1. Towards Trauma Informed Care in the NSW Homelessness Sector Presented by: Sage Saegenschnitter, Hopestreet Urban Compssion Rob Seaton, Regional Manager, Wesley Mission Philip Hilder, Sydney Integrative Psychology Clinic

2. Rough Living: Surviving Violence and HomelessnessPresented by Sage Saegenschnitteron behalf of Dr Catherine Robinson

3. Trauma-Informed Care and PracticeMeeting the Challenge Specialist Homelessness Services Presented by Rob Seaton

4. I thought I was doing the right thing… Project Origins

5. Once in a lifetime? Note: General Population At least 1 event Homeless Population At least 2 events, but 6 on average. 100% of women who were homeless experienced at least one major traumatic event in their lives. Hodder, Teesson & Buhrich (1998), Down and Out in Sydney: Prevalence of Mental Disorders, Disability and Health Service Use among Homeless People in Inner Sydney Taylor (2006), PTSD Among Homeless Adults in Sydney Exposure to Trauma

6. Home 75% of homeless people struggle to define ‘home’. People who are housed: House = just a house – four walls and a roof. Home = a place of warmth and belonging among friends and family. People who are homeless: House = a shared dwelling that isn’t yours. Home = a solitary living environment. Homeless = escaping home. Tomas and Dittmar (1995), The experience of homeless women: An exploration of housing histories and the meaning of home

7. Compassionate Engagement Listening A key starting point to developing long-term solutions to iterative homelessness by more effectively working to identify underlying rather than presenting issues. Core observation: those surviving both homelessness and violent victimisation do not understand themselves as precious and worthy of assistance. For whom and how many will compassionate engagement, will listening, come too late? Robinson (2010), Rough living: surviving violence and homelessness

8. Compassionate Engagement A persistent, reliable, intimate and respectful relationship “the particular qualities which facilitate the development of an effective working relationship in the context of case management. The quality of intimacy is a consequence of the genuine emotional dimension and the everyday nature of the case management activities” Rapport PLUS Rapport building that goes beyond, perhaps, our traditional or professional understanding. It demands that we keep less of an arms-length. It insists that some attachment is necessary and healthy. Attachment ≠ Dependence Serving ≠ Enabling Gronda (2009), What makes case management work for people experiencing homelessness?

9. Trauma-Informed Care in SHS

10. Trauma-Informed Care in SHS A Long Journey Home, National Centre on Family Homelessness, USA

11. Trauma-Informed Care in SHS Common Themes Trauma awareness Emphasis on safety Opportunities to rebuild control Strengths-based approach Hopper, Bassuk and Olivet (2010), Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings

12. Am I still not doing the right thing…? Reflections

13. Towards Trauma Informed Care This projectwasaimed at influencing cultural change for workers in the NSW Homelessness Sector, towards a trauma informed awareness and sensitivity in responding consumers and their needs Dr Catherine Robinson (Researcher) was contracted to research experiences of violence with homeless people Philip Hilder (Psychologist) was contracted to develop and provide training in complex trauma and mental health for sector coordinators and managers The first training was run over three days in Feb – March, 2011. Ongoing support for this project comes from Homelessness NSW, The Public Interest Advocacy Service, The NSW Consumer Advisory Group and the NSW Department of Human Services (SAAP Learning and Development)

14. Beyond Biological and Post Freudian Phantasy – becoming Trauma Informed Incest is thought to occur in approximately 1 out of 1.1 million women. There is little agreement about the role of father-daughter incest as a source of serious subsequent psychopathology. The father-daughter liaison satisfies instinctual drives in a setting where mutual alliance with an omnipotent adult condones the transgression… The act offers an opportunity to test in reality an infantile fantasy whose consequences are found to be gratifying and pleasurable… The ego’s capacity for sublimation is favoured by the pleasure offered by incest… such incestuous activity diminishes the subject’s chance of psychosis and allows for better adjustment to the external world. There is often found little deleterious influence on the subsequent personality of the incestuous daughter… one study found that the vast majority of them were none the worse for the experience. Freedman and Kaplan, Comprehensive Textbook of Psychiatry, 1972

15. Being Trauma Informed Limitations with the Current Diagnostic Nosology

16. Diagnostic Nosology At present, no current diagnostic grouping sufficiently acknowledges traumatic etiology or the wide variety of diagnostic categories in which trauma can have an impact. Sakheim and Devine, Cited in Ross and Pam Eds., 1995

17. Diagnostic Nosology There is clearly a need for an overarching diagnostic category such as “Disorders of Extreme Stress”, “Syndromes of Traumatic Etiology”, or “Complex Post-traumatic Stress Disorder” that would specifically reflect the traumatic etiology, as well as the areas of functioning that have been affected by trauma. Sakheim and Devine, Cited in Ross and Pam Eds., 1995 The core assumption of the trauma model is that chronic, severe childhood trauma is a major driver of serious psychopathology Ross, 1995

18. Beyond PTSD – Complex Trauma The traumatic stress field has adopted the term ‘Complex Trauma’ to describe the experience of multiple and/or chronic-prolonged, developmentally adverse traumatic events, most often of an interpersonal matter (e.g. sexual, physical, emotional/psychological abuse, abandonment and neglect) and early life onset. Bessel van derKolk, M.D. Complex trauma outcomes refer to the range of clinical symptomatology that appear after such exposures. Exposure to traumatic stress in early life is associated with enduring sequelae that not only incorporate, but extend beyond, Posttraumatic Stress Disorder (PTSD) Attachment and Defence dynamics are central in understanding complex trauma

