Serving Women who are Transitioning out of Homelessness

1. Serving Women who are Transitioning out of Homelessness Susan Foster, MPH, MSSW Megan Edson Grandin, MPH

2. Purpose • Understand the lived experience of women experiencing chronic homelessness. • Learn about the needs of women in supportive housing. • Explore strategies for providers serving formerly homeless women in permanent supportive housing.

3. The ache for home lives in all of us, the safe place where • we can go as we are and not be questioned.~ Maya Angelou

4. Background on women experiencing homelessness Part 1

5. Who are the Women Served by the Services in Supportive Housing Program? • Average age 45 to 54 years • Racial and ethnic minorities disproportionately represented

6. Risk Factors Associated with Homelessness • Undereducation • Lack of employment opportunities • Lack of social support • Domestic violence • Mental health issues • Substance use issues • Housing instability • Fixed incomes • Eviction • Unsafe housing • Poverty • Change in marital status • Lack of affordable housing • Military discharge • Death of last living parent • Widowhood • Divorce • Incarceration • Lack of access to health care and other services Baker, Niolon, Oliphant, 2009; Caton, Wilkins & Anderson, 2007; Feen-Calligan, Washington & Moxley, 2009; Hightower, 2009; Kisor & Kendal-Wilson, 2002; Lehmann, Kass, Drake & Nichols, 2007; US Department of Housing and Urban Development, 2010

7. “Many problems these women face are not of their own making and they find themselves in vicious cycles in which distress is reinforced by unresolved issues that literally ‘pile up.’” • ~Olivia Washington, Ph.D.Wayne State University Washington, Moxley, Garriott & Weinberger, 2009

8. Older women experiencing homelessness: a new trend? • Considered “older” at the age of 50, due to the physical effects of homelessness • Disconnected from services and benefits • Fixed income • Factors such as under-education, lack of employment training and economic inequalities may begin early in life Hightower, 2009; Kisor & Kendal-Wilson, 2002; Washington, Moxley, Garriott & Crystal, 2009; Washington, Moxley & Taylor, 2009

9. Women Experiencing Chronic Homelessness • Compared to women with situational homelessness, women experiencing chronic homelessness are: • Older • In poorer health • More likely to have a history of severe and persistent mental health issues • More likely to have substance use issues • Often separated from their children • Cumulative trauma • Persistent unemployment • Disconnected from services and benefits • Social isolation Caton, Wilkins & Anderson, 2007; U.S. Department of Housing and Urban Development Office of Community Planning and Development, 2010; Zlotnick, Tam, Bradley, 2007

10. Special Needs of Mothers Experiencing Homelessness • Number of families experiencing homelessness is increasing • Multiple moves • Family separations • Parenting in public • Fragmented social networks Friedman, 2000; National Alliance to End Homelessness, 2011; US Department of Housing and Urban Development, 2010

11. Fragile Support Networks Among Mothers Experiencing Homelessness • On average, families will live with three different friends and family members before going to a shelter • Social networks frequently exhausted before becoming homeless Friedman, 2000

12. Up to 70% of women experiencing homelessness are mothers who have been separated from their children. Bassuk, Buckner, Perloff, Bassuk, 1998; Cowal et al., 2002; Hoffman & Rosenheck 2001; Zlotnick, Roertson & Wright, 1999; Zlotnick, Tam, & Bradley, 2006

13. The Effects of Cumulative Loss and Trauma in the Lives of Women Bassuk, Buckner, Perloff, Bassuk, 1998; Cowal et al., 2002; Hoffman & Rosenheck 2001; Zlotnick, Roertson & Wright, 1999; Zlotnick, Tam, & Bradley, 2006

14. The Lived Experience of Women While Homeless Part 2

15. What is life like for a woman who is homeless and alone? STRUCTURAL Daily survival Low or no income “Shelter hopping” TRAUMA Violence Rape Sexual Abuse Robbery History of incarceration Lack of social networks HEALTH Substance use disorders Mental health problems Chronic medical issues Head injuries Malnutrition Lack of continuity of care Lack of linkages to services

