Community Ment Health J DOI 10.1007/s10597-014-9712-0
ORIGINAL PAPER
Homelessness, Behavioral Health Disorders and Intimate Partner Violence: Barriers to Services for Women Allison N. Ponce • Martha Staeheli Lawless Michael Rowe
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Received: 12 November 2012 / Accepted: 16 February 2014 Ó Springer Science+Business Media New York 2014
Abstract Homeless women comprise a significant portion of the homeless population and may encounter multiple life stressors including mental illness, substance abuse, and trauma. Women who are homeless may experience difficulty gaining access to resources such as shelter and health care. In addition, the interaction of behavioral health problems with intimate partner violence (IPV) may create extraordinary barriers to their engagement in services. This paper explores the co-occurrence of homelessness, behavioral health problems, and IPV and lessons learned through a gender-specific homeless services program designed to reach women who are unengaged in traditional services. Recommendations for providing gender-responsive services are discussed. Keywords Homeless women Intimate partner violence Gender-responsive services Homeless services
This work was supported by the Substance Abuse and Mental Health Services Administration and the State of Connecticut Department of Mental Health and Addiction Services. A. N. Ponce (&) Department of Psychiatry, Yale School of Medicine, 34 Park Street, New Haven, CT 06519, USA e-mail: [email protected] M. S. Lawless Center for Public Health and Health Policy, University of Connecticut Health Center, 99 Ash Street, 2nd Floor, MC 7160, East Hartford, CT 06108, USA M. Rowe Program for Recovery and Community Health, Department of Psychiatry, Yale School of Medicine, 319 Peck Street, Building 1, New Haven, CT 06513, USA
Introduction The US Department of Housing and Urban Development (2012) found that nearly 634,000 people were homeless in and outside of shelters in the United States on a single night in January 2012 and just under 40 % of those individuals are women. The continuing presence of homelessness in the US has been attributed to a variety of structural causes, including a faltering economy, lack of safe, affordable housing and housing vouchers, unemployment, and poverty which often co-occur with individual psychosocial and health vulnerabilities (US Conference of Mayors 2009). Homeless women are at high risk for mental health problems, substance use, high risk sexual behaviors, and health issues such as injury and sexually transmitted diseases including HIV (Frencher et al. 2010; Nyamathi et al. 2000; Nyamathi et al. 1995; Rayburn et al. 2005). In addition, interpersonal violence and other trauma often affect the lives of women who are homeless (Sacks et al. 2008; Stein et al. 2002) and the occurrence of psychiatric and behavioral health concerns among this population has been known to the research community for decades (Buckner et al. 1993). Further, women who are homeless are more likely to experience significantly decreased access to appropriate medical care and a lower quality of care for the services to which they are able to gain access (Teruya et al. 2010). There is a gap in knowledge about how to improve treatment services for women with co-occurring disorders, what the overall health needs of these women are, which services are associated with better outcomes, and how treatment services affect at-risk groups such as women who are victims of abuse and homeless women (Becker and Gatz 2005). Women who experience homelessness report high rates of childhood abuse (Browne and Bassuk 1997), and such abuse is a significant indirect predictor of
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substance use disorders among women without homes (Stein et al. 2002). Recent experiences of violence are also predictors of homelessness and substance abuse for women (Stein et al. 2002). In a study of individuals without homes with co-occurring substance abuse and mental health disorders, 100 % of women reported having experienced a trauma such as physical or sexual abuse (Christensen et al. 2005). Some women who are homeless with substance use disorders and trauma consume substances to cope with their trauma (Yeater et al. 2010). The experience of intimate partner violence (IPV) in adulthood has negative effects on poor and homeless women. Half of those abused at the hands of an intimate partner suffer physical injuries with more than a quarter requiring medical attention (Browne and Bassuk 1997). IPV against women is associated with increased incidence of injury, chronic pain, gastrointestinal, and gynecological problems including sexually transmitted diseases, depression, and PTSD (Bradley et al. 2005; Campbell 2002; Dutton et al. 2006). Supports, Services, and Service Seeking: Needs and Barriers Pathways to poor health outcomes among women who experience IPV are receiving increased scrutiny (Dutton et al. 2006), and poor health outcomes are known to be an issue for individuals who are homeless (Zlotnick and Zerger 2008). One study found that victims of IPV are twice as likely as non-victims to report unmet needs for mental health treatment, controlling for socioeconomic factors and substance abuse (Lipsky and Caetano 2007). Among African American women, those with IPV show increased use of outpatient mental health services, but may not have access to other types of community services such as support groups, legal assistance, and shelters. In fact, the rate of healthcare and community services utilization among this group is below 10 % (Pranjape et al. 2006). Particularly for women of color, IPV is associated with lower perceived social support, which is linked to increased distress (Thompson et al. 2000). Other research findings, however, indicate that recently abused women may receive less support from partners but receive support from others (Carlson et al. 2002). Among women who experience IPV, social support appears to buffer the negative effects related to poor perceived mental health (Coker et al. 2002). Weinreb et al. (2006) found that women with few supportive relationships made more outpatient and emergency department visits for health complaints and concerns even when they had access to ongoing care and carried health insurance. They hypothesized that there may be some therapeutic value in those visits, which if supported by research, would be important in light of the beneficial effects of social support for this population.
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Accepting housing-oriented services may be especially difficult for women with serious mental illnesses. Luhrmann (2008) examined the reasons that homeless women with psychosis refuse help. These include fear of losing their independence and a desire to fit into a street subculture. Regarding rejection of housing resources, Luhrmann found that many women saw acceptance of diagnosis-based services as acceptance of the ‘‘crazy’’ label, which they perceived as putting them at risk of predation. Understanding the reasons for some women’s inability or unwillingness to accept services is a complicated endeavor. However, the experience of trauma, including IPV, is a recurrent theme in the literature. Women who have survived family violence appear to have additional barriers to receiving services including the ongoing effects of trauma on their ability to navigate the service system. This includes contending with what they experience as service providers’ lack of sensitivity regarding the impact of trauma (Browne 1993). There are many barriers to engaging women without homes in the use of resources such as medical and dental care, contraceptive services and other women’s healthcare, legal assistance and support groups, with unsheltered women being even less likely to use these resources than others (Nyamathi et al. 2000). Obstacles to care often include transportation and childcare problems, nonexistent or unsafe shelter, under- or unemployment, scheduling problems, fear or anxiety, and stigma (Browne 1993; Gelberg et al. 2004; Weinreb et al. 2006). According to Rayburn et al. (2005), both homeless individuals and those with trauma histories are less likely to gain access to medical (Gelberg 1996) and mental healthcare than others (Breakey et al. 1989). Additional obstacles to engaging and sustaining involvement of homeless women in the mainstream service system may include the severity and persistence of mental illness and substance abuse, psychosocial stressors, insensitivity to cultural and trauma-related factors, and for some, exclusion from other programs due to substance abuse or other behaviors. In-depth interviews in the New York Services Study (Padgett et al. 2006) revealed that formerly homeless women with mental illness experienced betrayal of trust, anxiety of leaving immediate surroundings, and gender related status loss and stigma. These findings suggested that participants with mental illness desire autonomy, protection from further trauma, and help restoring identity and status. Multiple Vulnerabilities The triple challenge of homelessness, behavioral health problems, and IPV may complicate women’s access to resources, as the literature indicates that women with any one or two of these disadvantages have difficulty
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connecting with and benefiting from services. In this article we explore the special difficulties and risk of falling between the cracks of existing services systems that we observed, unexpectedly and over time, in this triply-challenged group. Members of this group were a small subset of our target group of women who were homeless with behavioral health problems and who received gender-specific services aimed at engaging them into treatment with associated supports including housing. We hope our initial findings will encourage more targeted quantitative and qualitative study aimed at developing effective interventions for this group of women who, by our observation, appeared to have even greater difficulty engaging than the dually challenged women with behavioral health disorders who experience homelessness.
The Community Living Room The Community Living Room (CLR) was initiated in 2005 with a grant from the Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. The project, inspired in part by Segal and Baumohl’s 1985 article of the same name, was an interagency collaboration that provided gender-specific, culturally-competent and trauma-informed services for adult women who were homeless and had substance use disorders and other mental health concerns. The drop-in nature of the program was a core component, as was an emphasis on engaging women for whom traditional homeless service structures had proved insufficient. CLR was administered by a community-based private non-profit agency that provides shelter, housing, and case management services to adults who are homeless. Community-based private non-profit partners provided three additional service sites: a federal Center for Substance Abuse Treatment-funded program with drop-in services and activities for African American women with substance use disorders; a low-demand drop-in center for men and women with substance use disorders; and a dropin center for homeless adults at a social clubhouse for women and men with serious mental illness. Thus, CLR was not one physical ‘‘living room.’’ Rather, it was a network of spaces in the community that allowed clients to select the environment in which they felt most comfortable to engage in services. The staff of CLR included a clinician/case manager, program director, and a project director for evaluation who also participated in direct management of the intervention, along with up to eight peer mentors. An essential component of the CLR model, the peer mentors–formerly homeless women in recovery—conducted outreach and drew on their lived experiences to engage program participants. In addition, an
interagency homeless outreach project provided support services and acted as a conduit to other service providers for homeless individuals who were difficult to locate, not otherwise engaged in services, or bouncing between and among multiple resources. CLR staff members and peer mentors received training on gender, trauma, and culture from a statewide training and advocacy organization that focuses on women’s issues in behavioral health. The training focused on issues such as creating trauma and gender sensitive physical environments, engaging women in a safe and respectful fashion and understanding how signs of behavioral health problems are often responses to trauma. Faculty from the Department of Psychiatry of the Yale University School of Medicine conducted a participatory, action-based qualitative and quantitative evaluation of the CLR. CLR clients received peer engagement, case management, and referral services, with baseline and 6 month assessments using the Government and Performance Results Act (GPRA) individual client outcome-reporting tool. A total of 343 women were served by the CLR. Among those served, 36.2 % (n = 124) women identified as White; 53.6 % (n = 184) identified as Black; 12.2 % (n = 42) identified as Latina, 1.2 % (n = 4) identified as Native American, and 1.2 % (n = 4) identified as other (percentages add up to more than 100 % because some clients indicated affiliation with more than one ethnic/racial background). Most women (63.5 %; n = 218) were between the ages of 35 and 55; another 30.3 % (n = 104) were between 18 and 34, and 6.1 % (21) were over age 56. Over 87 % (n = 300) of CLR clients remained engaged at the 6-month follow-up and there was evidence of improvement in psychosocial factors over this period. The average number of days of drug use (F(2) = 4.86, p = .008), depression (F(2) = 32.587, p = .000), anxiety (F(2) = 31.062, p = .000), poor brain function (F(2) = 7.82, p = .000) and hallucinations (F(2) = 3.684, p = .026) decreased at significant rates. Participation in job training programs (v2(4) = 31.3; p = .000) and employment rates (v2(14) = 24.3, p = .042) significantly increased, while the number of crimes committed by the women decreased significantly (F(2) = 4.439, p = .012) from almost 4 to around 2 in the previous 30 days. Participants also significantly increased their attendance at non-clinical programs such as 12 step support groups (F(2) = 5.08, p = .006). The most significant increase, however, was seen in the number of women who were housed during the course of the program: a majority of clients were housed in the shelter system at enrollment, and of these, 55 % were ultimately placed into housing (v2 (6) = 66.006, p = .000). Furthermore, in focus groups and qualitative interviews clients reported strongly positive experiences with the CLR program. Representative comments include: ‘‘I feel like finally someone believes in me’’ and ‘‘I can get help. I’m not
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alone.’’ While claims for the project’s success must be modest given the lack of a matched comparison group or randomization, the outcomes above appear promising and are consistent with staff and peer mentors’ general sense of their ability to have an impact in the lives of women who were homeless with behavioral health disorders. Our engagement with the program participants led to qualitative observations about subgroups of women in CLR and even with the project’s emphasis on trauma, gender, and culturally informed training for staff and mentors, we found that helping women with the triple challenges of homelessness, substance use, and IPV was especially difficult. These women, mostly in their twenties, appeared to have greater difficulty than dually challenged women in gaining access to, or accepting the offer of shelter and other social services and moving way from unsafe intimate relationships. Some but not all from what we were able to determine, had long histories of physical and sexual abuse and chaotic family lives growing up. CLR’s intention to provide a safe emotional and physical ‘‘living room’’ in its three community sites while, at the same time, endeavoring to engage women into available clinical and social services, seemed to fall short with this subgroup of women. Despite positive outcomes for the project in general, we came to understand that additional considerations in working with this population may threaten success in providing services to this subgroup. Discussion Our observations sent us back to the literature where we began to understand that what we were seeing had not yet been evaluated. It is true that difficulties gaining access to services for women with IPV are consistent with research findings that both women in violent interpersonal relationships with trauma histories, and homeless women in general are less likely than their counterparts in the general population to gain access to healthcare, shelter, and social support services (Browne 1993; Luhrmann 2008; Nyamathi et al. 2000; Rayburn et al. 2005). Little attention, however, has been paid to the subset of women who are: (a) homeless, (b) have mental health and substance use problems, and (c) are experiencing IPV. In CLR, women who were survivors of IPV were in hetero- or homosexual relationships and were married or living with a partner or not. Many had children, in their custody or not. They lived in shelters, on the streets, or on other people’s couches. Regardless of the individual’s particular situation, though, we found these women were often unwilling or unable to engage in services for reasons that appear to be related to their experiences with their violent or predatory partners.
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Vignettes Trauma related to IPV and fear of being retraumatized, losing relationships, or jeopardizing one’s safety are powerful motivators to reject services, if accepting them may lead to increased risk. Women reported that their partners did not want them to interact with male staff, believed that partners offer protection despite abuse, and feared being judged by providers for continuing the abusive relationships. Below, we give four case vignettes that are representative of the background and experiences of many women with IPV histories and of the difficulties staff and peer mentors with the CLR program had in trying to help them. (Details are changed and some composite material is included.) May. May, a woman in her mid-20 s, was 8 months pregnant when CLR staff met her. She had a history of mental illness and substance use and came from a family background marked by chaos and abuse. When CLR staff first had contact with her she was sleeping in a van with her much-older boyfriend who was the father of her child. May had stopped using substances when she learned she was pregnant. She hoped having a child would strengthen her relationship with her boyfriend and help her begin a new life. CLR case managers saw a pattern of controlling behaviors from her boyfriend. He would not allow staff to talk to May without him and he openly disapproved of the relationships she was beginning to develop with them. May was offered a place in a residential program for women, but turned down the opportunity when her boyfriend discouraged it. After she gave birth, May and her boyfriend moved to a substandard motel room using a voucher he obtained. When CLR staff visited her, it was evident that she was being abused. May was offered safe shelter, but chose to not leave her boyfriend. Staff heard rumors that her boyfriend was having relationships with other young women and that May’s pregnancy had been a result of his raping her. They contacted the state child and family agency, but learned that May, her baby, and the boyfriend disappeared. They have not been seen since. Linda. Linda, a woman in her forties with a substance use disorder and a suspected but undiagnosed psychiatric disorder, lived in a ‘‘tent city’’ with her boyfriend, also in his forties and with drinking and drug problems. He abused her physically and victimized other women physically and sexually. Unlike many other women contending with current IPV, Linda had been receiving support from the mental health outreach team that collaborated with CLR and
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had stayed in its parent agency’s emergency shelter. After her boyfriend beat her again, she went South to stay with her family. When she came back a few months later, Linda looked well. She reconnected with boyfriend, though, and moved back into the tent city. She maintained a connection with CLR staff, although she could be angry and threatening. CLR staff offered her support and helped connect her with a women’s group. They were left with what they described as a challenging question, though, as Linda waited on her pending SSI application: if housing was available, and she would only be housed with her boyfriend, would she be better off living inside with him than out? Terri. Terri, a young woman, lived on the streets or in an abandoned vehicle with an older man. Although she had not sought shelter services in the past, Terri began to consider this option after meeting with CLR staff. Her boyfriend, who had shown hostility toward CLR staff when they talked with her, accompanied Terri to the shelter, where she would have stayed in a separate dormitory for women. When he threatened to beat up Terri and the male front desk clerk at the shelter who, he claimed, was flirting with her, Terri refused to come into the shelter, and continued to live with her boyfriend on the streets. A CLR staff member had contact with her several months later. Terri was living with her boyfriend at her mother’s home. She said he was regularly physically abusing her. When asked if she would like to change her situation, she demurred, saying that she had shelter and food and that her boyfriend protected her from other victimizers. Beth. Beth, a woman in her twenties, was with a man who, CLR staff learned, had impregnated three other women associated with the shelter program that administered CLR. Beth was the fourth. She had a history of depression and alcohol abuse. For a time, she and her boyfriend lived in a rented room. Beth’s mother came to CLR staff asking for their help in getting her to come back home. Beth said she loved her boyfriend but did agree to move back home. She gave birth and entered treatment for her mental health and addiction problems. Two years later the CLR director bumped into her at a shopping mall. Beth was still living with her parents, was attending community college, and was not seeing her child’s father. While it is impossible to know the precise reasons for Beth’s success, or CLR’s contribution to it, the program helped her to get treatment, prenatal care, and to work her on her parenting skills.
IPV, homelessness, and mental illness, then, can often, though not always, converge to prevent women from receiving needed services. While a combination of factors led clients to acceptance or rejection of program services, the elements of predatory relationships, behavioral health problems, and IPV appear to be strongly related to rejection. In the next section we attempt to distill lessons learned from this 5-year project in the form of key themes and recommendations for future interventions that target women who are among the most difficult to engage and serve among those who are homeless. Recommendations Working with women who experience homelessness, substance abuse, mental illness and IPV is complex and challenging but can be rewarding as well. Here, we offer four ‘‘working points,’’ with overlap among them, in support of further such efforts. Strategic Design and Delivery of Services IPV among women with behavioral health problems adds an additional dimension of complexity to addressing their homelessness, since a violent, coercive, or predatory partner may pose barriers to women’s gaining access to and accepting services. As we have noted, we do not claim resounding success with this subgroup of women who are homeless with substance use disorders and IPV. We argue that further targeted programmatic and research efforts should be made to enhance our knowledge of this group and develop more effective intervention strategies. We offer here several strategies that were helpful, at times, in engaging or helping CLR staff and peer mentors maintain contact with women with IPV in their lives. Take a Non-judgmental Approach With women who experienced IPV, we used a non-judgmental approach coupled with attempts to offer suggestions and resources for taking care of themselves in healthier and safer ways. In addition to and perhaps despite offering this non-judgmental stance, taking steps to increase safety for women and their children is of utmost importance. Offering the support of treatment providers and resources for survivors of violence and utilizing child protection services are mechanisms for doing so. Even taken by itself, conveying a non-judgmental approach is a delicate matter: the supportive stance must not appear to the client as a tacit acceptance of the IPV she experiences and her decision to remain in the relationship. Maintaining and managing this distinction in manner, words, and actions requires good clinical skills and instincts and can be seen as comparable
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to the dilemma the outreach worker faces on a Friday afternoon, heading into a brutally cold weekend, with a client with mental illness who has been sleeping outside for years and refuses to come inside. It is necessary, as in all homeless outreach work, to strike a balance between the providers’ responsibility to help and the client’s choice and autonomy (Rowe et al. 2001). This might be accomplished by taking steps to acknowledge the problem and engage in collaborative problem solving with the woman without assigning blame to her, although, as with other aspects of maintaining the delicate balance discussed here, this general guideline does not provide a detailed map for in-themoment work. Assessing what needs are being met by the predatory or controlling partner can help staff work with women to meet their needs in healthier and safer ways. It may also be fruitful to address the service needs of perpetrators who may have their own behavioral health problems and trauma histories. CLR staff did, in fact, make such attempts more than once, admittedly with little success. In retrospect, we think a more effective response would have been closer liaison and teamwork with non-CLR case managers who could have offered to help perpetrators with their services needs. Perhaps these case managers would have been seen as neutral parties who were, in fact, addressing the abusers’ needs rather than trying to render them less harmful to their abused partners. Attend to Staff Gender While the principle of ‘‘women helping women’’ employed in the CLR program is not universally applicable—a woman in an IPV homosexual relationship will not necessarily find female staff less threatening than male staff—our observation was that the fact that CLR staff and peer mentors were female smoothed the still-difficult process of engagement with this group. Hiring women who are empathic and training them in employment of the other strategies suggested here is essential. Employ Principles and Practices of Mental Health Outreach Mental health outreach has developed over the past 30 years with the rise in homelessness in the late 1970s in the US Outreach work espouses and practices the principles of ‘‘going where the client is’’ both physically (streets, shelters, etc.) and existentially (marginalized, wary of mental health workers, etc.). It entails building trust slowly and not demanding motivation for change or acceptance of mental health treatment as conditions for receiving other services such as help finding housing. It is also important to build on the strengths of people as survivors of homelessness and make contact with the person, not the patient (Olivet et al. 2007; Rowe 1999). CLR staff received training in these practices from the supervisor of the parent
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agency outreach team director. We recommend them, among other strategies, for future community-based projects with this population. Utilize Peer Engagement Research suggests that trained peers—persons with behavioral health disorders—have a unique capacity to engage with and motivate their peers for treatment (Sells et al. 2006, 2008). Deployment of peer mentors was a core element of the CLR program. We note that length of time in recovery from mental illness or substance use, training, supervision, and individual and group support for this difficult work are factors to consider in employing peer mentors in this work. Provide Training in Understanding and Addressing Trauma Grief, loss, shame, identity, spirituality, and needs for connection and support are, in our experience, common emotional vulnerabilities among women who are homeless. Training and supervision in trauma sensitivity help staff develop an appreciation for how a history of trauma can lead a woman to avoid abuse at all costs, including refusal of shelter if she fears accepting it might prompt her partner’s violence. Offer Multiple Meeting Sites The CLR program included multiple drop-in sites for the simple reason that the availability of these sites would increase the number of opportunities to make contact with potential or current clients. We found this to be the case. However, we also found that violent partners frequented some sites and not others, which gave us the opportunity to meet with clients away from the watchful eye of an abusing partner if the client chose to meet at a location to which her partner was unlikely to go. Attend to Staff Needs and Mental Wellbeing The potential for vicarious trauma is always present as staff members learn about and witness the traumatizing experiences of women with behavioral health disorders and IPV. This can be especially troubling for those with their own trauma histories. Frequent team meetings with ample time for discussion of the difficult nature of the work are both means of support or of ‘‘spelling’’ each other when one or more are at the edge of burnout, and of maintaining strength through celebrating clients’ (and thus the team’s) small and large successes. Staff identification with clients may help to fuel their passion and commitment to the work, but such identification may also present risks to their own mental and emotional health. As stated above, research has demonstrated the special strengths of peer staff in engaging and motivating clients for treatment (Sells et al. 2006, 2008). Peer
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staff members are also exposed, however, to the struggles of women not so far away in time and circumstances from their own struggles, and ongoing mutual support and insight into the workings of trauma can help them, as well as their non-peer colleagues, maintain individual and collective stability and effectiveness. Provide an Effective and Supportive Administrative Structure Administrative support and structure is critical to programs that push at the boundaries of treatment and case management. In the CLR case, elements of this support included the direct involvement of the Executive Director of the parent agency as principal investigator of the project; a management committee composed of supervisors from each participating agency; and what appears to have been a good balance between oversight leadership and support, on one hand, and a willingness to let project staff take the lead in implementing and running the program, on the other. This balance supported efforts to adjust and tweak the program at a pace and with the timing that best suited the operations of the program, rather than requiring that decisions filter through an arduous bureaucratic process (Rowe et al. 1996). The success of programs such as the one we describe here is tied to collaboration with multiple agencies. Interagency partnerships were already in place for the CLR project through the local mental health authority, which is the nearby community mental health center. This facilitated coordination of services, greater resources, and diverse expertise. Also in the CLR case, the feasibility of multiple drop-in program sites was enhanced by existing agency collaborations and agreements. Interagency cooperation was, in turn, further enhanced by the ‘‘seeding effect’’ of multiple program sites through which more staff and agencies became familiar with the program and were better able to identify resources for women. When designing programs for women with social and personal vulnerabilities, we also recommend seeking community partnerships that may stand outside the formal system of care and drawing on the specific strengths of each stakeholder group. For example, developing organizational relationships with domestic violence providers would be especially important in working with homeless women with IPV to facilitate access to resources such as education, shelter, and support. Professionals who focus specifically on helping survivors of IPV can be valuable members of the service team. In addition, there is a need for education of staff, agencies, and service systems on women’s issues, gender specific services, and trauma specific services ‘‘from receptionists on up to the top,’’ as one CLR supervisor stated.
Acknowledge and Appreciate Synergy Programs and teams that work at the margins of practice with marginalized persons, including persons who are homeless, cultivate a sense of the ‘‘specialness’’ of the work and the attributes of heart, skill, and commitment it takes to do it (Rowe 1999). For the CLR team and its staff and peer mentors this specialness consisted, in part, of identification with their clients as women and as mothers. Staff and peer mentors, variously, came from abusive families, were in recovery, knew and grew up with some of the clients, were mothers, and were in relationships with men or women that sometimes bore similarities to those of CLR clients. There was protectiveness toward children born of troubled relationships and vulnerable mothers; support and solidarity for each other (the ‘‘community living room’’ started with the staff team, which then invited clients to come in from the street); and a sense that, as a group of women, they belonged to a community of discovery in regard to their clients. ‘‘We felt as though we were bringing the truth to light,’’ said one staff person. ‘‘When we talk to clinicians and service providers, they can’t believe it. We live in a third world country.’’ The sense of specialness of CLR was embodied not only in the makeup of the team (all female) but in its nonjudgmental character toward its clients (a value, we note, that mixed gender homeless outreach teams also emphasize), and in the principle of giving women a safe place to visit and spend time, that is, a community living room not just a social service program. The role of leaders includes the tasks of assuring that the ‘‘sense of specialness’’ is ineluctably linked with principles that are linked to practice, while also assuring that invidious distinctions with other practices and programs do not lead to isolation from them. Part of the sense of specialness of the CLR also emerged in relation to the team’s work with local service providers and within the behavioral health service system as a whole. As background, the parent agency provides a wide range of shelter, residential, and case management services and is a member of the local mental health services network. Local service coordination for persons was significantly enhanced by participation in the SAMHSA national Access to Community Care and Effective Services and Supports program from 1993 to 2000, which espoused a ‘‘No Wrong Door’’ systems-integration approach to care for persons who are homeless with behavioral health problems. Simultaneously, the lead community mental health center successfully applied for and administers substantial housing programs through the HUD Shelter Plus Care and Supportive Housing Programs. CLR staff and peer mentors articulated a difficulty that seemed to characterize its generally well-coordinated
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behavioral health system as a whole: the ‘‘No Wrong Door’’ approach is firmly in place in service-system agencies in terms of identifying points of access and having the interorganizational capacity to refer and accept referrals. What was missing, at times, was the ‘‘right person’’ at the ‘‘right door.’’ Systems of care that are integrated administratively from the ‘‘top down’’ (Randolph et al. 1997) or the ‘‘bottom up’’ (Rowe et al. 1998) must further ensure that staff at ‘‘the door’’ are equipped, by nature and by training, to provide patient, welcoming care to highly vulnerable and often reluctant clients such as women who are homeless with IPV. This initial finding can only serve as a suggestion for further research and programmatic attention, but it appeared to heighten the CLR team’s sense of exploring new territory on behalf of its clients. Finally, CLR not only launched the careers of, but provided life- and career- changing experiences for three professional women, who represent a group that is critical to the success of the work we describe here. The project has contributed to positive outcomes for many of the peer staff as well. In addition, support of female peer workers, many with their own histories of IPV, for each other and from professional staff on a supportive team engaged in the trials and triumphs of their difficult work, led to development of a unique ‘‘respite and relaxation’’ program for peer staff. ‘‘New Visions of Me,’’ built on principles including those of ‘‘trying something new,’’ ‘‘taking care of oneself and others,’’ and ‘‘connecting with other women in recovery’’—might inform like interventions with peer staff, and perhaps service components as well (Lawless et al. 2009).
Other Questions and Limitations A few remaining issues or questions, some referenced above, are of a piece with the limitations of this study. Most of our subset of triply-challenged women were in their twenties. This suggests that the subset of women we have discussed in this article may, in turn, have further subsets. If one of these is younger women, prevention and early intervention, and different outreach and clinical strategies must be considered, attending to the particular vulnerabilities and strengths of this group. It is possible that younger peer staff will be able to more effectively engage this group, although an older, mature presence on the peer engagement team may be helpful as well. Peer or co-led clinician and peer groups of young women, with attention to developmental issues and efforts to prevent or forestall further IPV, as well as alternatives visions of one’s life such as education and work, can be considered. Similar considerations may apply to race and ethnicity among this group. Our small subset of clients with IPV did not allow
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us to determine differences related to these variables, but culturally competent care, an area in which CLR staff and peers were trained, must be considered in regard to future research and intervention development. It is our hope that future research will answer some of the questions we can only raise here, and improve upon our recommendations based on more extensive data.
Future Directions Previous research supports the fact that homeless women have difficulty gaining access to services (Nyamathi et al. 2000), as do some women who experience IPV (Pranjape et al. 2006). Women who are homeless with behavioral health disorders have greater need for a range of social and clinical services than those with one or two of these elements, yet due to the circumstances of their lives and relationships may have more barriers to gaining access to and accepting them. They have even greater need for multifaceted, flexible, and creative programs with the capacity to provide outreach and engagement services, referral to treatment and social service programs, and a range of temporary and permanent housing options, including supportive housing. Further action-based research will reveal the prevalence of these co-occurring phenomena, the services best able to support individuals who live with them, and the resources needed to help them exit homelessness and improve their wellbeing. In programs and service systems that are male oriented and that have a dearth of female-specific programs, women may be at a disadvantage not only in terms of access to and use of services but in terms of the expressive aspect of social service and clinical programs. The latter go beyond, or behind, quantifiable services and goods to support their clients’ identity needs. In the case of women such as those that CLR served, identity needs may be related to unacknowledged legacies of oppression and trauma. Medical anthropologists and sociologists using ethnographic and indepth interview research methods may have a particular contribution to make in these areas. While CLR staff often were frustrated at their inability to engage or affect the circumstances of the ‘‘hardest-toreach’’ of their target group—those with IPV in addition to being homeless with behavioral health disorders—lowdemand programs such as CLR, including drop-in program support, appear to enhance the possibility of providing safe and supportive settings in which women can access muchneeded services and personal and group support. They may also provide the range and flexibility needed to offer social and personal services and activities such as helping women write resumes and find jobs, locate a church, decorate an apartment, and more. Organizational and services
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researchers may have much to offer in studying the forms and the impact of such collaborations. The poet John Keats wrote briefly but powerfully of ‘‘negative capability,’’ the capacity to live with ambiguity and acceptance of the fact that much in life remains unresolved. This is a concept that may speak to those who undertake programs such as the one we have described in this article. In such programs, staff, peers, and administrators must live with the reality that there are many paths out of, and many barriers to exiting homelessness and interpersonal violence for women. A particular staff member’s, or a program’s, contribution to individual women’s successful exit or continuing entrenchment often becomes clear only over time, and sometimes not at all. This capacity for living with ambiguity is, of course, not an excuse for inaction. Rather, it is a support for taking and sustaining action under the difficult circumstances of clients and under organizational constraints for programs and staff that venture into this demanding and important work.
