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
Part 1

• Background on women experiencing homelessness

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
Part 2

• The Lived Experience of Women While Homeless

15
What is life like for a woman who is homeless and
alone?
16
Structural Issues
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
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
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
Part 3

• Assessment and Service Planning

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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

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Part 4

• Overall Approach to Services Whats Working

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

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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
  ones 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/res
  ources.php?psm.

Olivet, McGraw, Grandin, Bassuk, 2009
50
Conclusion
51
Where Can I Learn More?

• Homelessness Resource Center
• www.homeless.samhsa.gov
• The National Center on Family Homelessness
• www.familyhomelessness.org
• SAMHSAs National Registry of Evidence-based
  Programs and Practices
• http//nrepp.samhsa.gov

52
References

• Austin, E. L., Andersen, R., Gelberg, L.
  (2008). Ethnic differences in the correlates of
  mental distress among homeless women. Womens
  Health Issues , 18, 26-34.
•  Baker, C. K., Niolon, P. H., Oliphant, H.
  (2009). A descriptive analysis of transitional
  housing programs for survivors of intimate
  partner violence in the United States. Violence
  Against Women , 15 (4), 460-481.
• Barrow, S. M., Laborde, N. D. (2008). Invisible
  Mothers Parenting by Homeless Women Separated
  from Their Children. Gender Issues , 25, 157172.
• Bassuk, E. L., Buckner, J. C., Perloff, J. N.,
  Bassuk, S. S. (1998). Prevalence of mental health
  and substance use disorders among homeless and
  low-income housed mothers. American Journal of
  Psychiatry , 155 (11), 1561-1564.
• Bassuk, E. L., Weinreb, L. F., Buckner, J. C.,
  Browne, A., Salomon, A., Bassuk, S. S. (1996).
  The characteristics and needs of sheltered
  homeless and low-income housed mothers. Journal
  of the American Medical Association , 276 (8),
  640-646.
• Bharel, M., Casey, C., Wittenberg, E. (2009).
  Disparities in cancer screening Acceptance of
  Pap smears among homeless women. Journal of
  Women's Health , 18, 2011-2016.
• Brown, A., Bassuk, S. (1997). Intimate violence
  in the lives of homeless and poor housed women
  Prevalence and patterns in an ethnically diverse
  sample. American Journal of Orthopsychiatry , 67
  (2), 261-276.
• Caton, C.L.M., Wilkins, C., Anderson, J. (2007).
  People Who Experience Long-Term Homelessness
  Characteristics and Interventions. Presented at
  the National Symposium on Homelessness Research,
  March 1-2, 2007. Office for the Assistant
  Secretary for Planning and Evaluation, USDHHS,
  and HUD.
• Center for Substance Abuse Treatment. (2010).
  Treating clients with traumatic brain injury.
  Substance Abuse Treatment Advisory, 9(2).
• Cowal, K., Shinn, M., Weitzman, B. C.,
  Stojanovic, D., Labay, L. (2002). Motherchild
  separations among homeless and housed families
  receiving public assistance in New York City.
  American Journal of Community Psychology , 30
  (5), 711-730.

