The Increasing Need for Trauma-informed Care Shelters

Merely Creating Conventional Shelters will Minimally Reduce the Number of
Homeless Persons Who Are Languishing on the Streets

It is time to realize that

• many homeless persons are not willing to live in large open spaces for long periods of time with many people they do not know and some that they may know but do not trust and a few that they fear;
• for a significant number of homeless persons, living on the streets in survival mode is the preferred choice over living in a shelter that is not trauma-informed; and
• the physical and social environment of homeless shelters can contribute to traumatizing and re-traumatizing experiences to shelter residents.

Trauma-informed shelters can eliminate many of the reasons why persons living homeless on the streets refuse to stay in a shelter.

Reasons include:

1. Do not want to live in an open warehouse type setting with little or no privacy day after day;
2. Living in a facility that offers little room for movement;
3. Lack of confidence that another shelter stay will be different from previous stay(s);
4. Will not be able to follow all the early check-in and early wake-up rules because of a disability, illness, work, and appointments;
5. Concern for personal safety once inside the shelter;
6. Feel too vulnerable to potential verbal and physical abuse from others;
7. Fear of potential violence by others to self and others;
8. Do not want to be separated from a partner, friend, or pet;
9. Very limited space with locks to store personal belongings;
10. Having to leave the shelter and possessions behind during the day;
11. Concern that personal possessions will be stolen;
12. Fear of having personal possessions thrown away;
13. Lack of privacy while using restroom and shower;
14. Unsanitary conditions;
15. Fear of other people’s infectious diseases;
16. Feelings of shame, blame, guilt, and stigma;
17. Inadequate staffing especially overnight;
18. Living in a shelter may be filled with one confrontational experience after another with staff;
19. Insufficient supportive services to obtain permanent affordable housing; and
20. Shortage of permanent affordable housing.

Next Steps

An increase in trauma-informed shelters is necessary in order to eliminate many of the reasons why homeless persons languishing on the streets refuse to live in a shelter and to encourage them to end their homelessness experience by obtaining and maintaining permanent housing.

As shelters developed over the last few decades, the impact of trauma on a homeless person’s health and well-being was not earnestly considered when designing a shelter or providing services and care. Although shelters may have trauma-informed trained staff, often the shelter environment and physical surroundings are not trauma-informed.

Principles for Trauma-informed Design and Tenets of Trauma-informed Care

Trauma-informed shelters incorporate trauma-informed design into the physical environment of the shelter to support the tenets of trauma-informed care and evidence-based practices, which also integrate well with the trauma-informed approach of Housing First, Harm Reduction, and Progressive Engagement.

Principles for Trauma-informed Design

The Substance Abuse and Mental Health Services Administration (SAMHSA) model provides three principles that serve as guidelines for trauma-informed design 

• Realizing how the physical environment effects [sic] an individual’s sense of identity, worth, dignity, and empowerment
• Recognizing that the physical environment has an impact on attitude, mood, and behavior, and that there is a strong link between our physiological state, our emotional state, and the physical environment.
• Responding by designing and maintaining supportive and healing environments for trauma-experienced residents or clients to resist re-traumatization.

SAMHSA’s design guidelines and recommendations for trauma-informed care design focus on 1) aesthetics; 2) spatial layout; 3) visual interest; 4) color; 5) furniture; 6) lighting/daylighting; 7) plants; and 8) art. SAMHSA has also described what each focus of design implies.

1. Aesthetics

• Facilities need to be aesthetically pleasing – not institutionally sparse – but visual complexity should be kept to a minimum
• Visual complexity reduces a service environment’s attractiveness. Visual complexity was determined by factors such as the irregularity, detail, dissimilarity, and quantity of objects; the asymmetry and irregularity of their arrangement; and the variations in color and contrast.
• Research has shown that an agency that was perceived as pleasant, beautiful, well kept, above average, neat, calming, efficient, etc., was considered more professional, believable, and offering a higher level of customer service in handling a customer complaint than one which was perceived as disorganized, unpleasant, etc.
• Staff and volunteers should avoid clutter, piles of paperwork or other stacks of boxes or supplies that may prove distracting or irritating to residents or clients.