16. Structural Issues STRUCTURAL Daily survival Low or no income “Shelter hopping” TRAUMA Violence Rape Sexual Abuse Robbery History of incarceration Lack of social networks HEALTH Substance use disorders Mental health problems Chronic medical issues Head injuries Malnutrition Lack of continuity of care Lack of linkages to services

17. Daily Survival • Lack of privacy • Lack of storage • Lack of bathing facilities • Interrupted sleep • Difficulties obtaining nutritious food • Lack of routine • Exposure • Fear of violence, robbery Davis & Shuler, 2000; Liebow, 1993

18. Social Isolation and Loneliness • Lack social networks or loss of family before becoming homeless • Difficulties remaining in contact with their networks while homeless • Supports on the street may be functional or dysfunctional. When a person transitions out of homelessness, she may have to leave unhealthy friendships behind. Friedman, 2000; Kisor & Kendal-Wilson, 2002; Toohey, Shinn & Weitzman, 2004

19. Health Issues STRUCTURAL Daily survival Low or no income “Shelter hopping” TRAUMA Violence Rape Sexual Abuse Robbery History of incarceration Lack of social networks HEALTH Substance use disorders Mental health problems Chronic medical issues Head injuries Malnutrition Lack of continuity of care Lack of linkages to services

20. Medical Issues • 82% have history of sexually transmitted infections • 22% asthma • 20% anemia • 13% HIV • 4% hypertension Bharel, Casey & Wittenberg, 2009; Kilbourne et al., 2001; Long, Tulsky, Chambers, Alpers, 1998; Nyamathi, Flaskerud, Dixon & Lu, 2001; Nyamathi, Leake & Gelberg, 2000; Stein, Lu, Gelberg, 2000; Hightower, 2009; Kilbourne et al., 2001; Stein, Lu, Gelberg, 2000; Washington, 2005

21. Medical Issues among Older Women Experiencing Homelessness • Health issues associated with aging occur at an earlier age for women experiencing homelessness. • High prevalence of chronic diseases such as: • 69% heart problems • 61% hypertension • 52% diabetes • 52% arthritis Gonyea & Bachman, 2009

22. Severe and Persistent Mental Health Issues • 28% Schizophrenia • 24% Bipolar disorders • 24% Personality disorder • 46% Co-occurring disorders Bassuk, Buckner, Perloff & Bassuk, 1998; Hoffman & Rosenheck, 2001; Nyamathi, Leake & Gelberg, 2000

23. Prevalence of Substance Use • 60% alcohol use • 47% illicit drug use • 10-20% injection drug use Heslin et al., 2007; Long et al., 1998; Nyamathi, Keenan & Bayley, 1998; Tucker et al., 2005

24. Substance Use • Use of substances to escape the harsh realities of living on the street • In addition to alcohol and illegal drugs, prescription and psychotropic medications are traded and misused • Increased victimization • Barrier to some services Nyamathi et al., 2003; Stump & Smith, 2008; Tucker et al., 2005

25. Traumatic Brain Injury • Approximately 42% of women experiencing homelessness have reported a brain injury • Manifests in different ways • May have different origins (domestic violence, attacks while living on the streets, etc.) • Range of motor and sensory effects, cognitive problems, and emotional symptoms • May mimic the symptoms of mental illness Center for Substance Abuse Treatment, 2010; Hwang et al., 2008

26. Lack of treatment

27. Barriers to Accessing Care • Lack of knowledge of where to seek care • Long waiting times • Lack of health insurance • Lack of documentation • Long wait lists • Lack of transportation • Conflicting priorities • Lack of child care • Language barriers • Cultural barriers • Fear of seeking care • Stigma Bharel, Casey & Wittenberg, 2009; Bonin et al., 20003; Gelberg et al., 2002; Lewis, Andersen & Gelberg, 2003; Long, Tulsky, Chambers & Alpers, 1998; Luhrmann, 2008; Nyamathi, Stein & Swanson, 2000; Swanson, Andersen & Gelberg, 2003

28. Trauma STRUCTURAL Daily survival Low or no income “Shelter hopping” TRAUMA Violence Rape Sexual Abuse Robbery History of incarceration Lack of social networks HEALTH Substance use disorders Mental health problems Chronic medical issues Head injuries Malnutrition Lack of continuity of care Lack of linkages to services

