Trauma-Informed Care for the Full Range of RHY Services

Trauma-informed care (TIC) is increasingly recognized as a best practice for serving young people who have experienced homelessness. Very often young people endure multiple types of physical, psychological, and emotional maltreatment or abuse, resulting in “complex trauma” that researchers have associated with significant mental health problems including depression, anxiety, Post Traumatic Stress Disorder (PTSD), suicidal ideation, and substance abuse.[1] In a 2015 study on the mental health of homeless youth, 79% of participants reported childhood abuse and 28% reported being victimized on the street.[2] Based on these findings, the researchers urged RHY organizations to provide TIC services that thoroughly screen, assess, and serve youth to identify and address trauma.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), TIC places survivors’ trauma at the center of the service or support they receive. SAMHSA’s goals for care are defined by “The 4 Rs”:

• Realizes the widespread impact of trauma on people who experience it.
• Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved in services.
• Responds by fully integrating knowledge about trauma into policies, procedures, and practices.
• Resists re-traumatization.

In 2009, researchers defined TIC in the homeless services setting as “a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors.”[3]  At its foundation, TIC helps establish an overall sense of safety for both providers and trauma survivors, which then helps create space for survivors, in this case young people experiencing homelessness, “to rebuild a sense of control and empowerment” in their lives.[4]

In a previous Issue Brief, the National Clearinghouse on Homeless Youth and Families (NCHYF) outlined the importance of TIC in mental health services for young people who have experienced homelessness. But TIC is relevant to the entire spectrum of RHY services. If an organization’s partners and referring organization share the same values and approaches, this helps to ensure a trauma-informed continuum of care for young people.

Health Care

Trauma-informed care was initially developed by health care providers and researchers to help counteract health risks among patients who were exposed to multiple Adverse Childhood Experiences (ACEs).[5] Early health-related studies found that “experiencing four or more ACEs increases the risk of alcoholism, drug abuse, depression, suicide attempts, smoking, sexually transmitted disease, physical inactivity, and obesity.” In response, the Center for Health Care Strategies (CHCS) led a national study of the health care sector’s implementation of TIC and subsequently developed foundational steps to guide the widespread application of TIC.[6] 

These steps begin with system-level changes: building awareness and securing buy-in within organizations; supporting a culture of wellness among staff; hiring new employees who embrace the TIC approach; ensuring organizational policies that support a trauma-informed approach; and creating a physically and emotionally safe work environment. 

From CHCS’s research, we know that a key element of clinical-level TIC is to actively involve patients in their own healing process. Youth-serving organizations can replicate this aspect since empowering clients “is especially important with youth who may have developed a deep mistrust of professionals from a young age” due to negative interactions with professionals and organizations.

CHCS also warns that staff members who are feeling chronically fatigued, emotionally exhausted, or worse, “may struggle to provide high-quality care and may experience burnout, leading to staff turnover—which can create a negative feedback loop that intensifies similar feelings in remaining employees.”[7] CHCS offers strategies to promote staff morale, productivity, and retention, which will help to prevent secondary traumatic stress. The national nonprofit Volunteers of America (VOA) agrees that, “addressing secondary traumatic stress and ensuring proper training in trauma-informed care are important components in the creation of a trauma-informed organization. However, these components, when not appropriately addressed, can also act as barriers to a successful system.”[8]

Recommendations for RHY 

• Identify young people’s immediate mental and behavioral health needs during intake and prioritize therapeutic interventions or service referrals as part of follow-up and ongoing care.
• Collaborate with trauma-informed health centers and providers in your area to provide screenings and services for youth in your program.

Education

Unmistakably, the RHY population is an at-risk subgroup of students. According to SchoolHouse Connection, “the mobility, poverty, and trauma associated with homelessness affects students’ emotional and physical health, hygiene, preparedness for school, transportation options, and other factors that increase absenteeism.”[9]

School systems throughout the U.S. have implemented trauma-informed approaches to education policy and practice. According to the National Child Traumatic Stress Network (NCTSN), “the primary mission of schools is to support students in educational achievement. To reach this goal, children must feel safe, supported, and capable of learning. Children exposed to violence and trauma may not feel safe and ready to learn.” NCTSN outlines 10 essential elements of TIC for school systems, including having partnerships with students and families, collaborating across systems, and establishing community partnerships.

The Treatment and Services Adaptation Center (TSA) has also created TIC guidelines for individual schools and their staffs. Building on research and resources from NCTSN and others, TSA says their guidelines “not only provide tools to cope with extreme situations but [also] create an underlying culture of respect and support.”