2. Spatial Layout

• Social density is measurable. Crowding is an emotional response to density.
• How space is laid out can have a significant impact on individuals’ perception of space, and have a profound impact on mood and behavior.
• If space is perceived as open, with clear sightlines and few barriers, it will increase the sense of safety as well as that of “spatial availability,” which mitigates perceived sense of crowding. Simple, linear and easy to navigate space is calming.
• Emphasis on personal space, i.e. individual chairs with arms, choices in where/with whom to sit, quiet areas vs. engaged areas, etc.

3. Visual Interest

• Regularity, detail, similarity, an appropriate quantity of objects, the symmetry and regularity of their arrangement, and coherent variations in color and contrast.
• Can serve as a distraction from perceived crowding and stress.
• A land or waterscape painting that can serve as a connection to nature is calming.
• Sight lines should be unobstructed as much as possible to reduce perceived crowded and stress. Too much visual complexity can increase stress and anxiety.

4. Color

• Avoid deeply hued warm colors (i.e. red, orange, yellow) that may arouse negative emotions.
• Cool colors (i.e. blue, green, purple) have a calming effect.
• Lighter-colored rooms are perceived as more open, less crowded (“spatially available”), and thus safer and more calming.
• Avoid the use of arousing colors in confined spaces to help reduce feelings of crowdedness. Avoid stark white walls.

5. Furniture

• Durable and easy to clean.
• Arrangement of furniture needs to be considered for how it affects residents’ sense of safety, perceived crowdedness, and relationship to staff (e.g., communicative or authoritative).
• Sitting face-to-face across a desk or table may be perceived as confrontational, whereas sitting corner to corner invites conversation and interaction.
• In waiting or common areas, orient seating so users are facing out from sheltering walls.
• Seating can be arranged to increase socialization, which can be a challenge for homeless individuals but is mentioned in research as an important benefit of being in a shelter, and a means of developing social networks to support transitioning into more permanent housing.
• Allowing residents to rearrange a chair or other small pieces of furniture enhances their sense of control and independence.
• Natural materials and colors increase connection to nature and a sense of calm.

6. Lighting/Daylighting

• Rooms with more natural light appear less crowded.
• Rooms with window space (even if blinds are closed) can make a space appear less crowded and more spatially available.
• Quality of light, i.e. color temperature and CRI, impacts mood and behavior.
• Lower levels of illumination also can mitigate perceived crowding and the resulting sense of stress and discomfort.
• Lighting should not buzz, hum, or flicker.
• Giving residents control over task lighting, such as a reading lamp, enhances their sense of independence and autonomy.

7. Plants

• Are decorative and beneficial to guests and staff.
• Research shows that settings that include vegetation reduce stress, promote peace, tranquility, enhanced self-esteem, and a sense of mastery of the environment.
• Plants perform an important biophilic function by connecting occupants to the natural world, which has been found to reduce stress and pain, and to improve mood.
• Views of nature and landscape paintings, as well as indoor plants, are all associated with increased positive affect and comfort.

8. Art

• Adds visual interest
• Can create a visual distraction that alleviates stress, improves mood, comfort, and customer satisfaction.
• Landscape paintings are all associated with increased positive affect and comfort, and doubles as a natural view.
• Attention should be paid so that the art does not convey meaning or symbolic significance that would generate or arouse negative feelings.

Tenets of Trauma-informed Care

Tenets of trauma-informed care have evolved from a greater realization and understanding that trauma in the lives of persons experiencing homelessness may have resulted from incidents experienced in childhood or throughout the lifespan, events leading up to homelessness, and experiences while homeless. Also, there is greater recognition that homelessness in itself is a traumatic experience and that persons experiencing homelessness are living in a constant state of survival.

