Homelessness, Unmet Basic Needs, and Social Marginalization: Broadening Conventional Definitions of Trauma

Background and Purpose: Since posttraumatic stress disorder (PTSD) became part of the DSM in 1980, there has been growing attention to understanding traumatic events, their biopsychosocial sequelae, and the effectiveness of treatments to assist people experiencing PTSD. While the DSM-IV identifies numerous types of experiences that meet its definition of a traumatic event (e.g., military combat, personal assault, being kidnapped, incarceration as a prisoner of war, exposure to disasters, diagnosis with a life-threatening illness), this study aimed to explore ways in which social service providers working with adults with mental health concerns and histories of homelessness define and conceptualize the traumatic events that clients may experience.

Methods: Participants were recruited through a large, urban social service organization. All staff members working in a residential and outpatient program serving adults at risk of homelessness were invited to participate. Semi-structured, in-depth interviews were conducted with 12 social service providers. Participants were 58% female, 75% White, and ranged in age from 23 to 56 years (mean age=35.9 years, SD= 10.5); 58% held master's degrees and 25% held master's degrees in social work. Grounded theory methods were used to analyze the qualitative data.

Results: The social service providers reported that all of the clients with whom they worked were diagnosed with a serious mental illness and most (75-100%) were also experiencing substance use disorders. The social service provider estimates of trauma exposure among the clients ranged from 80-100%. The providers defined the traumas in ways that are consistent with those identified in the DSM-IV, including experiencing physical and sexual abuse (in adulthood and/or childhood) and witnessing violence. Several providers also described homelessness as a traumatic event, both as a situation that heightens risk for victimization and witnessing victimization, and as a situation that is traumatic in and of itself. Relatedly, participants identified unmet basic needs as trauma. Experiencing stigma was also identified as traumatic, both as a factor that contributes to risk of victimization and as an experience that is traumatic in and of itself. Further, experiencing stigma and judgmental attitudes from service providers was seen as an additional trauma that negatively influences client disclosure and the therapeutic alliance. Finally, participants described the social isolation many of the clients experience and clients' involvement in sex work as traumatic.

Conclusions and Implications: The social service providers who participated in this study defined traumatic events in multidimensional ways that broaden conventional definitions of trauma. These multidimensional definitions included discrete events that are often defined as traumatic; however, the multidimensional definitions also extended to ongoing conditions related to homelessness, unmet basic needs, social isolation, and stigma. These findings build upon prior conceptual work regarding psychological trauma associated with homelessness (Goodman, Saxe, & Harvey, 1991) and suggest the need for further consideration, in both practice and research, of the ways in which homelessness, unmet basic needs, social isolation and stigma are experienced as traumatic and the ways in which biopsychosocial treatments can be effective for persons experiencing posttraumatic responses related to these experiences.