GLOBE EDITORIAL

First, try to help

February 8, 2008

'HE FELL on bad times and turned to the bottle."

"She's meds-seeking."

"He's relapsed eight times. . . . The hospital gave him Percocet."

"He has no problem getting a job when he's sober."

The details of the troubled lives of homeless clients flew quickly in a conversation held last week by a team of counselors, shelter and housing directors, an outreach worker, and a domestic violence specialist all crowded around a conference table in Framingham at the Common Ground Resource Center. It's a weathered and sprawling white house that serves as the first stop for getting housing services from the South Middlesex Opportunity Council (SMOC), an antipoverty agency. The house has the feel of an old railroad station: It's a good place to disembark before one's life veers completely out of control.

The talk is a part of a vital national effort to provide "trauma-informed care," which recognizes how much people can be harmed by addictions and physical abuse.

Two years ago, there probably wouldn't have been much talk at SMOC about the men and women who were failing at saving their own lives, because the situation was stark: Clients who broke the rules were simply kicked out of SMOC's housing.

"It was a lot easier," SMOC's director of planning, Gerard Desilets, says of the old approach.

The only problem was that these people still lived with daily crises. They could end up ricocheting through the public system, going to detox, jails, and other shelters. Family members would cut them off. Some might sleep in cars. And they'd still drink or use drugs and struggle with mental illnesses.

So SMOC changed course, training 400 of its staff members to provide trauma-informed care. And the resource center team was created so that no one staff person would go it alone. The new marching orders were to stop focusing too closely on clients' rule-breaking and reckless behavior, and to be conscious instead of their underlying trauma.

A different approach

The National Center for Trauma-Informed Care (part of the US Department of Health and Human Services) puts it this way: Don't ask people, "What is wrong with you?" But rather, "What has happened to you?"

The devastating answers include domestic violence, child abuse, witnessing violence as a child, and physical and sexual assault. Or it might be that a person has aged out of foster care or left juvenile detention, and suddenly has to build a life out of thin air.

If trauma is severe enough, it can impair people's cognitive, emotional, and physical well-being. With this in mind, the SMOC team keeps talking - about clients and to them; discussing strengths such as who has found housing and a job. When it comes to struggling clients, the team brainstorms about what other staff members or programs might help.

Among the guiding principles: Keep people engaged even if they do break rules, because rule-breaking, relapsing into an addiction, and other self-destructive actions may in fact be clients' attempts to cope with trauma or the result of trauma-impaired functioning.

For those whose lives are fractured by trauma, rhetorical sticks such as "zero tolerance" or "three strikes and you're out" are less likely to work. The words may only seem like so much breath to an adult who is plagued by the demon of chronic childhood beatings.

"We still push sobriety," says James Cuddy, SMOC's executive director. But there's also an effort to help clients understand that some old harmful habits - which might have helped them cope with an assault or chronic childhood abuse - are no longer necessary. SMOC doesn't require clients to reveal traumatic experiences, only to learn the skills they need to heal and function more effectively.

Realism and compassion

Instead of giving up on clients who relapse into addictions, SMOC staffers say "relapsing is part of recovery," and they ask clients, "How can we help you relapse less?"

The work is emotionally draining. Staff members say they invest their hearts and souls. Some are recovering from addictions themselves, so they know, first hand, about this struggle.

Not everyone succeeds. But more of SMOC's clients are achieving stability and independence as SMOC uses trauma-informed care as part of a larger effort to place and keep people in permanent housing.

It can sound like coddling. But Cuddy says it's a matter of treating clients with more respect. He adds that the approach can save money by keeping people out of jail, shelters, and other public facilities.

Trauma-informed care is also championed by the state's Bureau of Substance Abuse Services, which said in a 2006 report that, "While important work has been done both nationally and in Massachusetts to develop trauma-informed integrated care, it is clear that for consumers . . . multiple obstacles remain." Clients need more coordinated care, and more public entities, from courts to state agencies, should be involved.

In the report, the bureau and the Institute for Health and Recovery, a Cambridge nonprofit, (both of which provided technical assistance to SMOC) also pushed Massachusetts to do more to address trauma - by involving law enforcement, helping traumatized parents meet their children's needs, and providing more skilled care across gender, class, ethnic, and other socioeconomic lines.

The bureau already requires the agencies it funds to provide trauma-informed care. And the Department of Public Health is extending the approach to AIDS programs. Federal efforts include a conference in July that's being sponsored by the National Center for Trauma-Informed Care.

It's an effort that should grow. People can be remarkably fragile. And many of the poorest and most harmed don't respond to attempts to flog them into better lives. That's no reason to abandon them.