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problems among homeless women: Mediating roles of selfesteem and abuse in adulthood. Child Abuse and Neglect, 26(10), 1011–1027. doi:10.1016/S0145-2134(02)00382-4. Teruya, C., Longshore, D., Andersen, R. M., Aragua, L., Nyamathi, A., Leaker, B., et al. (2010). Health and health care disparities among homeless women. Women and Health, 50, 719–736. doi:10.1080/03630242.2010.532754. Thompson, M. P., Kaslow, N. J., Kingree, J. B., Rashid, A., Puett, R., Jacobs, D., et al. (2000). Partner violence, social support, and distress among inner-city African American women. American Journal of Community Psychology, 28, 127–143. doi:10.1023/A: 1005198514704. US Conference of Mayors (2009). Hunger and Homelessness Survey: A status report on hunger and homelessness in America’s cities. Washington, DC: Author. Retrieved from http://usmayors. org/pressreleases/uploads/USCMHungercompleteWEB2009.pdf. US Department of Housing and Urban Development. (2012). The 2011 annual homeless assessment report to congress. Retrieved from https://www.onecpd.info/resources/documents/2011AHAR_Final Report.pdf. Weinreb, L., Perloff, J., Goldberg, R., Lessard, D., & Hosmer, D. W. (2006). Factors associated with health service utilization patterns in low-income women. Journal of Health Care for the Poor and Underserved, 17, 180–199. doi:10.1353/hpu. 2006.0036. Yeater, E. A., Austin, J. L., Green, M. J., & Smith, J. (2010). Coping mediates the relationship between posttraumatic stress disorder (PTSD) symptoms and alcohol use in homeless, ethnically diverse women: A preliminary study. Psychological Trauma: Theory, Research, Practice, and Policy, 2(4), 307–310. doi:10. 1037/a0021779. Zlotnick, C., & Zerger, S. (2008). Survey findings on characteristics and health status of clients treated by federally funded (US) Health Care for the Homeless Programs. Health and Social Care in the Community, 17, 18–26. doi:10.1111/j.1365-2524.2008. 00793.x.
ORIGINAL PAPER
Homelessness, Behavioral Health Disorders and Intimate Partner Violence: Barriers to Services for Women Allison N. Ponce • Martha Staeheli Lawless Michael Rowe
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Received: 12 November 2012 / Accepted: 16 February 2014 Ó Springer Science+Business Media New York 2014
Abstract Homeless women comprise a significant portion of the homeless population and may encounter multiple life stressors including mental illness, substance abuse, and trauma. Women who are homeless may experience difficulty gaining access to resources such as shelter and health care. In addition, the interaction of behavioral health problems with intimate partner violence (IPV) may create extraordinary barriers to their engagement in services. This paper explores the co-occurrence of homelessness, behavioral health problems, and IPV and lessons learned through a gender-specific homeless services program designed to reach women who are unengaged in traditional services. Recommendations for providing gender-responsive services are discussed. Keywords Homeless women Intimate partner violence Gender-responsive services Homeless services
This work was supported by the Substance Abuse and Mental Health Services Administration and the State of Connecticut Department of Mental Health and Addiction Services. A. N. Ponce (&) Department of Psychiatry, Yale School of Medicine, 34 Park Street, New Haven, CT 06519, USA e-mail: [email protected] M. S. Lawless Center for Public Health and Health Policy, University of Connecticut Health Center, 99 Ash Street, 2nd Floor, MC 7160, East Hartford, CT 06108, USA M. Rowe Program for Recovery and Community Health, Department of Psychiatry, Yale School of Medicine, 319 Peck Street, Building 1, New Haven, CT 06513, USA
Introduction The US Department of Housing and Urban Development (2012) found that nearly 634,000 people were homeless in and outside of shelters in the United States on a single night in January 2012 and just under 40 % of those individuals are women. The continuing presence of homelessness in the US has been attributed to a variety of structural causes, including a faltering economy, lack of safe, affordable housing and housing vouchers, unemployment, and poverty which often co-occur with individual psychosocial and health vulnerabilities (US Conference of Mayors 2009). Homeless women are at high risk for mental health problems, substance use, high risk sexual behaviors, and health issues such as injury and sexually transmitted diseases including HIV (Frencher et al. 2010; Nyamathi et al. 2000; Nyamathi et al. 1995; Rayburn et al. 2005). In addition, interpersonal violence and other trauma often affect the lives of women who are homeless (Sacks et al. 2008; Stein et al. 2002) and the occurrence of psychiatric and behavioral health concerns among this population has been known to the research community for decades (Buckner et al. 1993). Further, women who are homeless are more likely to experience significantly decreased access to appropriate medical care and a lower quality of care for the services to which they are able to gain access (Teruya et al. 2010). There is a gap in knowledge about how to improve treatment services for women with co-occurring disorders, what the overall health needs of these women are, which services are associated with better outcomes, and how treatment services affect at-risk groups such as women who are victims of abuse and homeless women (Becker and Gatz 2005). Women who experience homelessness report high rates of childhood abuse (Browne and Bassuk 1997), and such abuse is a significant indirect predictor of
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substance use disorders among women without homes (Stein et al. 2002). Recent experiences of violence are also predictors of homelessness and substance abuse for women (Stein et al. 2002). In a study of individuals without homes with co-occurring substance abuse and mental health disorders, 100 % of women reported having experienced a trauma such as physical or sexual abuse (Christensen et al. 2005). Some women who are homeless with substance use disorders and trauma consume substances to cope with their trauma (Yeater et al. 2010). The experience of intimate partner violence (IPV) in adulthood has negative effects on poor and homeless women. Half of those abused at the hands of an intimate partner suffer physical injuries with more than a quarter requiring medical attention (Browne and Bassuk 1997). IPV against women is associated with increased incidence of injury, chronic pain, gastrointestinal, and gynecological problems including sexually transmitted diseases, depression, and PTSD (Bradley et al. 2005; Campbell 2002; Dutton et al. 2006). Supports, Services, and Service Seeking: Needs and Barriers Pathways to poor health outcomes among women who experience IPV are receiving increased scrutiny (Dutton et al. 2006), and poor health outcomes are known to be an issue for individuals who are homeless (Zlotnick and Zerger 2008). One study found that victims of IPV are twice as likely as non-victims to report unmet needs for mental health treatment, controlling for socioeconomic factors and substance abuse (Lipsky and Caetano 2007). Among African American women, those with IPV show increased use of outpatient mental health services, but may not have access to other types of community services such as support groups, legal assistance, and shelters. In fact, the rate of healthcare and community services utilization among this group is below 10 % (Pranjape et al. 2006). Particularly for women of color, IPV is associated with lower perceived social support, which is linked to increased distress (Thompson et al. 2000). Other research findings, however, indicate that recently abused women may receive less support from partners but receive support from others (Carlson et al. 2002). Among women who experience IPV, social support appears to buffer the negative effects related to poor perceived mental health (Coker et al. 2002). Weinreb et al. (2006) found that women with few supportive relationships made more outpatient and emergency department visits for health complaints and concerns even when they had access to ongoing care and carried health insurance. They hypothesized that there may be some therapeutic value in those visits, which if supported by research, would be important in light of the beneficial effects of social support for this population.
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Accepting housing-oriented services may be especially difficult for women with serious mental illnesses. Luhrmann (2008) examined the reasons that homeless women with psychosis refuse help. These include fear of losing their independence and a desire to fit into a street subculture. Regarding rejection of housing resources, Luhrmann found that many women saw acceptance of diagnosis-based services as acceptance of the ‘‘crazy’’ label, which they perceived as putting them at risk of predation. Understanding the reasons for some women’s inability or unwillingness to accept services is a complicated endeavor. However, the experience of trauma, including IPV, is a recurrent theme in the literature. Women who have survived family violence appear to have additional barriers to receiving services including the ongoing effects of trauma on their ability to navigate the service system. This includes contending with what they experience as service providers’ lack of sensitivity regarding the impact of trauma (Browne 1993). There are many barriers to engaging women without homes in the use of resources such as medical and dental care, contraceptive services and other women’s healthcare, legal assistance and support groups, with unsheltered women being even less likely to use these resources than others (Nyamathi et al. 2000). Obstacles to care often include transportation and childcare problems, nonexistent or unsafe shelter, under- or unemployment, scheduling problems, fear or anxiety, and stigma (Browne 1993; Gelberg et al. 2004; Weinreb et al. 2006). According to Rayburn et al. (2005), both homeless individuals and those with trauma histories are less likely to gain access to medical (Gelberg 1996) and mental healthcare than others (Breakey et al. 1989). Additional obstacles to engaging and sustaining involvement of homeless women in the mainstream service system may include the severity and persistence of mental illness and substance abuse, psychosocial stressors, insensitivity to cultural and trauma-related factors, and for some, exclusion from other programs due to substance abuse or other behaviors. In-depth interviews in the New York Services Study (Padgett et al. 2006) revealed that formerly homeless women with mental illness experienced betrayal of trust, anxiety of leaving immediate surroundings, and gender related status loss and stigma. These findings suggested that participants with mental illness desire autonomy, protection from further trauma, and help restoring identity and status. Multiple Vulnerabilities The triple challenge of homelessness, behavioral health problems, and IPV may complicate women’s access to resources, as the literature indicates that women with any one or two of these disadvantages have difficulty
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connecting with and benefiting from services. In this article we explore the special difficulties and risk of falling between the cracks of existing services systems that we observed, unexpectedly and over time, in this triply-challenged group. Members of this group were a small subset of our target group of women who were homeless with behavioral health problems and who received gender-specific services aimed at engaging them into treatment with associated supports including housing. We hope our initial findings will encourage more targeted quantitative and qualitative study aimed at developing effective interventions for this group of women who, by our observation, appeared to have even greater difficulty engaging than the dually challenged women with behavioral health disorders who experience homelessness.
