How Can We Better Treat PTSD in People Experiencing Homelessness?

What you need to know

• People experiencing homelessness have very high rates of trauma exposure and post-traumatic stress disorder (PTSD), but there is little research on effective treatments for this population.
• The review found few high-quality studies on PTSD treatments for vulnerably housed people. More research is needed on adapting evidence-based therapies for this population.
• Trauma-informed care approaches that emphasize safety, choice, and understanding of trauma’s impacts show promise, but it’s unclear which elements are most important.

The prevalence of trauma and PTSD in homeless populations

People who are vulnerably housed or experiencing homelessness face significant health challenges, including very high rates of trauma exposure and post-traumatic stress disorder (PTSD). Studies estimate that up to 91% of people experiencing homelessness have faced at least one traumatic event in their lives. Rates of diagnosed PTSD in this population range from 21% to 53%, much higher than in the general population.

Trauma and PTSD can make it even more difficult for vulnerably housed individuals to access healthcare and other support services. Many have experienced trauma at the hands of caregivers or authority figures, making it challenging to trust service providers. Being homeless also exposes people to ongoing trauma and victimization. Additionally, substance use is common as a way of coping with PTSD symptoms.

Treating PTSD in vulnerably housed populations

This review examined what research has been done on treating PTSD in people experiencing homelessness or unstable housing. The researchers found only 28 relevant studies, most with small sample sizes or other limitations.

The studies tested several types of interventions:

Trauma-focused psychotherapies

A few small studies looked at therapies that involve recalling traumatic memories, like eye movement desensitization and reprocessing (EMDR). These showed some promise in reducing PTSD symptoms, but were limited by very small sample sizes.

Non-trauma focused therapies

Several studies examined cognitive-behavioral therapy (CBT) approaches that don’t directly address trauma memories. While some showed benefits, overall these were not very effective for PTSD symptoms specifically. Researchers noted high dropout rates were common.

Housing interventions

A few studies looked at providing housing as a way to reduce PTSD symptoms. These showed modest benefits, but the evidence was low quality.

Medications

Only a handful of individual case reports described using medications to treat PTSD in this population.

Challenges in providing PTSD treatment

The studies highlighted several key challenges in treating PTSD for vulnerably housed individuals:

• Difficulty keeping people engaged in treatment, with high dropout rates
• Lack of private, quiet spaces to deliver therapy in shelter settings
• Co-occurring substance use disorders complicating treatment
• Ongoing exposure to trauma while homeless
• Barriers to follow-up due to housing instability and staff turnover

Trauma-informed care approaches

Many experts recommend using “trauma-informed care” approaches when working with vulnerably housed populations. This means shaping services to account for the impacts of trauma. However, the review found trauma-informed care was not clearly defined or implemented consistently across studies.

Key elements of trauma-informed approaches mentioned included:

• Prioritizing physical and emotional safety
• Offering choices and flexibility
• Helping clients feel heard and understood
• Building on individuals’ strengths
• Recognizing signs of trauma
• Integrating knowledge of trauma into policies and procedures

However, it was often unclear exactly how these principles were put into practice. More research is needed to determine which elements of trauma-informed care are most important and how to implement them effectively.

Conclusions

• There is a major lack of high-quality research on treating PTSD in vulnerably housed populations, despite the high prevalence.
• Adapting evidence-based PTSD treatments to work for this population is challenging but important. Creative approaches are needed to improve engagement and address practical barriers.
• Trauma-informed care principles show promise, but more work is needed to clearly define and evaluate trauma-informed practices.
• Future studies should include the perspectives of people with lived experience of homelessness and trauma to ensure treatments are relevant and acceptable.

While this review highlights significant gaps in knowledge, it also points to opportunities to improve care for a highly vulnerable population. With further research and thoughtful implementation of trauma-informed approaches, there is potential to better address PTSD and support healing for people facing homelessness and housing instability.