Research Matters Blog
Outreach programs are those that involve bringing services directly to where people are. Such programs have been developed because getting useful information, programs services and supplies that enhance safety to current or potential users can be problematic. This is particularly the case if the expectation is that one must actually go to the provider in question to get what one needs. Barriers, both personal and structural can prevent this from happening, particularly for people who are homeless. For instance, stigma, ill health, lack of money and transportation may make it difficult or unlikely that someone can get to an agency. This becomes even more problematic if a person is not aware that a service or program exists in the first place.
Outreach, when coupled with access to services, creates community linkages at both the client and systemic level. At the client level, it ensures referral to services that address problem substance use and other related health and basic needs. Systemically, it increases collaboration and coordination among service providers to maximize the use of limited resources and ensure the provision of multidisciplinary services to address the needs of individuals and their families. Potential outreach settings may include safe houses, employee assistance programs, health centres, community centres, prisons, mental health facilities, physicians' offices and community educational programs.
Outreach services for people with substance use problems typically involves meeting clients in their own environments. Outreach services provided through drop-in programs, mobile treatment services and street contacts, can increase access to services by providing flexible hours of operation in accessible locations. Outreach is most effective when trust is established and maintained over multiple brief sessions. Activities include dissemination of health information, education on harm reduction strategies, provision of information on community-based resources, identification of strategies for accessing services, and when needed, accompanying clients to preliminary appointments.
Early intervention and outreach strategies require an understanding of the circumstances and needs of each client in order to adapt services and include relevant supports. The goal is to reduce problem substance use as well as enhance overall health and social functioning. Outreach workers engage people in a personalized assessment of their own risk behaviours, and in realistic discussions of resources available to support sustainable changes. Outreach can promote life skills, including personal development, parenting, employment readiness, budgeting, self-esteem, nutrition, stress management, assertiveness and interpersonal relationships.
Peer outreach involves the use of members of the targeted community as outreach workers. For instance, if someone were needed to work with homeless youth, members of this group would be hired to do the work. This approach is seen to be effective because such persons bring a wealth of personal experience to their work. Peers consider their views and information trustworthy.
Service providers that are familiar with the range of services and programs available in the community and knowledgeable about how they may be accessed are invaluable to individuals that require assistance for their substance use problems. Evidence shows that service agreements, related to interagency referral and treatment protocols, are helpful mechanisms for increasing collaboration and coordination among service providers and providing better access to services.
Photo credit: Justin S. Campbell
In our latest website survey, Amanda A. asked: “How much do front-line service providers know about trauma-informed care? Is trauma-informed care taken into consideration when developing policies, especially for youth?”
Trauma plays a significant role in both the pathways to homelessness and the experience of homelessness itself, so the importance of trauma-informed care (TIC) can’t be overstated. But before I go deeper in answering this question, let’s explore what TIC is in the first place.
TIC is a somewhat flexible term that hasn’t always had a static meaning. SAMSHA describes TIC (or in the organization’s terms, “trauma-informed approach”) as an approach that:
- Realizes the widespread impact of trauma and understands potential paths for recovery;
- Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
- Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and
- Seeks to actively resist re-traumatization.”
Hopper, Bassuk and Olivet (2010) reviewed the existing research on TIC and created a consensus-based definition that conveys common themes and practices:
…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.
The authors also differentiate between trauma-informed services (TSS) and TIC, writing that TSS “are specific treatments for mental disorders resulting from trauma exposure, while TIC is an overarching framework that emphasizes the impact of trauma and that guides the general organization and behavior of an entire system” (p. 81). In other words, TIC is an approach established at the agency/organizational level that shapes policies and practices.
The importance of TIC
I have no answer about how much frontline workers know about TIC – it simply depends on each worker and where they practice. There have not been any large or rigorous studies about how many frontline workers or agencies/organizations provide TIC, but the movement to make services trauma-informed has been growing for many years.
Trauma is a major factor in the lives of a great many people, as well as those who experience homelessness. As the authors of the National Center for Family Homelessness’ Trauma-Informed Organizational Toolkit write:
The prevalence of traumatic stress in the lives of families experiencing homelessness is extraordinarily high. Often these families have experienced on-going trauma throughout their lives in the form of childhood abuse and neglect, domestic violence, community violence, and the trauma associated with poverty and the loss of home, safety and sense of security. These experiences have a significant impact on how people think, feel, behave, relate to others, and cope with future experiences.