29. Physical and Sexual Abuse in the Lives of Women Experiencing Homelessness Austin, Andersen, & Gelberg, 2008; Bassuk et al., 1996; Brown & Bassuk, 1997

30. Post-Traumatic Stress Disorder (PTSD) • Women experiencing homelessness have PTSD at three times the rate of the general population • For women who have experienced trauma, each additional trauma increases her risk of PTSD by 40% Bassuk et al., 1996; Stump & Smith, 2008

31. Austin, Andersen & Gelberg, 2008; Heslin, Robinson, Baker & Gelberg, 2007; Nyamathi et al., 2003; Nyamathi, Leake, Gelberg, 2000; Tucker et al., 2005; Stump & Smith, 2008; Wenzel, Koegel, Gelberg, 2000

32. Assessment and Service Planning Part 3

33. Assessment Principles • Assessment is about engagement and understanding, not just diagnosis • Assessment should be comprehensive • Consumer identifies needs and prioritizes services she can accept • Focus on strengths • Assessment is informed by culture • It takes time

34. Focus on Strengths • Builds trust among consumers and service providers • Focus on strengths • Encourage self efficacy and control • Emphasize faith/spirituality

35. Components of Comprehensive Assessments • Health/medical • Traumatic brain injury • Mental health/trauma • Substance use • Family/children • Income/benefits • Other tangible supports • Previous/current agency or system involvement

36. Overall Approach to Services – What’s Working Part 4

37. Evidence-Based Practices for Women Transitioning out of Homelessness

38. Evidence-Based Practices • Seeking Safety • Dialectical Behavioral Therapy (DBT) • Illness Management and Recovery (IMR) or Wellness Recovery Action Plans (WRAP) • Motivational Interviewing • Family Psycho-Education • Trauma-informed care

39. Seeking Safety • Designed for women with trauma and substance use histories • Integrated treatment • Helps clients attain safety in relationships, thinking, behavior and emotions • Focus on ideals • Content (which incorporates information on cognitive, behavioral, interpersonal, and case management) • Attention to clinical processes Desai, Harpaz-Rotem, Najavits, & Rosenheck, 2008

40. Dialectical Behavior Therapy • Teaches effective coping skills, distress tolerance, mindfulness, emotional regulation • Focus is on empowerment • Highly active and participatory • Can be conducted in groups or individually Washington, Moxley & Taylor, 2009

41. Illness Management and Recovery or Wellness Recovery Action Plans • Engages consumers in developing goals for recovery • Empowers individuals with MH and COD to manage their own recovery • Can be facilitated by non-clinicians • Good for programs with a recovery focus and ability to serve women long-term • Can be combined with other techniques such as motivational interviewing

42. Motivational Techniques • Effective for individuals in all stages of recovery from addiction • Helps consumers recognize triggers for relapse, develop coping skills to prevent future relapse • Encourages recovery through positive feedback • A way for staff to understand and respond therapeutically to active substance use

43. Psychoeducational Multifamily Groups • Treats schizophrenia, bipolar disorder, major depression, and other disorders • Focus on coping skills, solving problems, social supports, developing an alliance between consumers, practitioners, and their families or other support people • Takes place in group setting McFarlane et al., 2003

44. Trauma-Informed Care • Recognizes the impact of trauma in all aspects of one’s life • Recognizes that many symptoms are coping responses to past traumatic experiences • Recognizes the importance of people at all levels of the organization and decreases power imbalances in relationships • Creates a partnership between consumers and providers, recognizing that consumers are experts in their own care • Focuses on preventing re-traumatization • Empowers consumers with choices about care Prescott, Soares, Konnath & Bassuk, 2008

45. Beyond EBPs: Supporting the Whole Person

46. What do women experiencing homelessness need? Case Management

47. What Providers Need to Do Their Jobs

48. What Providers Need • Training, particularly in trauma-informed care, benefits, agency regulations • Strong team leadership • Strong team culture • Support for self-care • Strong supervision

49. Preventing Staff Burnout • Staff retreats • Regular staff meetings • Celebrations • Team social outings To download a free copy of “What About You? A Workbook for Those Who Work with Others,” please visit http://www.familyhomelessness.org/resources.php?p=sm. Olivet, McGraw, Grandin, Bassuk, 2009

50. Conclusion