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References

• Davis, J. E., Shuler, P. A. (2000). A
  biobehavioral framework for examining altered
  sleep-wake patterns in homeless women. Issues in
  Mental Health Nursing , 21, 171-183.
• Desai, R. A., Harpaz-Rotem, I., Najavits, L. M.,
  Rosenheck, R. A. (2008). Impact of the Seeking
  Safety Program on Clinical Outcomes Among
  Homeless Female Veterans With Psychiatric
  Disorders. Psychiatric Services , 59 (9),
  996-1003.
• Feen-Calligan, H., Washington, O. G., Moxley,
  D. P. (2009). Homelessness among older
  African-American women Interpreting a serious
  social issue through the arts in community-based
  participatory action research. New Solutions , 19
  (4), 423-448.
• Friedman, D. H. (2000). Parenting in Public
  Family Shelter and Public Assistance. New York,
  NY Columbia University Press.
• Gelberg, L., Leake, B., Lu, M. C., Nyamathi, A.
  M., Morganstern, H., Browner, C. (2002).
  Chronically homeless women's perceived deterrents
  to contraception. Perspectives on Sexual and
  Reproductive Health , 34 (6), 278-285.
• Gonyea, J.G. Bachman, S.S. (2009). Ending Elder
  Homelessness The Importance of Service-Enriched
  Housing. Boston Hearth.
• Heslin, K. C., Robinson, P. L., Baker, R. S.,
  Gelberg, L. (2007). Community characteristics and
  violence against homeless women in Los Angeles
  County. Journal of Health Care for the Poor and
  Underserved , 18, 203-218.
• Hightower, J. S. (2009). The Older Homeless
  Women's Perspective Regarding Antecedents to
  Homelessness. The University of Arizona, College
  of Nursing. Tucson The University of Arizona.
• Hoffman, D., Rosenheck, R. (2001). Homeless
  mothers with severe mental illness and their
  children Predictors of family reunification.
  Psychiatric Rehabilitation Journal , 25 (2),
  163-169.
• Hwang, S.W., Colantonio, A., Chiu, S.,
  Tolomiczenko, G., Kiss, A., Cowan, L.,
  Redelmeier, D.A. Levinson, W. (2008). The
  effect of traumatic brain injury on the health of
  homeless people. Canadian Medical Association
  Journal, 179(8), 779-784.

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References

• Kilbourne, A. M., Herndon, B., Andersen, R. M.,
  Wenzel, S. L., Gelberg, L. (2001). Psychiatric
  symptoms, health services, and HIV risk factors
  among homeless women. Journal of Health Care for
  the Poor and Underserved , 13 (1), 49-65.
• Kisor, A. J., Kendal-Wilson, L. (2002). Older
  homeless women Reframing the stereotype of the
  bag lady. Affilia , 17, 354-370.
• Lehmann, E. R., Kass, P. H., Drake, C. M.,
  Nichols, S. B. (2007). Risk factors for
  first-time homelessness in low-income women.
  American Journal of Orthopsychiatry , 77 (1),
  20-28.
• Lewis, J. H., Andersen, R. M., Gelberg, L.
  (2003). Health care for homeless women Unmet
  needs and barriers to care. Journal of General
  Internal Medicine , 18, 921-928.
• Liebow, E. (1993). Tell Them Who I Am The Lives
  of Homeless Women. New York, New York The Free
  Press.
• Long, H. L., Tulsky, J. P., Chambers, D. B.,
  Alpers, L. S. (1998). Cancer screening in
  homeless women Attitudes and behaviors. Journal
  of Health Care for the Poor and Underserved, , 9
  (3), 276-292.
• Luhrmann, T. M. (2008). The street will drive
  you crazy Why homeless psychotic women in the
  institutional circuit in the United States often
  say no to offers of help. American Journal of
  Psychiatry , 165, 15-20.
• McFarlane, W. R., Dixon, L., Lukens, E.,
  Lucksted, A. (2003). Family psychoeducation and
  schizophrenia A review of the literature.
  Journal of Marital and Family Therapy, 29(2),
  223-245.
• Najavits, L. M., Weiss, R. D., Shaw, S. R.,
  Muenz, L. R. (1998). "Seeking Safety" Outcome of
  a New Cognitive-Behavioral Psychotherapy for
  Women with Posttraumatic Stress Disorder and
  Substance Dependence. Journal of Traumatic Stress
  , 11 (3), 437-456.
• National Alliance to End Homelessness and
  Homelessness Research Institute. (2011). State of
  Homelessness in America A Research Report on
  Homelessness. Washington, DC National Alliance
  to End Homelessness.

