Providing Comprehensive, Family-Centered Mental Health Services to Homeless Trauma

Survivors

Samuel Girguis, Psy.D.

Project Heal

Childrens Hospital Los Angeles

USC UCEDD (University Center for Excellence in Developmental

Disabilities)

Working with Homeless Women and Children

• Population of Los Angeles County: 10,245,572 (January, 2007)

• 254,000 people/year experience homelessness in LA• 82,096 people every night

• 20% to 34% are single mothers with children• The average homeless family has 2 children

Working with Homeless Women and Children, cont.

• High correlation with domestic violence and homelessness• 50% of women become homeless after fleeing DV

• Majority of homeless women report a significant trauma history• Domestic violence, sexual abuse, physical abuse,

emotional abuse

• Homeless women are highly susceptible to PTSD, Depressive Disorders, Anxiety Disorders, Substance Abuse

Working with Homeless Women and Children, cont.

• Children – exposed to family violence and at-risk for traumatic experiences• Exposure to domestic violence• Sexual abuse• Physical abuse• Emotional abuse• Neglect

• Intergenerational transmission of trauma

Working with Homeless Women and Children, cont.

• Homeless school-aged children are highly susceptible to• Disruptive Behavior Disorders (acting out)• Depressive Disorders (turning inward)• Attentional difficulties• High-risk behaviors

Homelessness as a Trauma

• Pervasive impact on all family members• Loss of social support• Uprooted from familiar surroundings• Safety issues/concerns• Lack of consistency increased conflict &

decreased frustration tolerance

• Typical programs – Adult-focused:• Increase self-esteem, self-empowerment,

self-sufficiency• Increase social support• Increase healthy emotional expression &

relationship building• Address job-related skills• Linkage to services

Mental Health and the Homeless

Mental Health and the Homeless, cont.

• Fewer programs focus on the children:• Increase appropriate affective expression• Learn social skills• Increase self-esteem• Conflict resolution• Parenting classes to address behavioral

problems• Tutoring, linkage to socialization opportunities

Mental Health and the Homeless, cont.

• Interventions need to become more family-focused:• Teaching the caregivers how to address children’s

behavior consistently & introducing “new rules” to the children

• Teaching the caregivers and children about the connection between children’s behavioral issues & traumatic experiences

• Improving communication & conflict resolution• Addressing family’s exposure to violence and

traumatic experiences

Family-Focused Interventions with Homeless Families

• Culturally sensitive• Developmentally appropriate• Address unique boundary issues associated

with homelessness (e.g., lack of privacy, multiple caretakers)

• Short-term• Highly flexible

Comprehensive, Family-Centered Services

• Traditional mental health services• Clinic based services• Single modality

• Individual or Group or Family therapy

• Comprehensive, family-centered services• Multi-faceted, individualized treatment

• Individual and Group and Family therapy• Collateral therapy offered to caregivers• Parenting classes• Coordination of services• Consultation

Individual Child Therapy

• Trauma focused:• Traumatic experiences• Homelessness experience• Interrupting the intergenerational

transmission of abuse/trauma

• Developmentally appropriate• Skill-based with a safety focus

Family-Focused Interventions

• Conjoint family therapy• Address barriers to optimal parenting

• Caregiver’s untreated trauma history:• Flat affect• Inconsistent discipline• Lower frustration tolerance• Duplication of abusive relationships

• Child’s behavioral disturbances and emotional dysregulation

Family-Focused Interventions, cont.

• Trauma-focused collateral therapy for mothers• Impact of trauma history on the family• Impact of mood disorder on the family• Service coordination• Collaboration with other service providers

Group Therapy

• Short-term• Single session model• Curriculum-based • Skill based with practical application focus• Combination of psychoeducation and process

group • Conjoint children’s group and mother’s group

Group Therapy for Homeless Children

• “Making Friends and Staying Safe”• Abuse risk reduction

• Trauma-focused anger management group• Affect modulation• Coping skills

• Trauma-focused anxiety reduction group• Exposure/desensitization treatment through

trauma narrative technique• “Real Life Heroes” by Richard Kagan

Group Therapy for Homeless Women with Children

• “Supermom 101”• Parenting class – part psychoeducation,

part process group• Utilized Supernanny television show• Parent/peer mentoring

• Personality-based parenting skills class• Focus on strengths as well as areas of

skill-building

Consultation

• Collaboration with service providers

• Being available in the shelter setting• Attending staff meetings that are pertinent

to clinical care• Offering trainings for shelter staff• Offering consultation for shelter staff• Offering “office hours” for shelter residents

Clinical Challenges and Countertransference: Providing Services in the Shelter Setting

Practical Challenges of the Community Setting

• The community setting• Close proximity of residents, interpersonal

relationships and conflicts developing outside of the therapeutic context

• Confidentiality

• Space limitations • Impact on group cohesion• Impact on continuity of group/individual/family

therapy

Practical Challenges, cont.

• Inconsistent attendance• Late arrivals to group/individual therapy

appointments• Limit setting

• Lack of boundaries and rules in everyday life• Therapist countertransference

Population Challenges

• Maternal psychopathology• How trauma impacts parenting, communication,

and general family functioning

• History of trauma and manifestation of PTSD symptoms• Therapeutic content as triggers

• Language and cultural factors• Developmental factors

• Varying age ranges and developmental levels

Countertransference

• Community setting

• Reactions toward children

• Reactions toward caregivers

• Cultural countertransference

Reactions Toward Community Setting

• Becoming part of the community milieu • Severity of client needs• Appropriate roles/boundaries• Identification of personal biases and impact

on treatment• Safety concerns

• Children’s safety• Therapists’ safety

Reactions Toward Children

• Behavior problems and limit setting• Frustration at varying developmental

levels/ages and the pace of the group• Sadness and feelings of helplessness due to

compound traumas and severe levels of need• Anxiety about abuse disclosures• Desire to rescue/overprotect

Reactions Toward Parents

• Sadness regarding vulnerability of children and lack of parental resources

• Empathy about maternal trauma histories• Feelings of helplessness regarding ongoing

challenges (financial, occupational, etc.) • Anger and frustration due to lack of

appropriate parenting skills• Desire to rescue/overprotect

Cultural Countertransference

• Minimization of importance of culture• Lack of direct attention to culture• Failure to inquire about caregivers’ comfort with

information• Disregarding cues about parent receptiveness

• Misinterpreting hesitancy as resistance• Failure to recognize differences in

acculturation between parents and children