Implementing Trauma-Informed Care in the Proposed National Housing and Homelessness Plan
Exploring the pressing need for trauma-informed care in Australia's National Housing and Homelessness Plan, Research Fellow Chris Hartley sheds light on the deep links between trauma and homelessness while advocating for a unified, comprehensive approach to address the issue in line with global best practices.
Setting the Stage for 2023's National Homelessness Week
This week (Monday August 7th to Sunday August 13th) marks National Homelessness Week 2023, a week dedicated to raising awareness about the impact of homelessness and the solutions needed to address it. This year's theme, "It’s time to end homelessness," aptly underscores the urgency and collective responsibility needed to address this critical issue.
This week also saw the release of the Australian Government’s National Housing and Homelessness Plan Issues paper. This paper will guide the development of a 10-year plan, which aims to outline a unified national vision across different government levels, to improve housing outcomes and combat homelessness in Australia (Commonwealth of Australia – Department of Social Services, 2023).
Currently, Australia lacks a national plan to address homelessness with each state and territory government having its own separate, distinct housing and homelessness strategic plans. (Pawson et al., 2022). This has rightfully been criticised as leading to a lack of cohesion, coordination, and accountability in the country's homelessness and housing policies (Productivity Commission, 2022; Pawson et al., 2022). Australia’s scattered approach to housing and homelessness policy can be unfavourably contrasted with nationally strategic approaches adopted by Finland, Scotland and recently in Canada under the National Housing Strategy (Martin, et al., 2023).
For some time, researchers and homelessness advocacy groups have been advocating for a nationally coordinated housing and homelessness plan in Australia. (Martin, et al., 2023). Therefore, there is a cautious optimism within the sector surrounding the release of the National Housing and Homelessness Plan Issues paper this week with Kate Colvin, the CEO of Homelessness Australia, stating “The National Plan is an opportunity to question the root causes of homelessness in Australia and identify the necessary steps to resolve it” (Homelessness Australia, 2023).
Exploring the Links Between Trauma and Homelessness
One root cause of homelessness that the National Housing and Homelessness Plan needs to address are experiences of trauma.
Broadly defined, psychological trauma encompasses "events or circumstances that are experienced as physically and emotionally harmful or threatening, with lasting adverse effects on an individual's physical, social, emotional, or spiritual well-being" (SAMHSA, 2014). Clinically, trauma can be categorized into two main experiences:
Post-traumatic stress disorder (PTSD) refers to exposure to a single traumatic event or a series of events perceived as physically or emotionally harmful or life-threatening (Op den Kelder et al., 2017).
Complex trauma (sometimes termed CPTSD) describes the experiences of individuals who have endured chronic and prolonged trauma, often during childhood, without finding escape or protection from the abuse (Kezelman, 2019; Ford & Courtois, 2021).
Complex trauma is particularly damaging as it involves a violation of and challenge to the fragile, immature, and newly emerging self in children and leads to lifelong problems with self-regulation, integrity, and the ability to experience positive interpersonal relationships (Ford & Courtois, 2020).
Research has consistently shown high rates of PTSD and complex trauma among people experiencing homelessness when compared to those in the general community. When considering only PTSD, research has found that the 12-month prevalence rate of PTSD in the Australian general community is relatively low at 1.5%, as is the lifetime PTSD prevalence rate at 5−10% (O’Donnell, et al., 2014). National prevalence studies in relation to complex trauma have identified a prevalence in the community between 0.5% and 3.8% (Salter & Hall, 2020; Ford et al 2021). Australian studies in relation to homelessness have placed rates of PTSD at around 73% (O’Donnell et al., 2014) and complex trauma rates of 90% among people experiencing homelessness (Armstrong et al 2020).
These high rates exist as trauma serves both as a cause and consequence of homelessness. Multiple studies have shown that individuals with a history of traumatic events are at a higher risk of becoming and remaining homeless (Crawford, 2022; Bassuk et al., 1997). Experiences of trauma significantly impact individuals, altering their worldview, ability to connect with others, self-management skills, and overall thinking and behaviour (Guarino & Bassuk, 2010). Consequently, managing trauma experiences can present an almost insurmountable challenge to retaining housing stability and fulfilling housing responsibilities (Duncan & Oby, 2019)
Moreover, the experience of homelessness itself constitutes a traumatic experience. As research by Hopper et al. 2010 details:
“Homelessness deprives individuals of…basic needs, exposing them to risky, unpredictable environments. In short, homelessness is more than the absence of physical shelter, it is a stress-filled, dehumanizing, dangerous circumstance in which individuals are at high risk of being witness to or victims of a wide range of violent events”.
There is also increasing recognition that the process of navigating support systems can be traumatic experiences for people experiencing homelessness. Many features of the delivery of services specifically to people experiencing homelessness have been identified as causing or exacerbating trauma – including the process of intake, completing paperwork, participating in multiple assessments, experiencing strict rules and demands from shelter staff, and living with others (Robinson, 2010). All these experiences can result in feelings of disempowerment among survivors, with service responses coming to feel like prior experiences of victimisation (Guarino, 2014).