19. Are Childhood Trauma Symptoms Simply Outgrown? There is little indication that children “outgrow” these early problems: people with histories of early abuse and neglect have repeatedly been found to suffer from profound and pervasive psychiatric problems. Their problems with negotiating satisfying interpersonal relationships seems to play a particularly significant role in preventing them from leading satisfying lives: being able to engage in competent social relationships has been shown to be an important prognostic factor in the capacity to recover from traumatic experiences Bessel van derKolk (2001)

20. Is Being Trauma Informed about Dealing with Explicit Traumatic Memories?

21. Australian Guidelines for the Treatment of Adults with ASD and PTSD, 2007 Recommended treatments (trauma-focused cbt and emdr that includes in vivo exposure) share two key elements. They involve helping ptsd sufferers: Confront the memory of their traumatic experiences in a controlled and safe environment (imaginal exposure). Confront situations, people or places they have avoided since the traumatic event (in vivo exposure). Identify, challenge and modify any biased and distorted thoughts and memories of their traumatic experience as well as any subsequent beliefs about themselves and the world that are getting in the way of their recovery. With these methods, people accessing treatment are encouraged to gradually recall and think about traumatic memories until they no longer create high levels of distress. They are encouraged to do so at their own pace and are given skills to manage feelings as they emerge during sessions.

22. Pierre Janet (1859-1947): Phases of Trauma Treatment containment, stabilisation, and symptom reduction modification of traumatic memories personality integration and rehabilitation

23. Wilhelm Reich: Character Theory To Wilhelm Reich, dreams were no longer the cornerstones of therapy. The manner in which the patient comes to the treatment, his politeness or stubbornness, his mode of speech, his dress, the style and firmness of his handshake were all records of character. And character is real, it can be treated. Reich directed attention to this and away from the complications of content and free association, which engage and distract the interest of the regular analyst. Since the Freudian unconscious was basically latent sensations and impulses in the body itself, Reich saw no predominant need to go back in time to the traumatic moment or origin of the condition. He wrote, “The entire world of past experience is embodied in the present in the form of character attitudes. A person’s character is the fractional sum total of all past experiences. The doctor does not need to reconstruct a traumatic moment; the traumatic moment continues to exist in every breath the patient takes, in every gesture he makes.

24. Complex Trauma & Homelessness “It’s better to live on the streets than at home”… “a history of violent victimisation is associated with the initiation and prolongation of homelessness” (Kushel et al. 2003, p. 2492)

25. The Polyvagal Theory Stephen Porges, Ph.D. is Professor of Psychiatry and Director of the Brain-Body Center in the Department of Psychiatry in the College of Medicine, University of Illinois in Chicago

26. Evolution and Dissolution: Understanding the Mammalian Autonomic Nervous Systems Response to Trauma 3. Social Engagement System, calm pro-social states - safety (parasympathetic) 2. Movement/Action – fight/flight (sympathetic) Digestive and basic life functions, rest, recuperation - freeze (parasympathetic) Stephen Porges, 1995

27. The Face: A Critical Component of the Social Engagement System The face is “hardwired” to the neural regulation of visceral states via a mammalian “neural circuit.” At term the corticobulbar pathways that regulate the striated muscles of the face are myelinated. At birth the mammalian nervous system needs a “caregiver” to survive and signals the caregiver via the muscles of the face and head. But… metabolic demands, stress, trauma and illness can retract the “mammalian” neural circuit with the resultant symptoms of a face that does not work and social engagement behaviors are absent

29. Flat Expression It is important to remember that neuroreception of danger or a threat to life can occur with respect to the external environment (e.g., a dangerous person or situation) or the internal environment (e.g., fever, pain, or physical illness). Even flat (rather than angry) facial affect might prompt a neuroception of danger or fear and disrupt the development of normal spontaneous interactive and reciprocal social engagements. For example, the flat affect of a depressed parent or the flat affect of an ill child might trigger a transactional spiral that results in compromised emotional regulation and limited spontaneous social engagement

30. Our Social Nervous System - Still Face Experiments

31. Inclusion of Affect Keenan et al. (Cortex, 2005): “The right hemisphere, in fact, truly interprets the mental state not only of its own brain, but the brains (and minds) of others.” Diener et al. (American J. Psychiatry, 2007): Research shows that the more therapists facilitate affective experience/expression of patients in psychotherapy, the more patients exhibit positive changes; therapist affect facilitation is a powerful predictor of treatment success. “An affective treatment focus, represents a relevant mechanism of action, for short-term dynamic psychotherapy, as research indicates that contemporary psychodynamic therapies place greater emphasis on encouraging experience and expression of feelings, compared with cognitive behavior therapies.”

32. Training Managers and Workers within the NSW Homelessness sector - relationship, predictability & stability The focus of the current training in Trauma Informed Care has been on building a culture of positive, pro-social relationships with consumers that facilitates their subjective sense of safety, belonging and care Understanding and supporting in a trauma context consumers coping and avoidance behaviours Following and being guided by a consumer’s subjective experience and need The offering of secure attachment combined with longer-term stability of housing Sensing, feeling, holistic right-brain interactions Note: Trauma memory work is notpromoted, rather if a consumer wants to share their trauma history, workers are encouraged to listen empathically and share ”how sorry they are” to hear of the consumer’s trauma history, validate the consumer’s feelings and coping responses, check for ‘here and now’ needs/wants and thank them for sharing

33. The Trauma Informed Organisational Toolkit for Homeless Services