Trauma can affect anyone – not just families – and is a “common experience among homeless youth prior to homelessness” (Martiljin & Sharpe, 2006). Youth are particularly vulnerable as they are often forced to leave their homes due to violence, conflict and/or bigotry and do not have the supports necessary to live independently. Many youth agencies in the United States have used TIC to reduce the symptoms of diagnosed post-traumatic stress disorder (PTSD), with one participant stating: “This was the first time I felt safe” after receiving care.
McKenzie-Mohr, Coates and McLeod (2012) called for a politicized understanding of trauma in meeting the needs of youth experiencing homelessness and challenge our use of PTSD diagnoses, writing:
While diagnostic labeling of distress and the disregard of context locate the difficulty within the individual, a radicalized notion of trauma puts forward a necessary alternative to the overly narrow PTSD classification. Drawing upon a broadened and contextualized lens to explore distress, the daily experiences of living in a classist, racist, patriarchal and heterosexist society are taken into account…
Indeed, the use of PTSD diagnoses often overlooks the contexts through which youth (and others) experience trauma, and assumes the world is generally safe and not harmful. For many youth in this situation, it is anything but – thus confirming the need for TIC implemented in politicized ways.
Challenges of implementing TIC
Unfortunately, many services for people experiencing homelessness do not take trauma into account. There are many challenges involved in implementing TIC. As Barrow, McMullin, Tripp and Tsemberis not: “Change, especially within larger systems, can be time-consuming and requires a great deal of commitment across all levels of an organization.” Other issues were highlighted by Moses et al. (2003) in their study, including:
…philosophical differences between mental health and substance use treatment approaches, differences around issues of trauma, resistance at the service and administrative levels, limited resources, difficulties in achieving consistent participation in trauma groups, staff turnover, and the difficulty of change in general.
Furthermore, as Fallot and Harris (2009) note, trauma “has often occurred in the service context itself. Involuntary and physically coercive practices, as well as other activities that trigger trauma-related reactions, are still too common in our centers of help and care.” When services created to help people end up harming them, it is clear that we need to take a radically different approach.
More resources about TIC
Trauma-informed practice guide (BC Provincial Mental Health and Substance Use Planning Council, 2013)
10 tips for recovery-oriented, trauma-informed agencies (Center for Mental Health Services, Substance Abuse and Mental Health Services, 2009)
10 reasons for incorporating trauma-informed approaches in programs for runaway and homeless youth (Hollywood Homeless Youth Partnership, 2009)
8 tips for becoming trauma-informed in practice (SAMHSA, 2011)
Trauma-informed care 101 (SAMHSA, 2009)
This post is part of our Friday "Ask the Hub" blog series. Have a homeless-related question you want answered? E-mail us at email@example.com and we will provide a research-based answer.
Photo credit: WHP Women's HIV Program
Addictions programs consists of self-help (i.e. 12 step programs such as Alcoholics Anonymous or Narcotics Anonymous), residential or outpatient treatment facilities, harm reduction programs (including needle exchange programs, safe injection sites and ‘wet’ shelters), individual or group counselling, abstinence-only housing and support from community programs. People dealing with addictions issues may also seek mental health support or services from their primary care physician.
Management and treatment of addictions issues is best provided in a holistic context as there are often concurrent issues at play including mental health diagnosis, past abuse/trauma or physical health concerns. Client-centered support that allows for a partnership or collaboration between the client and practitioners can both empower and support people to make the necessary changes to achieve their treatment goals. Treatment may also be designed to help individual users as well as families, peer groups, communities, and society.
Housing First as a program is predicated on a belief that housing can be provided without any housing readiness requirements. Physical or mental health or addictions issues are often easier addressed once housed. As such, Housing First has a “recovery orientation” which supports individual well-being. Clients may chose to be placed in an abstinence-only housing setting to support their recovery but sobriety is not a requirement for housing.
Many programs that serve people experiencing homelessness who also face addictions challenges are embedded in the harm reduction model. This philosophy is designed to “meet people where they are at” and providing services and supports that best meet their needs. The goal is to reduce the risks and harmful effects of the individual’s addictive behaviours and substance use.