Staff who provide assistance in shelter systems of care have become increasingly aware of the past and present trauma that is affecting the ability of persons experiencing homelessness to achieve a permanent housing outcome and well-being. However, they may not have all the training and expertise in order to offer the level of trauma-informed care to help homeless persons achieve a permanent housing outcome and well-being.

SAMHSA has developed a framework for understanding trauma and developing a trauma-informed approach for behavioral health specialty sectors that can be adopted to help increase trauma-informed care shelters. The framework integrates three significant threads of work, which are “trauma focused research work; practice-generated knowledge about trauma interventions; and the lessons articulated by survivors of traumatic experiences who have had involvement in multiple service sectors.”

SAMSHA’s work generated the following definition of trauma:

Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.

SAMHSA’s concept of a trauma-informed approach is grounded in a set of four assumptions and six key principles.

Four assumptions

The four assumptions have helped a propelled a growing number of organizations and service systems to explore ways to make their services more responsive to people who have experienced trauma. A program, organization, or system that is trauma-informed:

1. Realizes the widespread impact of trauma and understands potential paths for recovery;
2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and
4. Seeks to actively resist re-traumatization.

The four assumptions are described in SAMHSA’s report on pages 9 and 10.

Six Key Principles

SAMSHA noted that

A trauma-informed approach reflects adherence to six key principles rather than a prescribed set of practices or procedures. These principles may be generalizable across multiple types of settings, although terminology and application may be setting- or sector-specific.

The six key principles are listed below and described in SAMHSA’s report on page 11.

1. Safety;
2. Trustworthiness and Transparency;
3. Peer Support;
4. Collaboration and Mutuality;
5. Empowerment, Voice, and Choice; and
6. Cultural, Historical, and Gender Issues.

SAMHSA’s concept of a trauma-informed approach is also grounded in “change at multiples levels of an organization and systematic alignment with the six key principles described above.

The guidance provided for change at multiple levels of an organization was provided within 10 Implementation Domains that are listed below and described in SAMHSA’s report on pages 12 – 14.

1. Governance and Leadership;
2. Policy;
3. Physical Environment;
4. Engagement and Involvement;
5. Cross-Sector Collaboration;
6. Screening, Assessment, Treatment Services;
7. Training and Workforce Development;
8. Progress Monitoring and Quality Assurance;
9. Financing; and
10. Evaluation.

Conclusion

It is time to realize that 1) many homeless persons are not willing to live in large open spaces for long periods of time with many people they do not know and some that they may know but do not trust and a few that they fear; 2) for a significant number of homeless persons, living on the streets in survival mode is the preferred choice over living in a shelter that is not trauma-informed; and 3) the physical and social environment of homeless shelters can contribute to traumatizing and re-traumatizing experiences to shelter residents.

Trauma-informed shelters can eliminate many of the reasons why persons living homeless on the streets refuse to live in a shelter. The reasons stem from traumatizing experiences and concern of being re-traumatized. Traumatizing experiences for persons living homeless are the result of physical and emotional abuse that can create or further mental health issues, such as depression, anxiety, and substance abuse problems. Their injuring experiences are often compounded by chronic health illnesses such as arthritis, asthma, cancer, chronic obstructive pulmonary disease and diabetes, and permanent physical disabilities.

Homelessness is in itself a traumatic experience. In fact, many persons experiencing homelessness are likely suffering the effects of cumulative traumatic experiences lived in childhood or throughout the life span, which also includes events precipitating or leading up to homelessness. The cumulative effect of traumatic experiences has left many a person languishing and coping with life on the streets and in a constant state of survival.

Merely creating conventional shelters will minimally reduce the number of homeless persons who are languishing on the streets.

____________________

Substance Abuse and Mental Health Services Administration (SAMHSA); Trauma-informed Care in Behavioral Health Services.

SAMHSA’s Trauma and Justice Strategic Initiative; SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach.