Homelessness solutions from a sexual assault perspective

Looking at the problem of homelessness through the lens of those who have also suffered sexual assault suggests different ways of understanding homelessness overall, and different solutions to the homelessness problem.

Crisis and shelter accommodation

Shelter accommodation will often be problematic for people who are homeless and have experienced sexual assault. Many shelters are neither "culturally sensitive nor trauma informed" (Goodman et al., 2006), so are unable to deal with clients who have experienced sexual and other trauma. Young people who are homeless and have been sexually assaulted report feeling constantly unsafe, and unable to trust adults. They may experience intrusive thoughts and imagery, nightmares, and have difficulty sleeping (see Morrison, Quadara, & Boyd (2007) for impacts of sexual assault).

All of these issues raise major concerns within a supported accommodation environment and often lead to young people being evicted from services or having difficult relationships with youth workers. (Tully, 2003, p. 3)

Shelters that are not trauma-informed may be unable to deal with victim/survivor's angry outbursts, or recognise the difference between (trauma-related) flash-backs and (general) psychosis: "a woman whose trauma-related nightmares wake up an entire dorm may be asked to leave" (Goodman et.al., 2006, p. 7).

Some shelter services and systems may create an environment that actually worsens a traumatised person's distress. Often, people in authority control access to basic resources such as food, clothing and shelter; there is little privacy; and entering many programs requires subjecting the private details of one's life to regulation and/or scrutiny. The very process of accessing the variety of programs necessary to escape homelessness may itself create a chaotic situation. This combination of chaos, power dynamics and power differentials can mirror and exacerbate the experience of violence many homeless people have survived (Goodman et al., 2006). Without an understanding of the experience of trauma and its manifestations, the behaviour of people who are homeless and have experienced sexual assault and other violence will not be recognised as the effects of abuse, and as the best way they know how to cope with these effects.

Long-term accommodation

A greater focus on achieving long-term housing outcomes for people who are homeless is a critical feature of the Council of Australian Governments' (COAG) National Affordable Housing Agreement (Australian Government, 2008c). For some women who are experiencing homelessness and adult survivors of child sexual abuse, the prospect of long-term accommodation can be experienced as threatening because they have never had a stable home - they don't know what to expect, whether they can handle it, and whether they "deserve it" (Jacobs, 2004).

Most women distrust offers of long term stable housing as it does not relate to their world view. We view this as a direct result of the training these women received in childhood from the perpetrators of their abuse. For a lot of women moving or fleeing a situation is the only way they have of dealing with conflict. (Jacobs, 2004, p. 4)

Preferring not to stay in one place can subsequently become a key issue if long-term housing is to be maintained. For one group of women who had experienced long-term homelessness, none could describe a place they thought of as home except for very short-term experiences (Casey, 2002). This went as far as the women identifying difficulties in having a home, compared to being homeless.

The living skills needed when a person is homeless, such as living in the present and having a survivalist orientation, may clash with those needed for maintaining long-term accommodation and achieving longer-term goals. Focusing on these women's strengths (rather than deficits) recognises the skills they have developed to survive homelessness, trauma and other severe hardship. Many of these skills are no longer needed or appropriate when safe long-term accommodation is available; therefore, different skills are required at this stage (Jacobs, 2004). Dealing with complex mental health issues can make such adaptation more complex. For example:

Our tenants often have nuisance complaints which follow them from tenancy to tenancy, regular difficulties in paying rent due to the interruption from drug and alcohol misuse or mental health issues ... Due  to the lack of opportunity [to develop these skills from childhood] our tenants often find themselves lacking basic living skills which can lead to [other] problems in their tenancies; such as eviction, rent arrears, nuisance and annoyance complaints, and/or failure to adequately maintain the property. (Jacobs, 2004, p. 4)

It is important that the approach to homelessness takes into account the issues faced by people who have experienced sexual and other trauma and recognises that "people are doing the best they can at any given time to cope with the life-altering and frequently catastrophic effects of trauma" (Prescott, Soares, Konnath, & Bassuk, 2008). This has implications for homelessness solutions overall:

Taking trauma seriously as a driver of persistent homelessness ... would entail a serious challenge to current welfare policy discourse around  "independence" and "full social and economic participation". (Robinson, 2006, p. 4)

For many people who are homeless, "the road home" will need to involve explicitly recognising their experience of trauma, including sexual assault, and building a response informed by this perspective. For some, this will surely lead to greater social and economic participation in the future.

Recognising sexual assault: Screening and supporting disclosure

Explicit recognition of the experience of sexual assault and other trauma facing many homeless people is necessary in policy and service provision. Without doing so, we contribute to a culture of silence - silencing the people who need to speak about it most. We minimise the impact of abuse, and prevent it from having a presence in homelessness priorities. Finally, without recognising sexual assault and abuse, service delivery is "often likely to be ineffectual or limited and may have dire consequences" (Tully, 2003, p.4).

When service providers fail to recognize abuse histories and their potential relationship to symptom severity, their intervention strategies have little chance of success. Too great a part of these women's everyday lives are left out. (Goodman et al., 1997, p. 67)

Some literature discusses recognising sexual assault and other violent trauma through "screening" people who are homeless (Browne, 1993), or ensuring a detailed victimisation history is taken (Wenzel et al., 2000). Browne (1993) argued that if the behaviour of victim/survivors is to be recognised as an appropriate reaction to trauma, the trauma must be known: "in many assessments of homeless women, a detailed victimization history is never obtained and effects are interpreted in isolation" (p. 377). Rather than simple screening to solve this problem, others discuss how to create the conditions and willingness to recognise sexual assault and abuse to enable and support disclosure:

The common story is that people wanted to speak out, but they felt no one provided them with the opportunity, or responded to them in a way that inspired trust ... Most people who have been subjected to sexual abuse wish they had the opportunity to disclose at a younger age. (Tully, 2003, p. 4)

The recommendation is that not all workers provide a therapeutic role, but at a minimum they need to acknowledge the impact of the abuse:

In the experience at SideStreet, when youth agencies give young people appropriate opportunities and information, many young people will choose to talk to a youth worker. (Tully, 2003, p. 4)

What can a service do to create opportunities for people to discuss their experiences of sexual abuse, to "open doors" around this issue? At SideStreet, they say to the young people with whom they work:

Many young people who we see at this service have experienced sexual abuse or violence. We understand this can be very difficult for people. But if you want to talk to us about anything like that you can or we can help refer you to another service that can assist you. (D. Tully, 2008, personal communication)

Of course, a system that screens for sexual assault or encourages disclosure will also need to be able to follow up with providing (or referring to) an expert response.

The paradigm of trauma-informed and trauma-specific services for people experiencing homelessness

Trauma-informed services for people experiencing homelessness are argued by some to be the "vital paradigm shift" that is needed (Hodas, 2006) (see Table 1). It is seen as a "profound cultural shift in which consumers and their conditions and behaviours are viewed differently, staff respond differently, and the day-to-day delivery of services is conducted differently" (Jennings, 2004). Trauma-informed and trauma-specific services were initially applied in the USA in the early 2000s in public mental health and substance abuse service system settings (Harris & Fallot, 2001a, 2001b). See Box 4 for a description of these terms. By 2004, approximately 12 US states had established an informal network to support the development of trauma-informed systems of care:

As awareness and the prevalence and impacts of trauma increases, the individuals for whom the trauma-informed and trauma-specific services ... were designed are increasingly viewed not as a subgroup or an anomalous or special population of clients, but as encompassing nearly all persons served by public mental health and substance abuse services. This increasing knowledge is reflected in the rising number of [US] States taking significant steps toward integrating knowledge about trauma into existing services and developing and/or implement new "trauma specific" services. (Jennings, 2004, p. 8)

Source: Adapted from Prescott et al., 2008, pp. 9-10.

Most recently, these ideas have been applied to the homelessness problem - modified and refined to meet the needs of women and children who are homeless (see Prescott et al., 2008). This work is based on the recognition that "despite all our knowledge about trauma and its prevalence, there remains a dearth of practical guidance about how to best support individuals and families in the healing process" (Jennings, 2004, p. 8).

According to Jennings (2004), a trauma-informed system is characterised by:

• safety from physical harm and re-traumatisation;
• an understanding of clients and their symptoms in the context of their life experiences and history, cultures and their society;
• open and genuine collaboration between provider and consumer at all phases of the service delivery;
• an emphasis on skill building and acquisition rather than symptom management;
• an understanding of symptoms as attempts to cope;
• a view of trauma as a defining and organising experience that forms the core of an individual's identity rather than a single discrete event; and
• a focus on what has happened to a person rather than what is wrong with a person.

This has substantial ramifications for workforce development. In a trauma-informed model all staff members - including grounds-keepers through to administrators - are trained to respond to individuals in distress (Prescott et al., 2008). However, these ramifications have been found to be "cost effective" in the US.

Research has found that trauma-informed services with trauma-specific services available have better outcomes than "treatment as usual". For example, adults have been found to experience a decrease in psychiatric symptoms and substance abuse; improved daily functioning; and a decrease in trauma symptoms, substance abuse, and mental health symptoms (Hopper, Bassuk, & Olivet, 2007). Research has also found trauma-informed services may have a positive effect on housing stability. For example, a multi-site study of trauma-informed services for homeless families found that 88% of participants had remained in provided housing or moved to permanent housing at 18 months (Rog, Holupka, & McCombs-Thornton, 1995). Trauma-informed services also appear to be cost effective (Domino et al., 2005), and both providers and consumers report positive outcomes (National Centre for Family Homelessness, n.d.).

Without the labels "trauma-informed" or "trauma-specialist", some providers will already be incorporating this sort of work into their practice in Australia. This work needs to be documented, and these concepts promoted. In an integrated services system, one option would be for existing trauma-specialist services, for instance sexual assault counselling providers, to be included into the integrated homelessness partnerships. However, existing capacity would need to be greatly increased for such services to meet the needs of people experiencing homelessness, and appropriate models would need to be developed for working with homeless clients (e.g., Jacobs, 2004), similar to the models that have been developed for other diverse service users (e.g., Cox, 2008).

Very few trauma-specialist services, specifically for people who are homeless, currently exist in Australia - neither the homelessness Green Paper or White Paper (Australian Government, 2008b, 2008c) mention specialist services for homeless victim/survivors of sexual assault. One existing service is the SAAP-funded SideStreet Counselling Service by UnitingCare Wesley Adelaide. This service works with young women and men who are homeless, or at risk of homelessness, and who have experienced sexual and/or physical abuse. It provides a counselling service that has the flexibility and responsiveness to engage young people dealing with the effects of abuse and homelessness, employing an active outreach model. It is unique in Australia and was developed because of an explicit recognition in South Australia that sexual abuse is a significant contributing cause and a factor in the continuation of youth homelessness (ACSSA, 2004). Services such as SideStreet work in a complex space, shaped by the therapeutic priority of establishing safety (both psychologically and physically) for clients who have experienced trauma (e.g., Connor & Higgins, 2008; Sanders & McNaughton, 2007), and the difficulty of doing this when working with people experiencing homelessness.

Addressing homelessness from a sexual assault perspective: Implications for policy and service provision

Integrated services, workforce development and a specialist approach

Housing is fundamental to solving homelessness, including for people who are homeless and have experienced sexual assault: "without a secure place to live it is impossible to rest and to begin the arduous process of healing from the long term effects of childhood sexual assault" (Jacobs, 2004, p. 10). But housing is just the beginning.

The Australian Government Green Paper suggested that the new national effort on homelessness needs to provide "housing plus" - a support package for homeless people in which "support needs [are] tailored to each individual and focused on the outcomes that will make the greatest long-term difference to their lives" (Australian Government, 2008b). Suggested reforms across the service sector included the delivery of services that "wrap-around" the individual - tailored services brought to the person for however long they need assistance.

There is strong evidence that linking short- and long-term accommodation with clinical support for people with severe or ongoing disability caused by mental illness would enable early intervention at points of crisis and instability, and would prevent avoidable homelessness for many people in this population group. (Australian Government, 2008b, p. 42).

The Green Paper acknowledges the implications of such an approach for the homelessness workforce, and discusses workforce developments that focus:

On the skills and competencies for delivering integrated case management, service partnerships and improved health, housing, education and employment outcomes. Salaries would reflect these competencies to attract and retain high quality staff. (Australian Government, 2008b, p. 68)

In the White Paper following the Green Paper it was found that specialist services "need to be able to wrap services around their clients" which would involve "using expertise to assess all of the clients' needs, identifying the services required, brokering these services and co-ordinating the delivery" (Australian Government, 2008c, p. 47). The White Paper also stated that "services should be funded to work with clients for as long as they need active support to maintain housing, rather than being subject to time limits on the support they provide" (p. 47). Specific policies recommended by the White Paper include:

• "no exits into homelessness" from statutory, custodial care and hospital, mental health and drug and alcohol service for people who are at high risk of homelessness. This entails "strengthening current post-release services so a person is connected to long-term (supported) housing, to education, training and employment assistance and, where required, family counselling" (p. 27); and
• new or expanded services to assist people with mental health issues to maintain their housing and participation in the community, including the Personal Helpers and Mentors program.

