Re-traumatization is a problem that trauma survivors face frequently and as a services provider being aware of the potential for this to occur is crucial. This article provides information that will aid service providers in becoming more aware and critical when dealing with trauma survivors.
Interpersonal violence and trauma permeate the lives of people who experience homelessness leaving trails of silence, terror, rage and pain in its wake. Intimate violence shatters relationships, creating disconnection and distrust, helplessness, loss of autonomy and a sense of a foreshortened future. Because trauma so often happens in the context of relationships, it is within relationships that healing occurs. Becoming trauma-informed means generating environments that help people re-establish a sense of control, connection and meaning.
In addition, being trauma-informed means acknowledging that people are fundamentally changed when traumatic events happen. Therefore, recovery from those events is a process of discovery rather than an attempt to go back to the way things once were. Discovery is made possible when services and programs explore the meaning of safety from multiple perspectives, foster authentic connections that build trust and share power by supporting choice and autonomy. It also means approaching service delivery and policy review from a perspective reflecting “trauma first…., diagnosis/liability second.” Establishing safety is the first step to co-creating environments with clients that foster recovery and avoid retraumatization. But how do we do this?
The principles of recovery are confluent with the principles of becoming trauma informed. Some of the common values are:
- Supporting people in becoming the central directors in their own healing.
- Healing starts with the person, no matter how vulnerable they appear to be.
- Hope is essential to healing.
- Autonomy and self-determination foster recovery.
- Building trust and establishing connection create opportunities for discovery.
- People are doing the best they can at any given time to cope with immeasurable losses.
- A sense of safety is key to recovery.
- Recovery is possible.
What does it mean to approach people in a way that is trauma-informed? It means approaching them in a way that honors their strengths as well as vulnerabilities. It means creating opportunities for people who are homeless to become empowered to act as the central directors of their own lives. This often happens when individuals serving clients are willing to share power by being honest and authentic in their interactions. It also means taking into account that feelings of powerlessness and terror are stimulated by loss of control. These feelings are awakened in environments and approaches to service delivery that are crisis-driven, reactive, restricted, crowded, noisy and chaotic.
Being Proactive Rather than Reactive
Crises can lead to the use of coercion and force, such as police or security intervention, when shelter staff and outreach workers are put in positions to react. The immediate nature of crises tends to strip clients of power and control, leading to escalation and re-enacting prior traumatic events. In order to avoid retraumatization, to foster empowerment and increase partnerships with clients, it’s essential to plan as far in advance as possible. The more proactive we can become by asking what helps and what makes things worse in times of crises, the greater the opportunity to align with clients in their healing. The more information that can be gathered with clients when they are not in crisis and a plan developed regarding how best to respond, the more likely it is we can avoid the retraumatization that happens when control is taken away.
The following steps reflect a process that fosters opportunities for recovery and healing by optimizing client choice through proactive planning to avoid crisis and retrauma.
Introduce yourself when you meet someone and tell them why you are speaking with them and what you hope to accomplish. Even if you’ve seen them many times before, they may need to be reminded, particularly if they are using substances, hearing voices, taking medications, have head injuries and focused on surviving day to day. Other useful questions include:
- What is your most important priority right now?
- What can we do together to ease the pain, discomfort, loneliness, fear….or whatever emotion you sense?
- Are you a mom/dad/sister/brother?
- What have you done for work in the past? What would you like to do?
- Did/Do you belong to a faith that provides support or comfort?
- Who is your closest friend?
- Do you have children? How long has it been since you have seen them?
Provide information about how services work. Regular program procedures and policies give people an opportunity to make informed choices. Fostering autonomy builds trust in relationships. This is particularly important when people have been physically and emotionally controlled and violated in the past. Homelessness itself amplifies and compounds these losses. It is, therefore, particularly important to share power by giving people information, so they can begin to make decisions for themselves.
Some useful information to provide might include:
- How services work.
