Transcript Serving Women who are Transitioning out of Homelessness

Serving Women who
are Transitioning out
of Homelessness
Susan Foster, MPH, MSSW
Megan Edson Grandin, MPH
Purpose
•Understand the lived experience of
women experiencing chronic
homelessness.
•Learn about the needs of women in
supportive housing.
•Explore strategies for providers serving
formerly homeless women in permanent
supportive housing.
The ache for home lives in all of us, the safe place where
we can go as we are and not be questioned.
~ Maya Angelou
Background on women experiencing homelessness
PART 1
Who are the Women Served by the Services in
Supportive Housing Program?
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Average age 45 to 54 years
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Racial and ethnic minorities disproportionately represented
Risk Factors Associated with Homelessness
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Undereducation
Lack of employment opportunities
Lack of social support
Domestic violence
Mental health issues
Substance use issues
Housing instability
Fixed incomes
Eviction
Unsafe housing
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Poverty
Change in marital status
Lack of affordable housing
Military discharge
Death of last living parent
Widowhood
Divorce
Incarceration
Lack of access to health care and
other services
Baker, Niolon, Oliphant, 2009; Caton, Wilkins & Anderson, 2007; Feen-Calligan, Washington & Moxley, 2009; Hightower, 2009;
Kisor & Kendal-Wilson, 2002; Lehmann, Kass, Drake & Nichols, 2007; US Department of Housing and Urban Development, 2010
“Many problems these women face are not of their own making and they find
themselves in vicious cycles in which distress is reinforced by unresolved issues that
literally ‘pile up.’”
~Olivia Washington, Ph.D.
Wayne State University
Washington, Moxley, Garriott & Weinberger, 2009
Older women experiencing homelessness: a new
trend?
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Considered “older” at the age of 50, due to the physical effects of homelessness
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Disconnected from services and benefits
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Fixed income
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Factors such as under-education, lack of employment training and economic
inequalities may begin early in life
Hightower, 2009; Kisor & Kendal-Wilson, 2002; Washington, Moxley, Garriott & Crystal, 2009; Washington, Moxley & Taylor, 2009
Women Experiencing Chronic Homelessness
•Compared to women with situational homelessness, women experiencing chronic
homelessness are:
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Older
In poorer health
More likely to have a history of severe and persistent mental health issues
More likely to have substance use issues
•Often separated from their children
•Cumulative trauma
•Persistent unemployment
•Disconnected from services and benefits
•Social isolation
Caton, Wilkins & Anderson, 2007; U.S. Department of Housing and Urban Development Office of Community Planning and
Development, 2010; Zlotnick, Tam, Bradley, 2007
Special Needs of Mothers Experiencing
Homelessness
•Number of families experiencing
homelessness is increasing
•Multiple moves
•Family separations
•Parenting in public
•Fragmented social networks
Friedman, 2000; National Alliance to End Homelessness, 2011; US Department of Housing and Urban Development, 2010
Fragile Support Networks Among Mothers
Experiencing Homelessness
•On average, families will live with three
different friends and family members before
going to a shelter
•Social networks frequently exhausted before
becoming homeless
Friedman, 2000
•Up to 70% of women experiencing
homelessness are mothers who have been
separated from their children.
Bassuk, Buckner, Perloff, Bassuk, 1998; Cowal et al., 2002; Hoffman & Rosenheck 2001; Zlotnick, Roertson & Wright, 1999;
Zlotnick, Tam, & Bradley, 2006
The Effects of Cumulative Loss and Trauma
in the Lives of Women
Foster
care/multiple
childhood
traumas
Early
homelessness
Multiple adult
traumas
Homelessness
and separation
from children
Grief and loss
Bassuk, Buckner, Perloff, Bassuk, 1998; Cowal et al., 2002; Hoffman & Rosenheck 2001; Zlotnick, Roertson & Wright, 1999;
Zlotnick, Tam, & Bradley, 2006
The Lived Experience of Women While Homeless
PART 2
What is life like for a woman who is homeless
and alone?