The Community Living Room The Community Living Room (CLR) was initiated in 2005 with a grant from the Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. The project, inspired in part by Segal and Baumohl’s 1985 article of the same name, was an interagency collaboration that provided gender-specific, culturally-competent and trauma-informed services for adult women who were homeless and had substance use disorders and other mental health concerns. The drop-in nature of the program was a core component, as was an emphasis on engaging women for whom traditional homeless service structures had proved insufficient. CLR was administered by a community-based private non-profit agency that provides shelter, housing, and case management services to adults who are homeless. Community-based private non-profit partners provided three additional service sites: a federal Center for Substance Abuse Treatment-funded program with drop-in services and activities for African American women with substance use disorders; a low-demand drop-in center for men and women with substance use disorders; and a dropin center for homeless adults at a social clubhouse for women and men with serious mental illness. Thus, CLR was not one physical ‘‘living room.’’ Rather, it was a network of spaces in the community that allowed clients to select the environment in which they felt most comfortable to engage in services. The staff of CLR included a clinician/case manager, program director, and a project director for evaluation who also participated in direct management of the intervention, along with up to eight peer mentors. An essential component of the CLR model, the peer mentors–formerly homeless women in recovery—conducted outreach and drew on their lived experiences to engage program participants. In addition, an
interagency homeless outreach project provided support services and acted as a conduit to other service providers for homeless individuals who were difficult to locate, not otherwise engaged in services, or bouncing between and among multiple resources. CLR staff members and peer mentors received training on gender, trauma, and culture from a statewide training and advocacy organization that focuses on women’s issues in behavioral health. The training focused on issues such as creating trauma and gender sensitive physical environments, engaging women in a safe and respectful fashion and understanding how signs of behavioral health problems are often responses to trauma. Faculty from the Department of Psychiatry of the Yale University School of Medicine conducted a participatory, action-based qualitative and quantitative evaluation of the CLR. CLR clients received peer engagement, case management, and referral services, with baseline and 6 month assessments using the Government and Performance Results Act (GPRA) individual client outcome-reporting tool. A total of 343 women were served by the CLR. Among those served, 36.2 % (n = 124) women identified as White; 53.6 % (n = 184) identified as Black; 12.2 % (n = 42) identified as Latina, 1.2 % (n = 4) identified as Native American, and 1.2 % (n = 4) identified as other (percentages add up to more than 100 % because some clients indicated affiliation with more than one ethnic/racial background). Most women (63.5 %; n = 218) were between the ages of 35 and 55; another 30.3 % (n = 104) were between 18 and 34, and 6.1 % (21) were over age 56. Over 87 % (n = 300) of CLR clients remained engaged at the 6-month follow-up and there was evidence of improvement in psychosocial factors over this period. The average number of days of drug use (F(2) = 4.86, p = .008), depression (F(2) = 32.587, p = .000), anxiety (F(2) = 31.062, p = .000), poor brain function (F(2) = 7.82, p = .000) and hallucinations (F(2) = 3.684, p = .026) decreased at significant rates. Participation in job training programs (v2(4) = 31.3; p = .000) and employment rates (v2(14) = 24.3, p = .042) significantly increased, while the number of crimes committed by the women decreased significantly (F(2) = 4.439, p = .012) from almost 4 to around 2 in the previous 30 days. Participants also significantly increased their attendance at non-clinical programs such as 12 step support groups (F(2) = 5.08, p = .006). The most significant increase, however, was seen in the number of women who were housed during the course of the program: a majority of clients were housed in the shelter system at enrollment, and of these, 55 % were ultimately placed into housing (v2 (6) = 66.006, p = .000). Furthermore, in focus groups and qualitative interviews clients reported strongly positive experiences with the CLR program. Representative comments include: ‘‘I feel like finally someone believes in me’’ and ‘‘I can get help. I’m not
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alone.’’ While claims for the project’s success must be modest given the lack of a matched comparison group or randomization, the outcomes above appear promising and are consistent with staff and peer mentors’ general sense of their ability to have an impact in the lives of women who were homeless with behavioral health disorders. Our engagement with the program participants led to qualitative observations about subgroups of women in CLR and even with the project’s emphasis on trauma, gender, and culturally informed training for staff and mentors, we found that helping women with the triple challenges of homelessness, substance use, and IPV was especially difficult. These women, mostly in their twenties, appeared to have greater difficulty than dually challenged women in gaining access to, or accepting the offer of shelter and other social services and moving way from unsafe intimate relationships. Some but not all from what we were able to determine, had long histories of physical and sexual abuse and chaotic family lives growing up. CLR’s intention to provide a safe emotional and physical ‘‘living room’’ in its three community sites while, at the same time, endeavoring to engage women into available clinical and social services, seemed to fall short with this subgroup of women. Despite positive outcomes for the project in general, we came to understand that additional considerations in working with this population may threaten success in providing services to this subgroup. Discussion Our observations sent us back to the literature where we began to understand that what we were seeing had not yet been evaluated. It is true that difficulties gaining access to services for women with IPV are consistent with research findings that both women in violent interpersonal relationships with trauma histories, and homeless women in general are less likely than their counterparts in the general population to gain access to healthcare, shelter, and social support services (Browne 1993; Luhrmann 2008; Nyamathi et al. 2000; Rayburn et al. 2005). Little attention, however, has been paid to the subset of women who are: (a) homeless, (b) have mental health and substance use problems, and (c) are experiencing IPV. In CLR, women who were survivors of IPV were in hetero- or homosexual relationships and were married or living with a partner or not. Many had children, in their custody or not. They lived in shelters, on the streets, or on other people’s couches. Regardless of the individual’s particular situation, though, we found these women were often unwilling or unable to engage in services for reasons that appear to be related to their experiences with their violent or predatory partners.
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Vignettes Trauma related to IPV and fear of being retraumatized, losing relationships, or jeopardizing one’s safety are powerful motivators to reject services, if accepting them may lead to increased risk. Women reported that their partners did not want them to interact with male staff, believed that partners offer protection despite abuse, and feared being judged by providers for continuing the abusive relationships. Below, we give four case vignettes that are representative of the background and experiences of many women with IPV histories and of the difficulties staff and peer mentors with the CLR program had in trying to help them. (Details are changed and some composite material is included.) May. May, a woman in her mid-20 s, was 8 months pregnant when CLR staff met her. She had a history of mental illness and substance use and came from a family background marked by chaos and abuse. When CLR staff first had contact with her she was sleeping in a van with her much-older boyfriend who was the father of her child. May had stopped using substances when she learned she was pregnant. She hoped having a child would strengthen her relationship with her boyfriend and help her begin a new life. CLR case managers saw a pattern of controlling behaviors from her boyfriend. He would not allow staff to talk to May without him and he openly disapproved of the relationships she was beginning to develop with them. May was offered a place in a residential program for women, but turned down the opportunity when her boyfriend discouraged it. After she gave birth, May and her boyfriend moved to a substandard motel room using a voucher he obtained. When CLR staff visited her, it was evident that she was being abused. May was offered safe shelter, but chose to not leave her boyfriend. Staff heard rumors that her boyfriend was having relationships with other young women and that May’s pregnancy had been a result of his raping her. They contacted the state child and family agency, but learned that May, her baby, and the boyfriend disappeared. They have not been seen since. Linda. Linda, a woman in her forties with a substance use disorder and a suspected but undiagnosed psychiatric disorder, lived in a ‘‘tent city’’ with her boyfriend, also in his forties and with drinking and drug problems. He abused her physically and victimized other women physically and sexually. Unlike many other women contending with current IPV, Linda had been receiving support from the mental health outreach team that collaborated with CLR and
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had stayed in its parent agency’s emergency shelter. After her boyfriend beat her again, she went South to stay with her family. When she came back a few months later, Linda looked well. She reconnected with boyfriend, though, and moved back into the tent city. She maintained a connection with CLR staff, although she could be angry and threatening. CLR staff offered her support and helped connect her with a women’s group. They were left with what they described as a challenging question, though, as Linda waited on her pending SSI application: if housing was available, and she would only be housed with her boyfriend, would she be better off living inside with him than out? Terri. Terri, a young woman, lived on the streets or in an abandoned vehicle with an older man. Although she had not sought shelter services in the past, Terri began to consider this option after meeting with CLR staff. Her boyfriend, who had shown hostility toward CLR staff when they talked with her, accompanied Terri to the shelter, where she would have stayed in a separate dormitory for women. When he threatened to beat up Terri and the male front desk clerk at the shelter who, he claimed, was flirting with her, Terri refused to come into the shelter, and continued to live with her boyfriend on the streets. A CLR staff member had contact with her several months later. Terri was living with her boyfriend at her mother’s home. She said he was regularly physically abusing her. When asked if she would like to change her situation, she demurred, saying that she had shelter and food and that her boyfriend protected her from other victimizers. Beth. Beth, a woman in her twenties, was with a man who, CLR staff learned, had impregnated three other women associated with the shelter program that administered CLR. Beth was the fourth. She had a history of depression and alcohol abuse. For a time, she and her boyfriend lived in a rented room. Beth’s mother came to CLR staff asking for their help in getting her to come back home. Beth said she loved her boyfriend but did agree to move back home. She gave birth and entered treatment for her mental health and addiction problems. Two years later the CLR director bumped into her at a shopping mall. Beth was still living with her parents, was attending community college, and was not seeing her child’s father. While it is impossible to know the precise reasons for Beth’s success, or CLR’s contribution to it, the program helped her to get treatment, prenatal care, and to work her on her parenting skills.