Acknowledging this, specialist homelessness services in Australia are increasingly adopting trauma-informed care service models. Broadly, "trauma-informed" services actively incorporate knowledge about trauma and its impact into all aspects of service delivery (Bransford & Cole, 2019). While there is no consensus on trauma-informed care guiding principles to operationalise the concept, increasingly services are utilising variations of six core principles developed by the American Substance Abuse and Mental Health Services Administration (SAMHSA):
Safety
Trustworthiness & transparency
Peer support
Collaboration & mutuality
Empowerment & choice
Cultural, historical & gender issues (SAMHSA, 2014)
Although evaluation data is limited (Crawford, 2022), Australian specialist homelessness services that have implemented trauma-informed approaches have so far demonstrated positive outcomes at both the client and service levels (Seivwright et al., 2020; Vallesi et al., 2019).
The Necessity of Trauma-Informed Social Policy Responses to Homelessness
While specialist homelessness services are increasingly becoming trauma-informed, there has been limited recognition of the role government policy and practice plays in causing and exacerbating trauma among those experiencing homelessness. As recently acknowledged in Homelessness NSW’s paper "Rare, Brief and Non-Recurring: A System-wide Approach to Ending Homelessness Together," there is a glaring lack of well-structured consideration of trauma within all levels of government when designing and implementing public policy responses to homelessness (Homelessness NSW, 2023). This oversight results in policies that unintentionally inflict or exacerbate trauma among those experiencing homelessness, as demonstrated by the recent robo-debt affair (Henriques-Gomes, 2022).
While Australia lags behind, Canada and the United States are leading in developing policy responses to social issues grounded in the principles of trauma-informed care. In 2016, Bowen et al. formulated a trauma-informed social policy framework that embraces the six fundamental principles of Trauma-Informed Care. This framework serves as a compass for both enacting and continuously assessing social policy interventions aimed at marginalised populations (Bowen et al 2016). Since its development the framework has been successfully utilised in social policy areas in Canada and the United States such as drug policy, domestic and family violence, HIV/AIDS (Bowen & Irish, 2022), and human trafficking (Scott et al., 2019). This has led to a significant increase in the integration of trauma-informed concepts into policy and legislation in the United States. In 2022 alone, 350 Legislative Proposals and 313 Bills across the United States aligned significantly with a trauma-informed approach (Campaign for Trauma-Informed Policy and Practice, 2022).
Considering the elevated prevalence of trauma within the homeless population and the well-documented influence of policy approaches in causing and exacerbating such traumatic experiences, adopting a trauma-informed social policy framework holds substantial potential in effectively addressing and mitigating homelessness.
Within the context of the National Housing and Homelessness Plan, the integration of a trauma-informed social policy framework could facilitate an assessment of the alignment between prevailing policy interventions affecting people experiencing homelessness and the principles of trauma-informed care. For maximum efficacy, this evaluation should encompass not only policies explicitly aimed at those experiencing homelessness (such as current state and territorial homelessness strategic plans), but also encompass broader policy realms which have significant impacts upon the lives of people experiencing homelessness- including in the areas of social security, housing, disability.
Akin to its current application in Canada and the United States, the National Housing and Homelessness Plan could employ the trauma-informed social policy framework before the introduction of new policy/legislative responses in homelessness. As demonstrated so far in its overseas implementation, the framework provides an effective structure from which to enhance the responsiveness of policy/legislative responses to the issues of trauma- an issue so prevalent in Australian homelessness communities.
References
Armstrong, R., Phillips, L., Alkemade, N., & Louise O'Donnell, M. (2020). Using latent class analysis to support the ICD‐11 complex posttraumatic stress disorder diagnosis in a sample of homeless adults. Journal of Traumatic Stress, 33(5), 677-687.
Bassuk, E. L., Weinreb, L. F., Dawson, R., Perloff, J. N., & Buckner, J. C. (1997) Determinants of behavior in homeless and low-income housed preschool children. Pediatrics, 100(1), 92–100.
Bransford, C.L., & Cole, M. (2019). Trauma-Informed Care in Homelessness Service Settings: Challenges and Opportunities. Homelessness Prevention and Intervention in Social Work.
Bowen, E. A., & Murshid, N. S. (2016). Trauma-informed social policy: A conceptual framework for policy analysis and advocacy. American journal of public health, 106(2), 223-229.
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Campaign for Trauma-Informed Policy and Practice (2022) 2022 Trauma-Informed Policy Development Highlights Accessed at 2022 Trauma-Informed Policy Development Highlights (ctipp.org)
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Chris Hartley is a Research Fellow at the Centre for Social Impact UNSW (CSI UNSW) with a research focus on housing and homelessness and expertise in social housing policy, outcomes measurement in specialist homelessness services, homelessness and trauma, and research co-design with people who have a lived experience of homelessness. You can follow him on Twitter here: @1chrishartley