youth at risk of developing PTSD. Journal of Child Psychology and Psychiatry, 52(6), 676-685.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

“Gold Standard” for childhood traumatic stress

25+ years research RCTs

Designed to treat PTSD symptoms

Individual, parent and joint sessions

Target Audience: 3-18 years old and non-offending caregivers

12-16 sessions More for complex

trauma Identify and implement

coping skills, creation/processing of trauma narrative

Source: Rowan University CARES Institute

Trauma-Focused Services in Emergency Housing

Jane Addams Place

Source:

Trauma Histories of Clients Families enter shelter following DV, house fires,

incarceration of parents, etc. Behavioral Presentation

Children involved in physical altercations, truancy/disciplinary issues at school, withdrawing from social activities, etc.

Service Access Issues Waiting lists for outside providers, families leave

shelter, change phone numbers, etc.

Our Challenges

Onsite clinician trained to provide TF-CBT to Jane Addams families Can respond to crisis cases immediately,

sensitive to the unique needs of homeless families

Formal and informal support for referrals and consultations Children’s Hospital of Philadelphia, local

behavioral health providers

Our Proposed Solution

Healing Takes PRACTICEP Psychoeducation, Parenting R RelaxationA Affect RegulationC Cognitive CopingT Trauma NarrativeI In Vivo ExposureC Conjoint SessionsE Enhancing Future Safety

More About TF-CBT

Source: Rowan University CARES Institute

Sample “PRAC” ActivitiesPsychoeducation: Reading a topical children’s bookParenting Skills: Creating a sticker chartRelaxation: Stress balls, blowing bubblesAffect Regulation: Feelings Bingo, Feelings JengaCognitive Coping: Safety Planning

Trauma Narrative = written work detailing the events of the traumatic experience.

Created in safety, making use of PRAC skills Therapist challenges negative cognitions (e.g.

“It was my fault that daddy hit mommy”) Flexibility of format

Prose, poetry, rap/spoke word, painting, etc. Ultimately shared with the parent/caregiver

More About TF-CBT

Source: Rowan University CARES Institute

Our Challenge Our SolutionLow participation rate Outreach with families around

the time of intake; ‘Breathing Buddies’

Low referral rates Outreach with shelter staff; explaining impact, increasing ‘buy in’

Low completion rates Consultation with local experts and scientific literature; adaptations made to model

Implementation Challenges

Enrollment (since May 2014) 80 children referred 45 children received counseling 29 children completed TF-CBT

Decreased Symptoms 86% children decreased PTSD symptoms (self

report) 97% children decreased problem behaviors

(parent report)

Our Outcomes

Sample Activities

Deep Breathing

“Breathing Buddy”1. Place breathing buddy on

your belly at bedtime2. Breath in and out 3 times-

watch breathing buddy move up and down

3. Repeat as needed

Pinwheels, Plastic Straws, Bubbles can all be used to practice deep breathing during a difficult moment

Mindfulness“Shake up your mind jar and imagine that the flecks of glitter are your thoughts swirling around inside your head. Watch the glitter settle down as you thoughts settle down.”

Emotions Identification

“I feel mad when you call me names”

“I felt sad when you took my toy”

“I am happy when we play Connect 4”

What Would You Do?

Questions?

Thank You!