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References

• Nyamathi, A., Flaskerud, J. H., Leake, B., Dixon,
  E. L., Lu, A. (2001). Evaluating the impact of
  peer, nurse case-managed, and standard HIV
  risk-reduction programs on psychosocial and
  health-promoting behavioral outcomes among
  homeless women. Research in Nursing Health ,
  24, 410-422.
• Nyamathi, A., Keenan, C., Bayley, L. (1998).
  Differences in personal, cognitive,
  psychological, and social factors associated with
  drug and alcohol use and nonuse by homeless
  women. Research in Nursing Health , 21,
  525-532.
• Nyamathi, A. M., Leake, B., Gelberg, L. (2000).
  Sheltered versus nonsheltered homeless women
  Differences in health, behavior, victimization
  and utilization of care. Journal of General
  Internal Medicine , 15, 565-572.
• Nyamathi, A. M., Stein, J. A., Dixon, E.,
  Longshore, D., Galaif, E. (2003). Predicting
  positive attitudes about quitting drug and
  alcohol use among homeless women. Psychology of
  Addictive Behaviors , 17 (1), 32-41.
• Nyamathi, A. M., Stein, J. A., Swanson, J. M.
  (2000). Personal, cognitive, behavioral, and
  demographic predictors of HIV testing and STDs in
  homeless women. Journal of Behavioral Medicine ,
  23, 123-147.
• Olivet, J., McGraw, S., Grandin, M. Bassuk, E.
  (2009). Staffing challenges and strategies for
  organizations serving individuals who have
  experienced chronic homelessness. Journal of
  Behavioral Health Services and Research, 37(2),
  226-238.
• Prescott, L., Soares, P., Konnath, K., Bassuk,
  E. (2008). A Long Journey Home A Guide for
  Creating TraumaInformed Services for Mothers and
  Children Experiencing Homelessness . Rockville
  Center for Mental Health Services, Substance
  Abuse and Mental Health Services Administration
  and the Daniels Fund National Child Traumatic
  Stress Network and the W.K. Kellogg Foundation .
• Stein, J. A., Leslie, M. B., Nyamathi, A.
  (2002). Relative contributions of parent
  substance use and childhood maltreatment to
  chronic homelessness, depression, and substance
  abuse problems among homeless women mediating
  roles of self-esteem and abuse in adulthood.
  Child Abuse Neglect , 26, 1011-1027.
• Stein, J. A., Lu, M. C., Gelberg, L. (2000).
  Severity of homelessness and adverse birth
  outcomes. Health Psychology , 19 (6), 524-534.

56
References

• Stump, M. J., Smith, J. E. (2008). The
  relationship between posttraumatic growth and
  substance use in homeless women with histories of
  traumatic experience. The American Journal on
  Addictions , 17, 478-487.
• Swanson, K. A., Andersen, R., Gelberg, L.
  (2003). Patient satisfaction for homeless women.
  Journal of Women's Health , 12 (7), 675-686.
• Toohey, S. M., Shinn, M., Weitzman, B. C.
  (2004). Social networks and homelessness among
  women heads of household. American Journal of
  Community Psychology , 33 (1/2), 7-20.
• Tucker, J. S., Wenzel, S. L., Straus, J. B.,
  Ryan, G. W., Golinelli, D. (2005). Experiencing
  interpersonal violence perspectives of sexually
  active, substance-using women living in shelters
  and low-income housing. Violence Against Women ,
  11, 1319-1340.
• U.S. Department of Housing and Urban Development
  Office of Community Planning and Development .
  (2010). The 2009 Annual Homeless Assessment
  Report . Washington, DC U.S. Department of
  Housing and Urban Development Office of Community
  Planning and Development.
• Washington, O. G., Moxley, D. P., Garriott, L.
  J. (2009). The Telling My Story Quilting
  Workshop Innovative group work with older
  African American women transitioning out of
  homelessness. Journal of Psychosocial Nursing ,
  47 (11), 42-52. 
• Washington, O. G., Moxley, D. P., Taylor, J. Y.
  (2009). Enabling older homeless minority women to
  overcome homelessness by using a life management
  enhancement group intervention. Issues in Mental
  Health Nursing , 30, 86-97.
• Wenzel, S. L., Koegel, P., Gelberg, L. (2000).
  Antecedents of physical and sexual victimization
  among homeless women A comparison to homeless
  men. American Journal of Community Psychology ,
  28 (3), 367-390.
• Zlotnick, C., Robertson, M. J., Wright, M. A.
  (1999). The impact of childhood foster care and
  other out-of-home placement on homeless women and
  their children. Child Abuse Neglect , 23 (11),
  1057-1068.
• Zlotnick, C., Tam, T., Bradley, K. (2006).
  Impact of adulthood trauma on homeless mothers.
  Community Mental Health Journal , 43 (1), 13-32.

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Questions