Megan H. asked us about the implications of Toronto’s upcoming fare system changes on people experiencing homelessness.
This week, news reports surfaced about the Toronto Transit Comission (TTC)’s decision to phase out tickets and tokens. Presto, a Metrolinx smartcard system – one that has cost $700 million to develop, according to the auditor general – will be fully integrated across the TTC by the end of 2016, with tokens and tickets being accepted into mid-2017. While this may be a welcome change for some of us, Presto raises a few concerns for people living in poverty and/or experiencing homelessness.
Public transit is very important for this population, as it is usually the only means of transportation available to them. Many are forced to choose between basic costs (like buying food) or a few tokens. The benefits of public transit can go beyond simply getting from point A to point B – providing transportation to people experiencing homelessness often opens up opportunities that weren’t there before. For example, an Edmonton study found that by providing youth with monthly transit passes, their encounters with police and the criminal justice system were reduced. Even so, it appears that people living in poverty or experiencing homelessness are not being fully considered in the TTC changes.
How Presto will work is mostly unknown
Presto, in its current form, charges $6 for new cards, which can be purchased in-person or by mail (takes 7-10 days to arrive). Users must load at least $10 onto each card. Debit, credit and cash can be used. It is unclear how this will change during its rollout, but as it stands, Presto does not make it easy for social agencies – who previously purchased tickets and tokens to distribute – to provide transportation passes to the people they serve. At $6 per card, that’s a hefty markup for handing out TTC rides.
Smartcard systems like Presto assume that people can pay via debit card, credit card or mobile device. That is, indeed, the biggest draw for people like me, who have these things. But what about people who don't have access to these cards? Many people without a fixed address don’t get the luxury of a bank account or a credit card. For these people, who then have to use change to load a card, the Presto process could be more of a hassle than handing over change, tickets or tokens.
Another concern is increased surveillance. Not only does Presto have access to people’s financial accounts, it also tracks our movements – something many people may not be comfortable with. Who has access to this information, and how will it be used?
According to The Toronto Star, there will be a report in November that makes recommendations on how Presto integration (including buying rides in bulk) will work for riders. Hopefully, some of these issues will be addressed.
Public transit in Toronto and other Canadian cities
In Toronto, fares are high and discounted transit plans are dismal. The 12-month pre-authorized plan offers passes to adults for $129.75, and $102.75 for seniors/students – which is as low as monthly passes get.
Most available discounts in the city – via preauthorized plans or Presto – are implicitly most beneficial to people who already have more money. If people get rewarded for loading more money onto a card (ie. buying transit rides in bulk), then they are really being rewarded for having more money to spend upfront. This is a luxury afforded by a minority of transit riders. In 2006, commuters with the lowest income (less than $20,000 a year) were 1.6 times more likely to use transit.
The city and the TTC claim Presto will make discount fares more possible, writing in a joint report:
Smartcard technology will allow for a wide range of fare-pricing options that could not be accommodated previously…For example, fare prices may be linked to travel time, peak/off hours, distance, or vehicle type. Moreover, the Presto cards could also be linked to a low-income rider’s registration in a discount transit fare program funded by the city or through a partnership with an external organization.
Of course, this would be great – if card signup fees were waived and there actually was a low-income program in Toronto. According to numbers compiled by The Toronto Star, Toronto has the second-highest ridership in North America, but receives the least amount of government subsidies – meaning it relies mostly on riders for funding. Because of this, Toronto riders see plenty of fare increases but few financial breaks. In 2014, city council voted to look into creating a low-income transit pass, but have not made any statements yet this year. The following infographic from Toronto Public Health, though somewhat dated, shows just how expensive transit can be in Toronto for people with low incomes:
Other Canadian cities are leading the way when it comes to creating low-income transit programs. Recognizing the relationship between poverty, transit and social isolation, Calgary implemented a low-income monthly transit pass. Edmonton Transit is considering a similar program. Other examples include the British Columbia buss pass discount (seniors and people receiving disability benefits) and Saskatchewan’s discounted public transit program (people receiving social assistance).