STRUCTURAL
Daily survival
Low or no income
“Shelter hopping”
TRAUMA
Violence
Rape
Sexual Abuse
Robbery
History of incarceration
Lack of social networks
HEALTH
Substance use disorders
Mental health problems
Chronic medical issues
Head injuries
Malnutrition
Lack of continuity of care
Lack of linkages to services
Structural Issues
STRUCTURAL
Daily survival
Low or no income
“Shelter hopping”
TRAUMA
Violence
Rape
Sexual Abuse
Robbery
History of incarceration
Lack of social networks
HEALTH
Substance use disorders
Mental health problems
Chronic medical issues
Head injuries
Malnutrition
Lack of continuity of care
Lack of linkages to services
Daily Survival
•Lack of privacy
•Lack of storage
•Lack of bathing facilities
•Interrupted sleep
•Difficulties obtaining nutritious food
•Lack of routine
•Exposure
•Fear of violence, robbery
Davis & Shuler, 2000; Liebow, 1993
Social Isolation and Loneliness
•Lack social networks or loss of family before
becoming homeless
•Difficulties remaining in contact with their
networks while homeless
•Supports on the street may be functional or
dysfunctional. When a person transitions out of
homelessness, she may have to leave unhealthy
friendships behind.
Friedman, 2000; Kisor & Kendal-Wilson, 2002; Toohey, Shinn & Weitzman, 2004
Health Issues
STRUCTURAL
Daily survival
Low or no income
“Shelter hopping”
TRAUMA
Violence
Rape
Sexual Abuse
Robbery
History of incarceration
Lack of social networks
HEALTH
Substance use disorders
Mental health problems
Chronic medical issues
Head injuries
Malnutrition
Lack of continuity of care
Lack of linkages to services
Medical Issues
•82% have history of sexually transmitted
infections
•22% asthma
•20% anemia
•13% HIV
•4% hypertension
Bharel, Casey & Wittenberg, 2009; Kilbourne et al., 2001; Long, Tulsky, Chambers, Alpers, 1998; Nyamathi, Flaskerud, Dixon & Lu,
2001; Nyamathi, Leake & Gelberg, 2000; Stein, Lu, Gelberg, 2000; Hightower, 2009; Kilbourne et al., 2001; Stein, Lu, Gelberg,
2000; Washington, 2005
Medical Issues among Older Women
Experiencing Homelessness
•Health issues associated with aging occur at an earlier
age for women experiencing homelessness.
•High prevalence of chronic diseases such as:
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69% heart problems
61% hypertension
52% diabetes
52% arthritis
Gonyea & Bachman, 2009
Severe and Persistent Mental Health Issues
•28% Schizophrenia
•24% Bipolar disorders
•24% Personality disorder
•46% Co-occurring disorders
Bassuk, Buckner, Perloff & Bassuk, 1998; Hoffman & Rosenheck, 2001; Nyamathi, Leake & Gelberg, 2000
Prevalence of Substance Use
•60% alcohol use
•47% illicit drug use
•10-20% injection drug use
Heslin et al., 2007; Long et al., 1998; Nyamathi, Keenan & Bayley, 1998; Tucker et al., 2005
Substance Use
•Use of substances to escape the harsh realities of living on
the street
•In addition to alcohol and illegal drugs, prescription and
psychotropic medications are traded and misused
•Increased victimization
•Barrier to some services
Nyamathi et al., 2003; Stump & Smith, 2008; Tucker et al., 2005
Traumatic Brain Injury
•Approximately 42% of women experiencing homelessness
have reported a brain injury
•Manifests in different ways
•May have different origins (domestic violence, attacks
while living on the streets, etc.)
•Range of motor and sensory effects, cognitive problems,
and emotional symptoms
•May mimic the symptoms of mental illness
Center for Substance Abuse Treatment, 2010; Hwang et al., 2008
LACK OF TREATMENT
Barriers to Accessing Care
•Lack of knowledge of where to seek care
•Long waiting times
•Lack of health insurance
•Lack of documentation
•Long wait lists
•Lack of transportation
•Conflicting priorities
•Lack of child care
•Language barriers
•Cultural barriers
•Fear of seeking care
•Stigma
Bharel, Casey & Wittenberg, 2009; Bonin et al., 20003; Gelberg et al., 2002; Lewis, Andersen & Gelberg, 2003; Long, Tulsky,
Chambers & Alpers, 1998; Luhrmann, 2008; Nyamathi, Stein & Swanson, 2000; Swanson, Andersen & Gelberg, 2003
Trauma
STRUCTURAL
Daily survival
Low or no income
“Shelter hopping”
TRAUMA
Violence
Rape
Sexual Abuse
Robbery
History of incarceration
Lack of social networks
HEALTH
Substance use disorders
Mental health problems
Chronic medical issues
Head injuries
Malnutrition
Lack of continuity of care
Lack of linkages to services
Physical and Sexual Abuse in the Lives of
Women Experiencing Homelessness
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Experienced physical or
sexual abuse in their lifetime
Experienced violence
throughout their lifespan
Experienced severe physical
Physically or sexually
violence by caretakers
assaulted before the age of
before the age of 18
12
Austin, Andersen, & Gelberg, 2008; Bassuk et al., 1996; Brown & Bassuk, 1997
Experienced sexual assault
within the past year
Post-Traumatic Stress Disorder (PTSD)
•Women experiencing homelessness have
PTSD at three times the rate of the general
population
•For women who have experienced trauma,
each additional trauma increases her risk of
PTSD by 40%
Bassuk et al., 1996; Stump & Smith, 2008
Victimization
Substance Use
Untreated Mental
Health Issues
Austin, Andersen & Gelberg, 2008; Heslin, Robinson, Baker & Gelberg, 2007; Nyamathi et al., 2003; Nyamathi, Leake, Gelberg,
2000; Tucker et al., 2005; Stump & Smith, 2008; Wenzel, Koegel, Gelberg, 2000
Assessment and Service Planning
PART 3
Assessment Principles
•Assessment is about engagement and understanding, not just diagnosis
•Assessment should be comprehensive
•Consumer identifies needs and prioritizes services she can accept
•Focus on strengths
•Assessment is informed by culture
•It takes time
Focus on Strengths
•Builds trust among consumers and service providers
•Focus on strengths
•Encourage self efficacy and control
•Emphasize faith/spirituality
Components of Comprehensive
Assessments
•Health/medical
•Traumatic brain injury
•Mental health/trauma
•Substance use
•Family/children
•Income/benefits
•Other tangible supports
•Previous/current agency or system involvement
Overall Approach to Services – What’s Working
PART 4
Evidence-Based Practices for Women
Transitioning out of Homelessness
Evidence-Based Practices
•Seeking Safety
•Dialectical Behavioral Therapy (DBT)
•Illness Management and Recovery (IMR) or Wellness Recovery Action Plans (WRAP)
•Motivational Interviewing
•Family Psycho-Education
•Trauma-informed care
Seeking Safety
•Designed for women with trauma and substance use histories
•Integrated treatment
•Helps clients attain safety in relationships, thinking, behavior and emotions
•Focus on ideals
•Content (which incorporates information on cognitive, behavioral, interpersonal, and
case management)
•Attention to clinical processes
Desai, Harpaz-Rotem, Najavits, & Rosenheck, 2008
Dialectical Behavior Therapy
•Teaches effective coping skills, distress tolerance, mindfulness, emotional regulation
•Focus is on empowerment
•Highly active and participatory
•Can be conducted in groups or individually
Washington, Moxley & Taylor, 2009
Illness Management and Recovery or Wellness
Recovery Action Plans
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Engages consumers in developing goals for recovery
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Empowers individuals with MH and COD to manage their own recovery
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Can be facilitated by non-clinicians
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Good for programs with a recovery focus and ability to serve women long-term
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Can be combined with other techniques such as motivational interviewing
Motivational Techniques
•Effective for individuals in all stages of recovery from addiction
•Helps consumers recognize triggers for relapse, develop coping skills to prevent future
relapse
•Encourages recovery through positive feedback
•A way for staff to understand and respond therapeutically to active substance use
Psychoeducational Multifamily Groups
•Treats schizophrenia, bipolar disorder, major depression, and other disorders
•Focus on coping skills, solving problems, social supports, developing an alliance
between consumers, practitioners, and their families or other support people
•Takes place in group setting
McFarlane et al., 2003
Trauma-Informed Care
•Recognizes the impact of trauma in all aspects of one’s life
•Recognizes that many symptoms are coping responses to past traumatic experiences
•Recognizes the importance of people at all levels of the organization and decreases
power imbalances in relationships
•Creates a partnership between consumers and providers, recognizing that consumers
are experts in their own care
•Focuses on preventing re-traumatization
•Empowers consumers with choices about care
Prescott, Soares, Konnath & Bassuk, 2008
Beyond EBPs: Supporting the Whole Person
What do women experiencing homelessness
need?
Structural Support
Income
Life skills
Employment
readiness
Housing retention
Advocacy
Money management
Trauma Services
Faith/spirituality
support
Client/
guest
Health and Wellness
Medical care
Dental Care
Trauma-informed
care
Assistance with ADLs
Trauma-specific
interventions
Peer groups
Recovery Groups
Arts groups
What Providers Need to Do Their Jobs
What Providers Need
• Training, particularly in trauma-informed care, benefits, agency
regulations
• Strong team leadership
• Strong team culture
• Support for self-care
• Strong supervision
Preventing Staff Burnout
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Staff retreats
Regular staff meetings
Celebrations
Team social outings
To download a free copy of “What About You? A Workbook for Those Who Work with Others,”
please visit http://www.familyhomelessness.org/resources.php?p=sm.
Olivet, McGraw, Grandin, Bassuk, 2009
CONCLUSION
Where Can I Learn More?
Homelessness Resource Center
www.homeless.samhsa.gov
The National Center on Family Homelessness
www.familyhomelessness.org
SAMHSA’s National Registry of Evidence-based Programs and Practices
http://nrepp.samhsa.gov
References
Austin, E. L., Andersen, R., & Gelberg, L. (2008). Ethnic differences in the correlates of mental distress among homeless women.
Women’s Health Issues , 18, 26-34.
Baker, C. K., Niolon, P. H., & Oliphant, H. (2009). A descriptive analysis of transitional housing programs for survivors of intimate
partner violence in the United States. Violence Against Women , 15 (4), 460-481.
Barrow, S. M., & Laborde, N. D. (2008). Invisible Mothers: Parenting by Homeless Women Separated from Their Children. Gender
Issues , 25, 157–172.
Bassuk, E. L., Buckner, J. C., Perloff, J. N., & Bassuk, S. S. (1998). Prevalence of mental health and substance use disorders among
homeless and low-income housed mothers. American Journal of Psychiatry , 155 (11), 1561-1564.
Bassuk, E. L., Weinreb, L. F., Buckner, J. C., Browne, A., Salomon, A., & Bassuk, S. S. (1996). The characteristics and needs of
sheltered homeless and low-income housed mothers. Journal of the American Medical Association , 276 (8), 640-646.
Bharel, M., Casey, C., & Wittenberg, E. (2009). Disparities in cancer screening: Acceptance of Pap smears among homeless
women. Journal of Women's Health , 18, 2011-2016.
Brown, A., & Bassuk, S. (1997). Intimate violence in the lives of homeless and poor housed women: Prevalence and patterns in an
ethnically diverse sample. American Journal of Orthopsychiatry , 67 (2), 261-276.
Caton, C.L.M., Wilkins, C., Anderson, J. (2007). People Who Experience Long-Term Homelessness: Characteristics and
Interventions. Presented at the National Symposium on Homelessness Research, March 1-2, 2007. Office for the Assistant
Secretary for Planning and Evaluation, USDHHS, and HUD.
Center for Substance Abuse Treatment. (2010). Treating clients with traumatic brain injury. Substance Abuse Treatment Advisory,
9(2).
Cowal, K., Shinn, M., Weitzman, B. C., Stojanovic, D., & Labay, L. (2002). Mother–child separations among homeless and housed
families receiving public assistance in New York City. American Journal of Community Psychology , 30 (5), 711-730.
References
Davis, J. E., & Shuler, P. A. (2000). A biobehavioral framework for examining altered sleep-wake patterns in homeless women.
Issues in Mental Health Nursing , 21, 171-183.
Desai, R. A., Harpaz-Rotem, I., Najavits, L. M., & Rosenheck, R. A. (2008). Impact of the Seeking Safety Program on Clinical
Outcomes Among Homeless Female Veterans With Psychiatric Disorders. Psychiatric Services , 59 (9), 996-1003.
