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Winter 2010/11 | Vol 14 No 2

Focus

Waiting on the welcome mat

How to be at home with trauma-informed care

By Richard Bebout

Nearly 10 years ago I articulated an argument for why service providers working in the supportive housing arena need to become “trauma informed.” The vast majority of men and women in mental health and substance abuse services have been exposed to traumatic violence. Whether violent victimization began in the childhood home, institutional settings like jail and hospital, or in shelter, on the streets, or in other precarious living arrangements, housing situations have the potential to evoke familiar trauma dynamics or, even worse, to set the stage for literal reenactments.

Power and control in supervised living arrangements, for example, may reactivate feelings of vulnerability and powerlessness, and of having no choice and no voice. When staff control access to housing resources, or even literally control the front door because a resident does not have keys or the legal protections of a lease, real or perceived threats of housing loss can recall childhood or later interpersonal violence situations and the very real sense of having “no escape.”

Beyond minimizing the risk that supportive housing situations might replicate old dynamics associated with traumatic violence, delivering support services in people’s homes also presents unique opportunities to observe behaviour patterns that are linked to past experiences of violence. Rather than construing these behaviours as “symptoms” or purely “problems,” staff should understand them as the best coping strategies available to the survivor. Self-injury, obsessive-compulsive behaviours, the use of drugs and alcohol for managing common trauma sequelae such as hyper-vigilance, sleep difficulties, intrusive memories or numbing and dissociation—all of these may announce themselves more readily during in-home contacts than at structured, office-based appointments.

This does not mean that all housing specialists need to be experts in treating acute PTSD–related symptoms. It does mean, however, that frontline staff can and should be educated about common trauma impacts through traumatraining, for instance. Even landlords, housing quality inspectors, property managers and repair staff or vendors should be sensitized to the importance of scheduling visits, calling ahead and knocking to gain entry rather than simply letting themselves into someone’s apartment. The person may be heavily medicated or in a dissociative state, or may have an exaggerated startle reaction or aggressive, self-protective response triggered by an intrusion. Well-trained frontline staff are more likely to respond helpfully by emphasizing what’s healthy and adaptive and by relabeling problem behaviours like substance use, self-harm or recurrent relationship problems as possible examples of trauma-related coping strategies that were once the only things that worked for a survivor, despite the obvious fact that they now have increasingly costly adverse effects.

Whether violent victimization began in the childhood home, institutional settings like jail and hospital, or in shelter, on the streets, or in other precarious living arrangements, housing situations have the potential to evoke familiar trauma dynamics or, even worse, to set the stage for literal reenactments.

Likewise, trauma-informed housing support staff understand and reframe key skill deficits as expectable occurrences in the wake of life-long traumatic violence. A shift then becomes possible, so that the housing specialist is not merely cautioning someone about violations of the “guest policy” in their program or lease agreement or about drug and alcohol infractions, but instead seeks to engage a tenant in an ongoing dialogue that frames his or her struggles with managing boundaries, setting limits or appropriate self-protection as a common part of trauma recovery.

Trauma-informed housing specialists might use in-home contacts to develop and monitor a housing-focused Wellness Recovery Action Plan, which encourages individuals to identify, practice, evaluate and refine their use of coping tools and resources available to them in their homes. Such a toolkit should include strategies for self-soothing, emotional modulation and health promotion that can be easily and safely accessed at home. It should include things one can do alone as well as things that might require the help of others, such as a trusted neighbour who is included in and aware of key plan elements. Home should be designed to support and facilitate use of such a plan. For one person, this might mean having his favourite comfort foods on hand. For another, it might mean re-discovering the restorative joy of a hot shower or bath enjoyed in privacy and safety not available to her for years.

My earlier writing about trauma-informed housing support focused on specialized residential treatment settings. However, today’s prevailing models for linking housing and supports emphasize reliance on ordinary housing with flexible, voluntary supports with the rise of the housing first approach. This strategy removes prerequisites such as documented “clean time” and contingent demands for adherence to a standard set of requirements such as anti-psychotic medication or a fixed schedule of individual and group therapies. In the United States, permanent supported housing is now recognized as an evidence-based practice and has been codified in the form of a toolkit published recently by the Substance Abuse and Mental Health Services Administration. The Permanent Supportive Housing: Knowledge Informing Transformation guide includes a tool that programs can use to assess their adherence to core principles and practices, as well as training modules for consumer-tenants and frontline staff.

In order to avoid doing harm and inadvertently re-traumatizing individuals, workers providing supports in housing settings and seeking to adopt universal trauma precautions would do well to borrow from the toolkit. “House Call Do’s & Don’ts,” for example, implores workers to call ahead, to be transparent about the purpose of the home visit, to offer and honour meaningful choices wherever possible. Indeed, there is considerable concordance between the core values manifested by trauma-informed systems of care and the guiding principles that frame the permanent supportive housing (PSH) approach. (See sidebar for practice recommendations linked to principles drawn from the trauma-informed and PSH literature).

Most importantly, housing staff who are trauma-informed are committed to safe and trustworthy avenues that create opportunities for meaningful choice, active collaboration and recovery-oriented skill building. Effective housing support staff work with tenants to develop an accurate housing history and shared understanding of the issues that have led to housing loss or that have threatened housing tenure in the past. Someone who has lived with chaos and violence throughout life may know only too well that “bad things happen to me” and has a fragmented narrative explanation of why things have happened in the past. Treating the person as “the expert” and a full partner in the development of both an accurate housing history and a customized housing support plan – these are the ordinary, life-size activities that promote recovery, resuscitate hope and help individuals find their voice.

Richard Bebout is associate director for housing at Community Connections in Washington, D.C.