1. Providing Comprehensive, Family-Centered Mental Health Services to Homeless Trauma Survivors Samuel Girguis, Psy.D. Project Heal Childrens Hospital Los Angeles USC UCEDD (University Center for Excellence in Developmental Disabilities)

2. Working with Homeless Women and Children Population of Los Angeles County: 10,245,572 (January, 2007) 254,000 people/year experience homelessness in LA 82,096 people every night 20% to 34% are single mothers with children The average homeless family has 2 children

3. Working with Homeless Women and Children, cont. High correlation with domestic violence and homelessness 50% of women become homeless after fleeing DV Majority of homeless women report a significant trauma history Domestic violence, sexual abuse, physical abuse, emotional abuse Homeless women are highly susceptible to PTSD, Depressive Disorders, Anxiety Disorders, Substance Abuse

4. Working with Homeless Women and Children, cont. Children – exposed to family violence and at- risk for traumatic experiences Exposure to domestic violence Sexual abuse Physical abuse Emotional abuse Neglect Intergenerational transmission of trauma

5. Working with Homeless Women and Children, cont. Homeless school-aged children are highly susceptible to Disruptive Behavior Disorders (acting out) Depressive Disorders (turning inward) Attentional difficulties High-risk behaviors

6. Homelessness as a Trauma Pervasive impact on all family members Loss of social support Uprooted from familiar surroundings Safety issues/concerns Lack of consistency  increased conflict & decreased frustration tolerance

7. Typical programs – Adult-focused: Increase self-esteem, self-empowerment, self-sufficiency Increase social support Increase healthy emotional expression & relationship building Address job-related skills Linkage to services Mental Health and the Homeless

8. Mental Health and the Homeless, cont. Fewer programs focus on the children: Increase appropriate affective expression Learn social skills Increase self-esteem Conflict resolution Parenting classes to address behavioral problems Tutoring, linkage to socialization opportunities

9. Mental Health and the Homeless, cont. Interventions need to become more family- focused: Teaching the caregivers how to address children’s behavior consistently & introducing “new rules” to the children Teaching the caregivers and children about the connection between children’s behavioral issues & traumatic experiences Improving communication & conflict resolution Addressing family’s exposure to violence and traumatic experiences

10. Family-Focused Interventions with Homeless Families Culturally sensitive Developmentally appropriate Address unique boundary issues associated with homelessness (e.g., lack of privacy, multiple caretakers) Short-term Highly flexible

11. Comprehensive, Family-Centered Services Traditional mental health services Clinic based services Single modality Individual or Group or Family therapy Comprehensive, family-centered services Multi-faceted, individualized treatment Individual and Group and Family therapy Collateral therapy offered to caregivers Parenting classes Coordination of services Consultation

12. Individual Child Therapy Trauma focused: Traumatic experiences Homelessness experience Interrupting the intergenerational transmission of abuse/trauma Developmentally appropriate Skill-based with a safety focus

13. Family-Focused Interventions Conjoint family therapy Address barriers to optimal parenting Caregiver’s untreated trauma history: Flat affect Inconsistent discipline Lower frustration tolerance Duplication of abusive relationships Child’s behavioral disturbances and emotional dysregulation

14. Family-Focused Interventions, cont. Trauma-focused collateral therapy for mothers Impact of trauma history on the family Impact of mood disorder on the family Service coordination Collaboration with other service providers

15. Group Therapy Short-term Single session model Curriculum-based Skill based with practical application focus Combination of psychoeducation and process group Conjoint children’s group and mother’s group

16. Group Therapy for Homeless Children “ Making Friends and Staying Safe” Abuse risk reduction Trauma-focused anger management group Affect modulation Coping skills Trauma-focused anxiety reduction group Exposure/desensitization treatment through trauma narrative technique “Real Life Heroes” by Richard Kagan

17. Group Therapy for Homeless Women with Children “Supermom 101” Parenting class – part psychoeducation, part process group Utilized Supernanny television show Parent/peer mentoring Personality-based parenting skills class Focus on strengths as well as areas of skill-building

18. Consultation Collaboration with service providers Being available in the shelter setting Attending staff meetings that are pertinent to clinical care Offering trainings for shelter staff Offering consultation for shelter staff Offering “office hours” for shelter residents

19. Clinical Challenges and Countertransference: Providing Services in the Shelter Setting

20. Practical Challenges of the Community Setting The community setting Close proximity of residents, interpersonal relationships and conflicts developing outside of the therapeutic context Confidentiality Space limitations Impact on group cohesion Impact on continuity of group/individual/family therapy

21. Practical Challenges, cont. Inconsistent attendance Late arrivals to group/individual therapy appointments Limit setting Lack of boundaries and rules in everyday life Therapist countertransference

22. Population Challenges Maternal psychopathology How trauma impacts parenting, communication, and general family functioning History of trauma and manifestation of PTSD symptoms Therapeutic content as triggers Language and cultural factors Developmental factors Varying age ranges and developmental levels

23. Countertransference Community setting Reactions toward children Reactions toward caregivers Cultural countertransference

24. Reactions Toward Community Setting Becoming part of the community milieu Severity of client needs Appropriate roles/boundaries Identification of personal biases and impact on treatment Safety concerns Children’s safety Therapists’ safety

25. Reactions Toward Children Behavior problems and limit setting Frustration at varying developmental levels/ages and the pace of the group Sadness and feelings of helplessness due to compound traumas and severe levels of need Anxiety about abuse disclosures Desire to rescue/overprotect

26. Reactions Toward Parents Sadness regarding vulnerability of children and lack of parental resources Empathy about maternal trauma histories Feelings of helplessness regarding ongoing challenges (financial, occupational, etc.) Anger and frustration due to lack of appropriate parenting skills Desire to rescue/overprotect

27. Cultural Countertransference Minimization of importance of culture Lack of direct attention to culture Failure to inquire about caregivers’ comfort with information Disregarding cues about parent receptiveness Misinterpreting hesitancy as resistance Failure to recognize differences in acculturation between parents and children