Implementing a trauma-informed approach in public assistance programs

Trauma-informed care has become more widely adopted throughout the human services field, but public assistance programs like TANF and SNAP have largely not adopted a trauma-informed approach. For some individuals, the experience of living in poverty is a form of chronic trauma, resulting in negative health outcomes and creating additional barriers to self-sufficiency. Could states and county administrators adopt a trauma-informed approach to administering work requirements for safety net programs? What results could such an approach yield?

The Poverty-Trauma Connection

After decades of convincing research, it is now widely accepted that trauma can have severe impacts on the brain and overall health and wellness. While a significant portion of the overall population has experienced some form of trauma, studies show that trauma is more prevalent among individuals living in low-income environments. In fact, the trauma that results from living in poverty for long periods of time can result in a chronic, toxic stress that has substantial consequences for each individual and society as a whole. According to the American Psychological Association, chronic stress is a “long term form of stress, derived from unending feelings of despair/hopelessness, as a result of factors such as poverty, family dysfunction, feelings of helplessness and/or traumatic early childhood experiences.”[1] One expert likened the experience of growing up in poverty, and the subsequent high levels of stress hormone released, to the “heart pounding stress an adult feels after a car wreck,” yet experienced perpetually, resulting in a significant impact on an individual’s ability to focus and respond appropriately to the challenges of daily life.[2] Research has linked trauma and toxic stress to high rates of anxiety, depression, disengagement and lapses in cognitive abilities, difficulties with concentration and memory, and fear when facing new situations, along with an increased risk for a host of chronic physical health conditions. [bctt tweet="What would happen if administrators of safety net programs adopted a trauma-informed approach to administering work requirements? " username="CommunitySols"]

 The trauma that results from living in poverty for long periods of time can result in a chronic, toxic stress that has substantial consequences for each individual and society as a whole.

Increasingly, behavioral health providers, educators and other human service professionals who serve individuals living in poverty, are embracing a trauma-informed approach to care and services, in recognition of the profound implications of this growing body of research, and with awareness of the staggering number of those impacted. Of great significance to the human services is the contention that a trauma-informed approach is appropriate in any type of service organization.[3] While the concept of trauma-informed care has its roots in clinical practice, administrators are incorporating these same principles into the overall structure and workflow of agencies. This requires providing professional development opportunities for staff on the impact of trauma and toxic stress and acknowledging triggers that may exist for clients and employees. In doing this, the aim is to create workplace cultures where all individuals feel safe and are empowered to seek help when necessary.[4]

Trauma and Work Requirements

Recently, the prospect of work requirements for Medicaid recipients has reinvigorated the debate about the practicality and benefits of these mandates. It is important to note, however, that work requirements have long been in place for cash assistance (Ohio Works First or OWF), for some individuals receiving the Supplemental Nutrition Assistance Program (SNAP), and were established far prior to our growing understanding of the prevalence of trauma in our society, and the effects of poverty and other traumas on brain development. While work requirements predated welfare reform, the new law made them more rigid with an increased expectation that families face penalties for not complying. Today, failure to participate can result in increasingly punitive sanctions, including a potential for the loss of any benefits for a family. As OWF targets only the poorest of families across the state these sanctions often result in some of our most vulnerable households losing any source of cash income.

 While work requirements predated welfare reform, the new law made them more rigid with an increased expectation that families face penalties for not complying.

Upon application and verification of eligibility for cash assistance all work eligible individuals are assigned to a work assignment, which may involve subsidized or unsubsidized work, job training, a work experience program, education activities or some combination thereof. For many, in addition to providing income to a household living in deep poverty, work requirements could provide an opportunity to receive much needed occupational training and work experience resulting in a career pathway and a family sustaining wage. The data makes clear, however, that a failure to report compliance with assigned work activities is a regular occurrence among those who receive cash assistance. The reasons why families fail to comply with the work requirement are no doubt multifaceted and highly individualized. Ideology and life experience likely inform each stakeholder’s perspective on this divisive topic. While some will cite a lack of motivation or other personal defects as the primary motivator, others will point to system complexity, the lack of availability of quality work assignments and familial challenges as crucial factors. Public assistance recipients often lack access to transportation and reliable child care, both major barriers to participation. Regardless of the reason, the loss of much needed cash assistance and important job experience for our most vulnerable is something that requires attention from an economic development perspective and a compassionate, social stability, standpoint.

 The reasons why families fail to comply with the work requirement are no doubt multifaceted and highly individualized.

Trauma may play an oversized, and less-recognized role. A 2016 study found an increased prevalence of trauma and violence exposure among a group of Temporary Assistance for Needy Families (TANF) participants. According to researchers, more than 35 percent of the TANF participants in their study reported four or more Adverse Childhood Experiences (ACEs), compared to 6.2 percent in a large scale study of patients in the Kaiser Permanente healthcare system. Rates of exposure to substance abuse, parental absence and abuse were particularly elevated. [5] In addition, these researchers found that most TANF participants in their study had experienced community violence, reporting that “60 percent of participants reported being slapped, punched or hit by someone, 30 percent reported they had been beaten up or mugged and [more than] 17 percent reported being attacked or stabbed with a knife. Additionally, witnessing violence was also prevalent, as 86 percent heard [the] sound of gunfire near their homes, 65 percent saw a seriously wounded person after an incident of violence, and 27 percent had seen someone killed.” Other studies have demonstrated similarly higher ACE scores among the TANF population compared to the general population.

 Individuals who have experienced trauma may face additional barriers to successfully engaging in their public assistance work assignment.

Individuals who have experienced trauma may face additional barriers to successfully engaging in their public assistance work assignment. This may include anxiety and fear about learning a new skill or interacting with strangers, feelings of hopelessness or difficulties in establishing trust with the professionals assigned to assist them. Additionally, lapses in cognition or difficulty with memory may interfere with an individual’s ability to always be on time or develop plans in advance to handle scheduling challenges. Even if trauma is ruled out, groundbreaking research conducted by Eldar Shafir and Jiaying Zhao, suggests that the realities and experiences of being poor may by themselves prevent a person from successfully negotiating their way out of poverty. Shafir and Jhao’s research, published in the journal Science, showed the damaging impact on an individual’s “cognitive function” by the “the constant and all-consuming effort of coping with the immediate effects of having little money.” The result is in an individual who has fewer “mental resources” available to tend to the typically understood and, in the case of OWF, mandated, avenues out of poverty – education and job training. As such, individuals living in poverty may struggle to comply with work requirements without some lapses and a great deal of flexibility and support.[6] This effect is also well-documented in Shafir and Sendhil Mullainathan’s book Scarcity: Why Having Too Little Means So Much. In studies Shafir and his co-authors argue that in designing effective services for individuals living in poverty it is important to “accommodate the dominance that poverty has on a person’s time and thinking.” Among their specific recommendations are “training and educational programs structured to be more forgiving of unexpected absences, so that a person who has stumbled can more easily try again.”[7]

Implications for Ohio and Proposed Solutions

In Ohio, the lack of a trauma-informed public assistance system has had stark consequences. While welfare recipients have historically been labeled as lacking the essential skills necessary to be successful in the workplace, there has been little to no attention paid to how trauma and chronic stress may have impacted their ability to be self-sufficient. Strict enforcement of work requirements and an increase in sanctions has been a major factor in the steep drop in OWF caseloads over the past 10 years. According to an October 2018 report by The Center for Community Solutions, in December 2005 there were 180,000 individuals in Ohio who received cash assistance. In April of 2018 that number was almost halved to just more than 93,000. That drop can be accounted for by individuals reaching the 36 month lifetime limit set by the state of Ohio and by recipients failing to report work-mandated work hours. According to Community Solutions report the lack of statewide “robust work support programs” has made meeting this requirement challenging for providers to “meaningfully engage clients.”[8]

 While welfare recipients have historically been labeled as lacking the essential skills necessary to be successful in the workplace, there has been little to no attention paid to how trauma and chronic stress may have impacted their ability to be self-sufficient.

Adopting a trauma-informed approach in the public assistance system could lead to improved engagement and better outcomes for benefit recipients, and reduce the societal costs associated with poverty and trauma exposure. County administrators and state policymakers could look to innovative practices in the education field for a blueprint. Educators across the country have aggressively realized how trauma impacts their students’ ability to learn and have integrated trauma-informed approaches to their teaching. For example, in recognizing that certain zero-tolerance approaches to working with students who have experienced trauma are not effective, many educators promote focusing more on restorative practices that examine the roots of the behavior rather than on purely punitive actions.  

Counties and policymakers may also consider other programmatic adjustments to better address issues of trauma. For example:

• Consider integrating a trauma-specific screening tool, such as the ACEs questionnaire or a similar tool, into the enrollment process, and implement a protocol for employees to employ when trauma experiences are identified. This may include outside referrals to behavioral health providers or other services. These steps would provide an opportunity to identify triggers that may exist for individuals engaged with the system and offer necessary supports to help address any symptoms.
• Provide trauma training for staff at county job and family service agencies that addresses trauma, toxic stress, and related behaviors and health outcomes. Help individuals who work directly with clients to understand that disengagement or avoidance may not indicate a lack of motivation, but rather may be the brain’s response to a new or scary situation. This training would provide staff with resources and tools to better interact with individuals who may have experienced trauma and live with toxic stress, and provide a roadmap to avoid re-traumatization.
• The state’s Prevention Retention and Contingency (PRC) Program provides counties with opportunities to utilize TANF dollars to help families overcome barriers to self-sufficiency and find and maintain employment. County PRC plans should be developed with a recognition of the chronic stress that results from a lack of basic needs and emergencies like broken down vehicles or unpaid utility bills.
• The current law allows counties leeway in determining what constitutes a valid excuse for failing to comply with a work assignment, and they may elect to take a less punitive, or rehabilitative, approach to how they administer these requirements. Existing language within the policy enables local staff to take a more individualized approach to supporting an individual through the work requirement process. In addition, counties have discretion to determine what action to take if an individual misses a work assignment, and may allow the individual to make up the missed hours rather than issue a sanction. [9]
• Given that work participation rates of 100 percent are not mandated under federal TANF law, counties could be less aggressive in issuing sanctions on individuals and still meet the participation requirement.
• Continue efforts to develop more meaningful and flexible work experience programs, that take into account an individual’s specific work history and skills, and are built around developing career pathways, rather than arbitrary hour requirements. The state’s Comprehensive Case Management and Employment Program (CCMEP), targeting young people and marrying TANF funding with federal workforce dollars, is an initial step towards developing such an approach, though much more data is needed to fully evaluate its impact
• End the state’s full-family sanction policy. When entire households lose benefits due to a parent’s noncompliance with a work requirement, the cycle of poverty, and the cycle of trauma and toxic stress, is perpetuated. The residual impact of this situation disrupts communities and poses lifelong risks for children.

 When entire households lose benefits due to a parent’s noncompliance with a work requirement, the cycle of poverty, and the cycle of trauma and toxic stress, is perpetuated.

The significant gap between the number of families living in deep poverty and the number of families receiving cash assistance suggests that meeting the work requirement is a huge obstacle for many families who desperately need help. Children who live in homes who lack access to resources experience negative outcomes on almost all indicators of health and wellness. Likewise, parents whose households are poor enough to be eligible for cash assistance are necessary candidates for the work training and work experience that counties can provide, to help move families forward and improve their quality of life. When sanctions are issued and families disengage from the system this opportunity is lost. As such, it should be in the interest of our society to develop trauma-informed strategies to better to keep individuals engaged in their work assignments.

 Children who live in homes who lack access to resources experience negative outcomes on almost all indicators of health and wellness.

Mayo Angelou said “When you know better, do better.” Due to gains in knowledge about brain science and our overall understanding of how poverty and trauma impact cognition and social-emotional health, we know more about how to better support individuals living with low-incomes than we did when many of these policies were adopted. Today, we can do better. If policymakers determine that work requirements are a necessary component within the system, they should make it a priority to utilize the science to develop programs that are attainable and that don’t set people up for failure. Embracing a trauma-informed approach to administering benefits would put Ohio at the forefront of compassionate public assistance service delivery, and could yield long-term results for families and communities.  

[1] American Psychological Association, Health Disparities Fact Sheet, https://www.apa.org/topics/health-disparities/fact-sheet-stress.aspx  

[2] https://www.keranews.org/post/kids-living-poverty-living-chronic-trauma-experts-say  

[3] SAMHSA, Trauma-Informed Approach and Trauma-Specific Interventions, https://www.samhsa.gov/nctic/trauma-interventions  

[4] Case Western Reserve University, Center for Evidence Based Practice, Trauma-Informed Care, https://www.centerforebp.case.edu/practices/trauma  

[5] Sun, J., Patel, F., Kirzner, R., Newton-Famous, N., Owens, C., Welles, S. L., & Chilton, M. (2016). The Building Wealth and Health Network: methods and baseline characteristics from a randomized controlled trial for families with young children participating in temporary assistance for needy families (TANF). BMC public health, 16, 583. doi:10.1186/s12889-016-3233-4  

[6] Morgan, Kelly, “Poor concentration: Poverty reduces brainpower needed for navigating other areas of life,”https://www.princeton.edu/news/2013/08/29/poor-concentration-poverty-reduces-brainpower-needed-navigating-other-areas-life  

[7] Morgan, Kelly, “Poor concentration: Poverty reduces brainpower needed for navigating other areas of life,” https://www.princeton.edu/news/2013/08/29/poor-concentration-poverty-reduces-brainpower-needed-navigating-other-areas-life  

[8] Britton, Tara, Lusheck, Brie, The Center for Community Solutions, October, 2018 https://comsolutionst.wpengine.com/research/temporary-assistance-needy-families-ohio-balancing-program-integrity-entitlement-reducing-poverty-not-goal/  

[9] Ohio Administrative Code, 5101:1-3-13 Ohio Works First: good cause for work activity failures. http://codes.ohio.gov/oac/5101:1-3-13