Some American cities with homeless populations have similar transit systems:
- New York City’s system, MTA, offers mixed fares available at booths, on buses and in vending machines. Metrocard users get an 11% bonus and various discounts, while others can use cash to pay fares. MTA only charges $1 for new cards, and they can otherwise be refilled and reused. Like Toronto, MTA only offers discounts for seniors and people with disabilities.
- In San Diego, MTS offers discounted fares and passes for seniors, people with disabilities, and people receiving Medicare/social assistance. MTS uses a smartcard system called Compass, which charges a $2 administration fee for new cards. People with discounted passes and fares can only reload their cards in person.
- In San Francisco, the SFMTA uses a multi-pass system like the TTC currently does, with single-rides, smartcards (called Clipper cards). The system offers discounts to seniors, students and people with disabilities/who receive Medicare; as well as those who are considered low income. Clipper cards cost $3, which is waived for discount fares/passes and for adults who opt to use the autoload feature.
What can be done?
While the city of Toronto and the TTC both seem committed to full Presto integration, there are still many unanswered questions, including:
- How will rider details (finances, travel information) be used and/or protected?
- Will card fees be waived for bulk purchases (by social agencies) or for people designated as low income?
- Can multiple cards be easily loaded? (Is there a way to reproduce the simple act of handing out tokens and tickets?)
- How can people without debit/credit cards and cell phones going to receive and maintain cards? Will this option be available at all stations/points of access, or just a few?
- Will a low-income transit pass program be implemented after all?
Write your local councillors! Let them know that these questions are important to you and that you expect the city of Toronto and the TTC to take poverty and homelessness into account while integrating Presto.
This post is part of our Friday "Ask the Hub" blog series. Have a homeless-related question you want answered? E-mail us at firstname.lastname@example.org and we will provide a research-based answer.
The health and well-being of children is strongly related to the environmental conditions that they grow up in. A growing body of research has found strong links between adverse childhood experiences and long-term negative effects on children across the lifespan. The term adverse childhood experiences (ACEs) is used to refer to potentially traumatic events that can have lasting negative effects on health and well-being. The term ACE originates from an ongoing research project that looks at what impact traumatic events in childhood have on future social and health outcomes. The below infographic, published by the Robert Wood Johnson Foundation as part of their series on ACEs, provides some details on the prevalence of ACEs and their impact.
The three types of ACEs include abuse, neglect and household dysfunction. A large U.S. study has revealed that a significant portion of its study participants have a history of ACEs. Over a quarter of all participants reported physical abuse, and 20% of participants reported sexual abuse. Under the household dysfunction header, 27% of participants reported the presence of household substance abuse and 12.7% of participants reported domestic violence against their mother. Over 60% of all participants reported at least one ACE. These are startling figures.
An increase in the number of ACEs corresponds with increased risk for several negative outcomes, meaning an individual with three ACEs is significantly more likely to experience poor health outcomes than an individual with no ACEs. These risk outcomes can be broken up into two main categories: risks to behavioural trends and risk to physical and mental health. Behavioural risks include things like low physical activity, smoking, alcoholism and drug use. Poor behavioural outcomes can function in causal pathways leading to poor physical and mental health outcomes. Physical health outcomes that have shown strong correlations with ACEs include severe obesity, diabetes, contracting STDs or heath disease, and even getting cancer. Mental health outcomes associated with ACEs include depression, as well as affective and anxiety disorders.
In 1997, researchers working with the New York State Psychiatric Institute conducted a study to see if adverse childhood experiences were risk factors for homelessness. 92 individuals who had previously experienced homelessness were compared with a control group of 395 individuals who had no prior homelessness. Telephone surveys, designed with a focus on childhood physical and sexual abuse and inadequate parental care, were administered to participants. Researchers found that a lack of parental care significantly increased subsequent homelessness. The same trend was observed for individuals who had experienced physical abuse; these individuals were 16 times more likely to have experienced homelessness than their counterparts who had not experienced physical abuse. Researchers concluded that adverse childhood experiences are “powerful risk factors for adult homelessness”.
The ACEs study provides a great platform for discussions on the importance of healthy childhood development on the lifespan. Increasing awareness about the link between negative health outcomes can help develop innovative prevention and treatment approaches that can help reduce risks associated with ACEs.
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The analysis and interpretations contained in the blog posts are those of the individual contributors and do not necessarily represent the views of the Canadian Observatory on Homelessness.