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

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providing comprehensive family centered mental health services to homeless trauma survivors

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

Samuel Girguis, Psy.D.

Project Heal

Childrens Hospital Los Angeles

USC UCEDD (University Center for Excellence in Developmental Disabilities)

working with homeless women and children
Working with Homeless Women and Children
  • Population of Los Angeles County: 10,245,572 (January, 2007)
  • 254,000 people/year experience homelessness in LA
    • 82,096 people every night
  • 20% to 34% are single mothers with children
  • The average homeless family has 2 children
working with homeless women and children cont
Working with Homeless Women and Children, cont.
  • High correlation with domestic violence and homelessness
    • 50% of women become homeless after fleeing DV
  • Majority of homeless women report a significant trauma history
    • Domestic violence, sexual abuse, physical abuse, emotional abuse
  • Homeless women are highly susceptible to PTSD, Depressive Disorders, Anxiety Disorders, Substance Abuse
working with homeless women and children cont1
Working with Homeless Women and Children, cont.
  • Children – exposed to family violence and at-risk for traumatic experiences
    • Exposure to domestic violence
    • Sexual abuse
    • Physical abuse
    • Emotional abuse
    • Neglect
  • Intergenerational transmission of trauma
working with homeless women and children cont2
Working with Homeless Women and Children, cont.
  • Homeless school-aged children are highly susceptible to
    • Disruptive Behavior Disorders (acting out)
    • Depressive Disorders (turning inward)
    • Attentional difficulties
    • High-risk behaviors
homelessness as a trauma
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
mental health and the homeless
Mental Health and the Homeless
  • 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 cont
Mental Health and the Homeless, cont.
  • Fewer programs focus on the children:
  • Increase appropriate affective expression
  • Learn social skills
  • Increase self-esteem
  • Conflict resolution
  • Parenting classes to address behavioral problems
  • Tutoring, linkage to socialization opportunities
mental health and the homeless cont1
Mental Health and the Homeless, cont.
  • Interventions need to become more family-focused:
    • Teaching the caregivers how to address children’s behavior consistently & introducing “new rules” to the children
    • Teaching the caregivers and children about the connection between children’s behavioral issues & traumatic experiences
    • Improving communication & conflict resolution
    • Addressing family’s exposure to violence and traumatic experiences
family focused interventions with homeless families
Family-Focused Interventions with Homeless Families
  • Culturally sensitive
  • Developmentally appropriate
  • Address unique boundary issues associated with homelessness (e.g., lack of privacy, multiple caretakers)
  • Short-term
  • Highly flexible
comprehensive family centered services
Comprehensive, Family-Centered Services
  • Traditional mental health services
    • Clinic based services
    • Single modality
      • Individual or Group or Family therapy
  • Comprehensive, family-centered services
    • Multi-faceted, individualized treatment
      • Individual and Group and Family therapy
      • Collateral therapy offered to caregivers
      • Parenting classes
      • Coordination of services
      • Consultation
individual child therapy
Individual Child Therapy
  • Trauma focused:
  • Traumatic experiences
  • Homelessness experience
  • Interrupting the intergenerational transmission of abuse/trauma
  • Developmentally appropriate
  • Skill-based with a safety focus
family focused interventions
Family-Focused Interventions
  • Conjoint family therapy
  • Address barriers to optimal parenting
    • Caregiver’s untreated trauma history:
    • Flat affect
    • Inconsistent discipline
    • Lower frustration tolerance
    • Duplication of abusive relationships
  • Child’s behavioral disturbances and emotional dysregulation
family focused interventions cont
Family-Focused Interventions, cont.
  • Trauma-focused collateral therapy for mothers
    • Impact of trauma history on the family
    • Impact of mood disorder on the family
    • Service coordination
    • Collaboration with other service providers
group therapy
Group Therapy
  • Short-term
  • Single session model
  • Curriculum-based
  • Skill based with practical application focus
  • Combination of psychoeducation and process group
  • Conjoint children’s group and mother’s group
group therapy for homeless children
Group Therapy for Homeless Children
  • “Making Friends and Staying Safe”
    • Abuse risk reduction
  • Trauma-focused anger management group
    • Affect modulation
    • Coping skills
  • Trauma-focused anxiety reduction group
    • Exposure/desensitization treatment through trauma narrative technique
    • “Real Life Heroes” by Richard Kagan
group therapy for homeless women with children
Group Therapy for Homeless Women with Children
  • “Supermom 101”
    • Parenting class – part psychoeducation, part process group
    • Utilized Supernanny television show
    • Parent/peer mentoring
  • Personality-based parenting skills class
    • Focus on strengths as well as areas of skill-building
consultation
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
practical challenges of the community setting
Practical Challenges of the Community Setting
  • The community setting
    • Close proximity of residents, interpersonal relationships and conflicts developing outside of the therapeutic context
    • Confidentiality
  • Space limitations
    • Impact on group cohesion
    • Impact on continuity of group/individual/family therapy
practical challenges cont
Practical Challenges, cont.
  • Inconsistent attendance
  • Late arrivals to group/individual therapy appointments
  • Limit setting
    • Lack of boundaries and rules in everyday life
    • Therapist countertransference
population challenges
Population Challenges
  • Maternal psychopathology
    • How trauma impacts parenting, communication, and general family functioning
  • History of trauma and manifestation of PTSD symptoms
    • Therapeutic content as triggers
  • Language and cultural factors
  • Developmental factors
    • Varying age ranges and developmental levels
countertransference
Countertransference
  • Community setting
  • Reactions toward children
  • Reactions toward caregivers
  • Cultural countertransference
reactions toward community setting
Reactions Toward Community Setting
  • Becoming part of the community milieu
  • Severity of client needs
  • Appropriate roles/boundaries
  • Identification of personal biases and impact on treatment
  • Safety concerns
    • Children’s safety
    • Therapists’ safety
reactions toward children
Reactions Toward Children
  • Behavior problems and limit setting
  • Frustration at varying developmental levels/ages and the pace of the group
  • Sadness and feelings of helplessness due to compound traumas and severe levels of need
  • Anxiety about abuse disclosures
  • Desire to rescue/overprotect
reactions toward parents
Reactions Toward Parents
  • Sadness regarding vulnerability of children and lack of parental resources
  • Empathy about maternal trauma histories
  • Feelings of helplessness regarding ongoing challenges (financial, occupational, etc.)
  • Anger and frustration due to lack of appropriate parenting skills
  • Desire to rescue/overprotect
cultural countertransference
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