Recommendations for RHY Providers

• Initiate and expand your outreach to local school districts to offer trainings or share resources on trauma-informed care, especially for vulnerable youth.
• Make sure the young people you serve are aware of their right to an education—including the right to stay at the school of their choice to avoid potential future trauma.

Juvenile Justice

Researchers note that the U.S. Department of Justice has endorsed the use of trauma-informed care in juvenile justice systems “in order to combat the negative impact of trauma on youth offenders and front-line staff.”[10] Given that juvenile offenders are already a vulnerable population and system-involvement itself is often traumatic, “those with histories of trauma exposure and/or symptoms of posttraumatic stress disorder (PTSD) have higher rates of recidivism, co-occurring disorders, school drop-out, and suicide attempts.” These risk factors all overlap with the RHY population. To become more trauma-informed, the National Council of Juvenile and Family Court Judges (NCJFCJ) developed a list of 10 recommendations for judges and court staff. These include creating a shared definition of trauma, promoting diversity among personnel, and supporting healing through positive interactions with youth.

At the forefront of this shift is the courts' response to minor victims of human trafficking. According to the NCJFCJ, “courts across the country are implementing victim-centered approaches to exploited and trafficked children.” While some jurisdictions have established courts specifically for cases of domestic child sex trafficking, “others have modified court practices and implemented trauma-informed and responsive protocols.” While on the bench, NCJFCJ encourages judges to build relationships with young victims using a strengths-based approach that supports their accomplishments and talents while fully involving them in their case planning. When off the bench, NCJFCJ advises judges to advocate for the youth they see in the courtroom through training and community activities.

Recommendations for RHY Providers

• Advocate for TIC among your local juvenile court judges, many of whom are increasingly aware of the unique dangers to RHY.
• Provide mentoring and peer-mentoring opportunities for young people, which have been shown to reduce certain risk behaviors that can lead to interactions with the juvenile justice system.

TIC is essential for RHY, who are more likely than their peers to experience trauma exposure and traumatic incidents in their lives. Whatever additional systems RHY are involved with, and no matter what other services they receive from those system providers, there are concrete strategies RHY providers can employ to complement, build upon, and advance their trauma-informed orientation and care.

About RHY Issue Briefs

Issue Briefs, developed by the National Clearinghouse on Homeless Youth and Families, provide information about runaway and homeless youth and the issues that affect them.

[1] SAMHSA’s Trauma and Justice Strategic Initiative. (2014). “SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach.” https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4884.pdf

[2] Bender, Kimberly & Brown, Samantha & Thompson, Sanna & Ferguson, Kristin & Langenderfer-Magruder, Lisa. (2015). “Multiple Victimizations Before and After Leaving Home Associated With PTSD, Depression, and Substance Use Disorder Among Homeless Youth.” Child Maltreatment. 20.

[3] Hopper, Elizabeth K., Ellen L. Bassuk, and Jeffrey Olivet. (2009). “Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings.” The Open Health Services and Policy Journal, 2, 131-151.

[4] Kinoglu, Sera, Stephanie Nelson-Dusek, and Maggie Skrypek. (2017). “Creating a Trauma-Informed Organization: Literature Review for Volunteers of America.” Wilder Research. https://www.wilder.org/sites/default/files/imports/VOA_TraumaReport_1-17.pdf

[5] Dubay, Lisa, Rachel A. Burton, and Marni Epstein. (2018). “Early Adopters of Trauma-Informed Care: An Implementation Analysis of the Advancing Trauma-Informed Care Grantees.” The Urban Institute. https://www.urban.org/sites/default/files/publication/98979/early_adopters_of_trauma-informed_care.pdf

[6] Schulman, Meryl and Christopher Menschner. (2018). “Laying the Groundwork for Trauma-Informed Care

Center for Health Care Strategies.” Center for Health Care Studies. https://www.chcs.org/media/Brief-Laying-the-Groundwork-for-TIC.pdf

[7] Menschner, Christopher and Alexandra Maul. (2016). “Key Ingredients for Successful Trauma-Informed Care

Implementation.” Center for Health Care Strategies. https://www.chcs.org/media/Brief-Key-Ingredients-for-TIC-Implementation-1.pdf

[8] Kinoglu et al.

[9] Schoolhouse Connection. (2020). “Supporting Attendance for Students Experiencing Homelessness.” https://www.schoolhouseconnection.org/wp-content/uploads/2020/01/Attendance-Brief.pdf

[10] Branson, Christopher Edward, Carly Lyn Baetz, Sarah McCue Horwitz, and Kimberly Eaton Hoagwood. (2017). Psychological Trauma; 9(6): 635–646.