IPV, homelessness, and mental illness, then, can often, though not always, converge to prevent women from receiving needed services. While a combination of factors led clients to acceptance or rejection of program services, the elements of predatory relationships, behavioral health problems, and IPV appear to be strongly related to rejection. In the next section we attempt to distill lessons learned from this 5-year project in the form of key themes and recommendations for future interventions that target women who are among the most difficult to engage and serve among those who are homeless. Recommendations Working with women who experience homelessness, substance abuse, mental illness and IPV is complex and challenging but can be rewarding as well. Here, we offer four ‘‘working points,’’ with overlap among them, in support of further such efforts. Strategic Design and Delivery of Services IPV among women with behavioral health problems adds an additional dimension of complexity to addressing their homelessness, since a violent, coercive, or predatory partner may pose barriers to women’s gaining access to and accepting services. As we have noted, we do not claim resounding success with this subgroup of women who are homeless with substance use disorders and IPV. We argue that further targeted programmatic and research efforts should be made to enhance our knowledge of this group and develop more effective intervention strategies. We offer here several strategies that were helpful, at times, in engaging or helping CLR staff and peer mentors maintain contact with women with IPV in their lives. Take a Non-judgmental Approach With women who experienced IPV, we used a non-judgmental approach coupled with attempts to offer suggestions and resources for taking care of themselves in healthier and safer ways. In addition to and perhaps despite offering this non-judgmental stance, taking steps to increase safety for women and their children is of utmost importance. Offering the support of treatment providers and resources for survivors of violence and utilizing child protection services are mechanisms for doing so. Even taken by itself, conveying a non-judgmental approach is a delicate matter: the supportive stance must not appear to the client as a tacit acceptance of the IPV she experiences and her decision to remain in the relationship. Maintaining and managing this distinction in manner, words, and actions requires good clinical skills and instincts and can be seen as comparable
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to the dilemma the outreach worker faces on a Friday afternoon, heading into a brutally cold weekend, with a client with mental illness who has been sleeping outside for years and refuses to come inside. It is necessary, as in all homeless outreach work, to strike a balance between the providers’ responsibility to help and the client’s choice and autonomy (Rowe et al. 2001). This might be accomplished by taking steps to acknowledge the problem and engage in collaborative problem solving with the woman without assigning blame to her, although, as with other aspects of maintaining the delicate balance discussed here, this general guideline does not provide a detailed map for in-themoment work. Assessing what needs are being met by the predatory or controlling partner can help staff work with women to meet their needs in healthier and safer ways. It may also be fruitful to address the service needs of perpetrators who may have their own behavioral health problems and trauma histories. CLR staff did, in fact, make such attempts more than once, admittedly with little success. In retrospect, we think a more effective response would have been closer liaison and teamwork with non-CLR case managers who could have offered to help perpetrators with their services needs. Perhaps these case managers would have been seen as neutral parties who were, in fact, addressing the abusers’ needs rather than trying to render them less harmful to their abused partners. Attend to Staff Gender While the principle of ‘‘women helping women’’ employed in the CLR program is not universally applicable—a woman in an IPV homosexual relationship will not necessarily find female staff less threatening than male staff—our observation was that the fact that CLR staff and peer mentors were female smoothed the still-difficult process of engagement with this group. Hiring women who are empathic and training them in employment of the other strategies suggested here is essential. Employ Principles and Practices of Mental Health Outreach Mental health outreach has developed over the past 30 years with the rise in homelessness in the late 1970s in the US Outreach work espouses and practices the principles of ‘‘going where the client is’’ both physically (streets, shelters, etc.) and existentially (marginalized, wary of mental health workers, etc.). It entails building trust slowly and not demanding motivation for change or acceptance of mental health treatment as conditions for receiving other services such as help finding housing. It is also important to build on the strengths of people as survivors of homelessness and make contact with the person, not the patient (Olivet et al. 2007; Rowe 1999). CLR staff received training in these practices from the supervisor of the parent
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agency outreach team director. We recommend them, among other strategies, for future community-based projects with this population. Utilize Peer Engagement Research suggests that trained peers—persons with behavioral health disorders—have a unique capacity to engage with and motivate their peers for treatment (Sells et al. 2006, 2008). Deployment of peer mentors was a core element of the CLR program. We note that length of time in recovery from mental illness or substance use, training, supervision, and individual and group support for this difficult work are factors to consider in employing peer mentors in this work. Provide Training in Understanding and Addressing Trauma Grief, loss, shame, identity, spirituality, and needs for connection and support are, in our experience, common emotional vulnerabilities among women who are homeless. Training and supervision in trauma sensitivity help staff develop an appreciation for how a history of trauma can lead a woman to avoid abuse at all costs, including refusal of shelter if she fears accepting it might prompt her partner’s violence. Offer Multiple Meeting Sites The CLR program included multiple drop-in sites for the simple reason that the availability of these sites would increase the number of opportunities to make contact with potential or current clients. We found this to be the case. However, we also found that violent partners frequented some sites and not others, which gave us the opportunity to meet with clients away from the watchful eye of an abusing partner if the client chose to meet at a location to which her partner was unlikely to go. Attend to Staff Needs and Mental Wellbeing The potential for vicarious trauma is always present as staff members learn about and witness the traumatizing experiences of women with behavioral health disorders and IPV. This can be especially troubling for those with their own trauma histories. Frequent team meetings with ample time for discussion of the difficult nature of the work are both means of support or of ‘‘spelling’’ each other when one or more are at the edge of burnout, and of maintaining strength through celebrating clients’ (and thus the team’s) small and large successes. Staff identification with clients may help to fuel their passion and commitment to the work, but such identification may also present risks to their own mental and emotional health. As stated above, research has demonstrated the special strengths of peer staff in engaging and motivating clients for treatment (Sells et al. 2006, 2008). Peer
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staff members are also exposed, however, to the struggles of women not so far away in time and circumstances from their own struggles, and ongoing mutual support and insight into the workings of trauma can help them, as well as their non-peer colleagues, maintain individual and collective stability and effectiveness. Provide an Effective and Supportive Administrative Structure Administrative support and structure is critical to programs that push at the boundaries of treatment and case management. In the CLR case, elements of this support included the direct involvement of the Executive Director of the parent agency as principal investigator of the project; a management committee composed of supervisors from each participating agency; and what appears to have been a good balance between oversight leadership and support, on one hand, and a willingness to let project staff take the lead in implementing and running the program, on the other. This balance supported efforts to adjust and tweak the program at a pace and with the timing that best suited the operations of the program, rather than requiring that decisions filter through an arduous bureaucratic process (Rowe et al. 1996). The success of programs such as the one we describe here is tied to collaboration with multiple agencies. Interagency partnerships were already in place for the CLR project through the local mental health authority, which is the nearby community mental health center. This facilitated coordination of services, greater resources, and diverse expertise. Also in the CLR case, the feasibility of multiple drop-in program sites was enhanced by existing agency collaborations and agreements. Interagency cooperation was, in turn, further enhanced by the ‘‘seeding effect’’ of multiple program sites through which more staff and agencies became familiar with the program and were better able to identify resources for women. When designing programs for women with social and personal vulnerabilities, we also recommend seeking community partnerships that may stand outside the formal system of care and drawing on the specific strengths of each stakeholder group. For example, developing organizational relationships with domestic violence providers would be especially important in working with homeless women with IPV to facilitate access to resources such as education, shelter, and support. Professionals who focus specifically on helping survivors of IPV can be valuable members of the service team. In addition, there is a need for education of staff, agencies, and service systems on women’s issues, gender specific services, and trauma specific services ‘‘from receptionists on up to the top,’’ as one CLR supervisor stated.