The New National Partnership on Homelessness will also include expanded models of integrated support to enable women and children experiencing domestic and family violence to remain at home safely, while also recognising that some women and children are at too high risk of violence within the home to do this and need a speedy transition from crisis accommodation to safe, secure long-term housing.

In relation to implications for workforce development, the White Paper states that a key priority is to address the need for increased skills and competency in specialist homelessness services, to achieve sustainable outcomes for people with high and complex needs. The Australian Government, with state and territory governments, will consider the development of "advanced practitioners" within the awards covering employees in specialist homelessness services. However, as outlined previously, such services need to be trauma-informed, as well as providing specialist trauma services.

Implications for violence prevention and underlying social and cultural inequalities

Addressing issues of trauma will assist those who are already homeless. It can help to prevent subsequent homelessness, including that of their children. Prevention initiatives will need to not only target the general population and young people within educational institutions, but also groups most vulnerable to social exclusion, such as those in transitional housing, living in disadvantaged areas, at risk of homelessness due to family breakdown, and outside of the education system. Prevention should also involve measures to prevent the abuse of power in personal relationships and society more broadly and to promote the respect, recognition and equal rights of certain disrespected social groups, including women (particularly poor women), children, and Indigenous people. These issues are also relevant to the social inclusion agenda.

Implications for the social inclusion and human capital agendas

The current Australian Government previously stated that its approach to social inclusion would be "underpinned by its investment in our human capital" (Gillard & Wong, 2007):

[A] framework based around investment in people and communities that deliver the right interventions, at the right time, in the right place. (Gillard & Wong, 2007, p. 5)

It was further stated that:

Community and government programs which focus on investment in human capital ultimately build social capital, because by building capabilities in communities and disadvantaged groups we are reducing social isolation. (Gillard & Wong, 2007, p. 10)

Part of investing in human capital and reducing the social exclusion and isolation of people who are homeless will often involve investing in their ability to recover from sexual trauma. Such a measure differs from commonly defined human capital issues of education and workforce participation. Recognising other much-needed primary supports for acutely disadvantaged groups, such as the episodically homeless, is fundamental to their ability to make the most of the opportunities available to them. The aim of this work is also ultimately to increase people's overall social and economic participation.

Implications for further research

This paper has highlighted the lack of research on homelessness and sexual assault, particularly in an Australian context. Future research on this topic should include explicit attention to groups of homeless people not currently represented in Australian literature - including Indigenous homeless people, people living in rural and remote areas, and people from culturally and linguistically diverse backgrounds. Research also needs to examine and document the specific pathways to homelessness created by sexual abuse and assault, with a view to envisaging effective intervention.

Research that would deepen understanding of the ways homeless people experience sexual violence - "what meaning do they make of it in their lives? How do they understand its causes and effects?" (Goodman et al., 1997) - could also help inform models of future service provision. This could include more research into the overlap, and distinctions between the experiences, of family violence and sexual assault. For example, for those who have experienced domestic violence, to what extent has this included sexual assault, and does this create particular issues and needs?

Research (including evaluation) is needed to document successful models of care that work with people who are homeless and could further investigate the effectiveness of trauma-informed and trauma-specialist models. Research is also needed on how social and economic participation is facilitated for people with histories of homelessness and violent trauma (e.g., modifications that may need to be made by employment services providers). Finally, research could also look at how to bring together the efforts to prevent both violence and homelessness.

Conclusion

This ACSSA Wrap has shown the significance of the issues of sexual assault and abuse to the issue of homelessness. It has described the high prevalence of sexual assault of people who are homeless, particularly of young and adult women. It has documented ways that standard homelessness "solutions" may be unsuitable for homeless people who have experienced sexual assault. It has suggested ways an explicit recognition of sexual assault could be incorporated into Australia's new approach to homelessness. This paper has described a trauma-informed and trauma-specialist service system, with an explicit recognition for more trauma-specialist services for people who are homeless. It has also suggested that preventing homelessness needs to be more explicitly linked to preventing violence against women and children, and that these issues are also relevant to the social inclusion and human capital agendas. The successful addressing of this issue could potentially have an immense impact, particularly among young homeless people and children, and those who are most disadvantaged and entrenched in the homeless population.

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