- How often they are provided and where.
- What alternatives might be available.
- Benefits and consequences of accepting services.
- Requirements/ rules/procedures for staying in certain shelters.
- Rules/ requirements for accepting benefits.
- What happens during intake. Are there exams for medical clearance? Do people have to remove their clothing? Are the same gender staff available?
The following approaches and questions are meant to provide an outline of things to consider when designing and implementing an assessment process. They won’t apply in all situations and should be tailored to the particular group of people being assessed. The point is to create a dialogue with clients at the first opportunity about their histories and to draw on their self-knowledge about what helps and what makes things worse when they are having a hard time. In this way, providers and clients can enter into a partnership with the goal of helping people avoid triggering situations and crises. The information also assists providers in getting to know clients better, the survival skills they have learned, and strengths they have developed.
Some thing to consider about the assessment process:
- Is privacy provided when clients are being asked personal questions about themselves, their background or health? Even if someone is on the street, are they assessed away from other people who can overhear? This is important because the information someone provides could potentially put them at risk if the wrong people hear it. In our attempt to help, it’s important not to make people more vulnerable.
- If we are assessing people for medical problems, how is privacy protected?
- Are people being assessed under fluorescent or high pulse lights? People who have been subject to head trauma are predisposed to seizures. High pulse lighting makes it more difficult to focus and is far less soothing than incandescent lighting.
- Are there implements that are reminders of prior weapons? These might be such common items as scissors, knives, forks, needles, gurneys with restraint straps, nightclubs, handcuffs, and mace.
- Are there people present wearing uniforms, badges or other symbols of power?
- Time of the day: night time is notoriously difficult for people who have been assaulted.
- Is the environment unlocked so people can exit the interview easily?
- Are entrances and exits unblocked? Make sure you’re not blocking someone’s exit.
- Are providers positioned at the same height as clients? (Are people standing over those using wheelchairs or other assistive devices?) You want to be at the same height so you can make good eye contact with someone.
- Asking specific questions will yield more accurate information than general questions. For instance, asking: “Have you ever been abused?” is likely to yield a negative response. People often do not associate abusive actions with that label. All too often, being assaulted is normative. So questions should address the information you seek such as: “Have you ever been hit, kicked or punched?” This is more likely to yield an accurate response.
Here are some things to consider when assessing someone:
- Are people in physical danger at the moment?
It seems odd to ask this question when we know that people who are homeless are obviously vulnerable to physical threat all the time. And yet, it is still a useful question to ask, given the rates of violence people experience. People are often fleeing violent situations and have past or present experiences of being stalked, threatened and hurt. Therefore, we need to ask if they are being threatened with physical harm in the present.
- Asking about prior histories of trauma. Have they been hit, knocked out (hit in the head and lost consciousness), kicked, punched, assaulted with a weapon, forced to have unwanted sex in the past?
- What are some things that help (make a list) when they are having a hard time?
- What are some things that make it worse (triggers) when they are having a hard time? (Make a list)
- Is there someone who can be contacted if they are having a hard time? Who are they? Do we have permission to contact them?
How do we act in ways that are trauma-informed, recovery-oriented and person-centered? Some things to consider include:
- Is privacy provided for people to change, sleep, use the shower and bathroom?
- Are the shelter rules the same for men and women?
- Are there support groups for people to access?
- Are there groups that address grief, loss, rage, trauma, parenting, substance use?
- Is there a known presence of people who are formerly homeless providing services?
- Do people use people-first language? (Ex: “People with substance use problems” People diagnosed with mental illness”)
- Does staff believe recovery is possible for everyone including those diagnosed with a mental illness who are homeless?
- Do we repeat back what people say so they know they have been heard?
For more information:
Prescott, L. and Bassuk, E. The Long Journey Home: A Companion Guide for Creating Trauma–Informed Services for Homeless Mothers and Children. Newton, MA: National Center for Family Homelessness.