Acknowledge and Appreciate Synergy Programs and teams that work at the margins of practice with marginalized persons, including persons who are homeless, cultivate a sense of the ‘‘specialness’’ of the work and the attributes of heart, skill, and commitment it takes to do it (Rowe 1999). For the CLR team and its staff and peer mentors this specialness consisted, in part, of identification with their clients as women and as mothers. Staff and peer mentors, variously, came from abusive families, were in recovery, knew and grew up with some of the clients, were mothers, and were in relationships with men or women that sometimes bore similarities to those of CLR clients. There was protectiveness toward children born of troubled relationships and vulnerable mothers; support and solidarity for each other (the ‘‘community living room’’ started with the staff team, which then invited clients to come in from the street); and a sense that, as a group of women, they belonged to a community of discovery in regard to their clients. ‘‘We felt as though we were bringing the truth to light,’’ said one staff person. ‘‘When we talk to clinicians and service providers, they can’t believe it. We live in a third world country.’’ The sense of specialness of CLR was embodied not only in the makeup of the team (all female) but in its nonjudgmental character toward its clients (a value, we note, that mixed gender homeless outreach teams also emphasize), and in the principle of giving women a safe place to visit and spend time, that is, a community living room not just a social service program. The role of leaders includes the tasks of assuring that the ‘‘sense of specialness’’ is ineluctably linked with principles that are linked to practice, while also assuring that invidious distinctions with other practices and programs do not lead to isolation from them. Part of the sense of specialness of the CLR also emerged in relation to the team’s work with local service providers and within the behavioral health service system as a whole. As background, the parent agency provides a wide range of shelter, residential, and case management services and is a member of the local mental health services network. Local service coordination for persons was significantly enhanced by participation in the SAMHSA national Access to Community Care and Effective Services and Supports program from 1993 to 2000, which espoused a ‘‘No Wrong Door’’ systems-integration approach to care for persons who are homeless with behavioral health problems. Simultaneously, the lead community mental health center successfully applied for and administers substantial housing programs through the HUD Shelter Plus Care and Supportive Housing Programs. CLR staff and peer mentors articulated a difficulty that seemed to characterize its generally well-coordinated
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behavioral health system as a whole: the ‘‘No Wrong Door’’ approach is firmly in place in service-system agencies in terms of identifying points of access and having the interorganizational capacity to refer and accept referrals. What was missing, at times, was the ‘‘right person’’ at the ‘‘right door.’’ Systems of care that are integrated administratively from the ‘‘top down’’ (Randolph et al. 1997) or the ‘‘bottom up’’ (Rowe et al. 1998) must further ensure that staff at ‘‘the door’’ are equipped, by nature and by training, to provide patient, welcoming care to highly vulnerable and often reluctant clients such as women who are homeless with IPV. This initial finding can only serve as a suggestion for further research and programmatic attention, but it appeared to heighten the CLR team’s sense of exploring new territory on behalf of its clients. Finally, CLR not only launched the careers of, but provided life- and career- changing experiences for three professional women, who represent a group that is critical to the success of the work we describe here. The project has contributed to positive outcomes for many of the peer staff as well. In addition, support of female peer workers, many with their own histories of IPV, for each other and from professional staff on a supportive team engaged in the trials and triumphs of their difficult work, led to development of a unique ‘‘respite and relaxation’’ program for peer staff. ‘‘New Visions of Me,’’ built on principles including those of ‘‘trying something new,’’ ‘‘taking care of oneself and others,’’ and ‘‘connecting with other women in recovery’’—might inform like interventions with peer staff, and perhaps service components as well (Lawless et al. 2009).
Other Questions and Limitations A few remaining issues or questions, some referenced above, are of a piece with the limitations of this study. Most of our subset of triply-challenged women were in their twenties. This suggests that the subset of women we have discussed in this article may, in turn, have further subsets. If one of these is younger women, prevention and early intervention, and different outreach and clinical strategies must be considered, attending to the particular vulnerabilities and strengths of this group. It is possible that younger peer staff will be able to more effectively engage this group, although an older, mature presence on the peer engagement team may be helpful as well. Peer or co-led clinician and peer groups of young women, with attention to developmental issues and efforts to prevent or forestall further IPV, as well as alternatives visions of one’s life such as education and work, can be considered. Similar considerations may apply to race and ethnicity among this group. Our small subset of clients with IPV did not allow
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us to determine differences related to these variables, but culturally competent care, an area in which CLR staff and peers were trained, must be considered in regard to future research and intervention development. It is our hope that future research will answer some of the questions we can only raise here, and improve upon our recommendations based on more extensive data.
Future Directions Previous research supports the fact that homeless women have difficulty gaining access to services (Nyamathi et al. 2000), as do some women who experience IPV (Pranjape et al. 2006). Women who are homeless with behavioral health disorders have greater need for a range of social and clinical services than those with one or two of these elements, yet due to the circumstances of their lives and relationships may have more barriers to gaining access to and accepting them. They have even greater need for multifaceted, flexible, and creative programs with the capacity to provide outreach and engagement services, referral to treatment and social service programs, and a range of temporary and permanent housing options, including supportive housing. Further action-based research will reveal the prevalence of these co-occurring phenomena, the services best able to support individuals who live with them, and the resources needed to help them exit homelessness and improve their wellbeing. In programs and service systems that are male oriented and that have a dearth of female-specific programs, women may be at a disadvantage not only in terms of access to and use of services but in terms of the expressive aspect of social service and clinical programs. The latter go beyond, or behind, quantifiable services and goods to support their clients’ identity needs. In the case of women such as those that CLR served, identity needs may be related to unacknowledged legacies of oppression and trauma. Medical anthropologists and sociologists using ethnographic and indepth interview research methods may have a particular contribution to make in these areas. While CLR staff often were frustrated at their inability to engage or affect the circumstances of the ‘‘hardest-toreach’’ of their target group—those with IPV in addition to being homeless with behavioral health disorders—lowdemand programs such as CLR, including drop-in program support, appear to enhance the possibility of providing safe and supportive settings in which women can access muchneeded services and personal and group support. They may also provide the range and flexibility needed to offer social and personal services and activities such as helping women write resumes and find jobs, locate a church, decorate an apartment, and more. Organizational and services
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researchers may have much to offer in studying the forms and the impact of such collaborations. The poet John Keats wrote briefly but powerfully of ‘‘negative capability,’’ the capacity to live with ambiguity and acceptance of the fact that much in life remains unresolved. This is a concept that may speak to those who undertake programs such as the one we have described in this article. In such programs, staff, peers, and administrators must live with the reality that there are many paths out of, and many barriers to exiting homelessness and interpersonal violence for women. A particular staff member’s, or a program’s, contribution to individual women’s successful exit or continuing entrenchment often becomes clear only over time, and sometimes not at all. This capacity for living with ambiguity is, of course, not an excuse for inaction. Rather, it is a support for taking and sustaining action under the difficult circumstances of clients and under organizational constraints for programs and staff that venture into this demanding and important work.
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