Feen-Calligan, H., Washington, O. G., & Moxley, D. P. (2009). Homelessness among older African-American women: Interpreting a
serious social issue through the arts in community-based participatory action research. New Solutions , 19 (4), 423-448.
Friedman, D. H. (2000). Parenting in Public: Family Shelter and Public Assistance. New York, NY: Columbia University Press.
Gelberg, L., Leake, B., Lu, M. C., Nyamathi, A. M., Morganstern, H., & Browner, C. (2002). Chronically homeless women's perceived
deterrents to contraception. Perspectives on Sexual and Reproductive Health , 34 (6), 278-285.
Gonyea, J.G. & Bachman, S.S. (2009). Ending Elder Homelessness: The Importance of Service-Enriched Housing. Boston: Hearth.
Heslin, K. C., Robinson, P. L., Baker, R. S., & Gelberg, L. (2007). Community characteristics and violence against homeless women in
Los Angeles County. Journal of Health Care for the Poor and Underserved , 18, 203-218.
Hightower, J. S. (2009). The Older Homeless Women's Perspective Regarding Antecedents to Homelessness. The University of
Arizona, College of Nursing. Tucson: The University of Arizona.
Hoffman, D., & Rosenheck, R. (2001). Homeless mothers with severe mental illness and their children: Predictors of family
reunification. Psychiatric Rehabilitation Journal , 25 (2), 163-169.
Hwang, S.W., Colantonio, A., Chiu, S., Tolomiczenko, G., Kiss, A., Cowan, L., Redelmeier, D.A. & Levinson, W. (2008). The effect of
traumatic brain injury on the health of homeless people. Canadian Medical Association Journal, 179(8), 779-784.
References
Kilbourne, A. M., Herndon, B., Andersen, R. M., Wenzel, S. L., & Gelberg, L. (2001). Psychiatric symptoms, health services, and HIV
risk factors among homeless women. Journal of Health Care for the Poor and Underserved , 13 (1), 49-65.
Kisor, A. J., & Kendal-Wilson, L. (2002). Older homeless women: Reframing the stereotype of the bag lady. Affilia , 17, 354-370.
Lehmann, E. R., Kass, P. H., Drake, C. M., & Nichols, S. B. (2007). Risk factors for first-time homelessness in low-income women.
American Journal of Orthopsychiatry , 77 (1), 20-28.
Lewis, J. H., Andersen, R. M., & Gelberg, L. (2003). Health care for homeless women: Unmet needs and barriers to care. Journal of
General Internal Medicine , 18, 921-928.
Liebow, E. (1993). Tell Them Who I Am: The Lives of Homeless Women. New York, New York: The Free Press.
Long, H. L., Tulsky, J. P., Chambers, D. B., & Alpers, L. S. (1998). Cancer screening in homeless women: Attitudes and behaviors.
Journal of Health Care for the Poor and Underserved, , 9 (3), 276-292.
Luhrmann, T. M. (2008). “The street will drive you crazy”: Why homeless psychotic women in the institutional circuit in the United
States often say no to offers of help. American Journal of Psychiatry , 165, 15-20.
McFarlane, W. R., Dixon, L., Lukens, E., & Lucksted, A. (2003). Family psychoeducation and schizophrenia: A review of the
literature. Journal of Marital and Family Therapy, 29(2), 223-245.
Najavits, L. M., Weiss, R. D., Shaw, S. R., & Muenz, L. R. (1998). "Seeking Safety": Outcome of a New Cognitive-Behavioral
Psychotherapy for Women with Posttraumatic Stress Disorder and Substance Dependence. Journal of Traumatic Stress , 11
(3), 437-456.
National Alliance to End Homelessness and Homelessness Research Institute. (2011). State of Homelessness in America: A
Research Report on Homelessness. Washington, DC: National Alliance to End Homelessness.
References
Nyamathi, A., Flaskerud, J. H., Leake, B., Dixon, E. L., & Lu, A. (2001). Evaluating the impact of peer, nurse case-managed, and
standard HIV risk-reduction programs on psychosocial and health-promoting behavioral outcomes among homeless women.
Research in Nursing & Health , 24, 410-422.
Nyamathi, A., Keenan, C., & Bayley, L. (1998). Differences in personal, cognitive, psychological, and social factors associated with
drug and alcohol use and nonuse by homeless women. Research in Nursing & Health , 21, 525-532.
Nyamathi, A. M., Leake, B., & Gelberg, L. (2000). Sheltered versus nonsheltered homeless women: Differences in health, behavior,
victimization and utilization of care. Journal of General Internal Medicine , 15, 565-572.
Nyamathi, A. M., Stein, J. A., Dixon, E., Longshore, D., & Galaif, E. (2003). Predicting positive attitudes about quitting drug and
alcohol use among homeless women. Psychology of Addictive Behaviors , 17 (1), 32-41.
Nyamathi, A. M., Stein, J. A., & Swanson, J. M. (2000). Personal, cognitive, behavioral, and demographic predictors of HIV testing
and STDs in homeless women. Journal of Behavioral Medicine , 23, 123-147.
Olivet, J., McGraw, S., Grandin, M. & Bassuk, E. (2009). Staffing challenges and strategies for organizations serving individuals who
have experienced chronic homelessness. Journal of Behavioral Health Services and Research, 37(2), 226-238.
Prescott, L., Soares, P., Konnath, K., & Bassuk, E. (2008). A Long Journey Home A Guide for Creating Trauma–Informed Services for
Mothers and Children Experiencing Homelessness . Rockville: Center for Mental Health Services, Substance Abuse and
Mental Health Services Administration; and the Daniels Fund; National Child Traumatic Stress Network; and the W.K. Kellogg
Foundation .
Stein, J. A., Leslie, M. B., & Nyamathi, A. (2002). Relative contributions of parent substance use and childhood maltreatment to
chronic homelessness, depression, and substance abuse problems among homeless women: mediating roles of self-esteem
and abuse in adulthood. Child Abuse & Neglect , 26, 1011-1027.
Stein, J. A., Lu, M. C., & Gelberg, L. (2000). Severity of homelessness and adverse birth outcomes. Health Psychology , 19 (6), 524534.
References
Stump, M. J., & Smith, J. E. (2008). The relationship between posttraumatic growth and substance use in homeless women with
histories of traumatic experience. The American Journal on Addictions , 17, 478-487.
Swanson, K. A., Andersen, R., & Gelberg, L. (2003). Patient satisfaction for homeless women. Journal of Women's Health , 12 (7),
675-686.
Toohey, S. M., Shinn, M., & Weitzman, B. C. (2004). Social networks and homelessness among women heads of household.
American Journal of Community Psychology , 33 (1/2), 7-20.
Tucker, J. S., Wenzel, S. L., Straus, J. B., Ryan, G. W., & Golinelli, D. (2005). Experiencing interpersonal violence perspectives of
sexually active, substance-using women living in shelters and low-income housing. Violence Against Women , 11, 1319-1340.
U.S. Department of Housing and Urban Development Office of Community Planning and Development . (2010). The 2009 Annual
Homeless Assessment Report . Washington, DC: U.S. Department of Housing and Urban Development Office of Community
Planning and Development.
Washington, O. G., Moxley, D. P., & Garriott, L. J. (2009). The Telling My Story Quilting Workshop: Innovative group work with older
African American women transitioning out of homelessness. Journal of Psychosocial Nursing , 47 (11), 42-52.
Washington, O. G., Moxley, D. P., & Taylor, J. Y. (2009). Enabling older homeless minority women to overcome homelessness by
using a life management enhancement group intervention. Issues in Mental Health Nursing , 30, 86-97.
Wenzel, S. L., Koegel, P., & Gelberg, L. (2000). Antecedents of physical and sexual victimization among homeless women: A
comparison to homeless men. American Journal of Community Psychology , 28 (3), 367-390.
Zlotnick, C., Robertson, M. J., & Wright, M. A. (1999). The impact of childhood foster care and other out-of-home placement on
homeless women and their children. Child Abuse & Neglect , 23 (11), 1057-1068.
Zlotnick, C., Tam, T., & Bradley, K. (2006). Impact of adulthood trauma on homeless mothers. Community Mental Health Journal ,
43 (1), 13-32.
QUESTIONS