Family Health and Wellbeing in Domestic Violence Transitional Housing: Service Provider Perspectives

Abstract

Survivors of intimate partner violence (IPV) and their children face threats to mental and physical health and economic stability. Housing stability is addressed in domestic violence transitional housing (DVTH) programs across the country, which provide longer-term (6–24 month) housing paired with supportive advocacy. Little is known about DVTH participant needs related to health, or accompanying DVTH program approaches. The current study seeks to understand DVTH service providers’ (n = 22) perspectives on the needs and supports in DVTH for physical and mental health. Staff members participated in qualitative interviews, which were analyzed thematically. Service providers discussed physical and mental health needs, key advocacy strategies and barriers that prevent effective services. Advocates also identified important aspects of health trajectories for DVTH participants.

Survivors of intimate partner violence (IPV) and their children face cascading impacts from violence and trauma exposure, economic and housing instability, and disruptions in formal and informal supports during periods of crisis. Community based IPV service providers address these combined challenges using advocacy approaches that pair access to tangible needs with support and empowerment (Wood, 2017). For survivors and families facing acute housing instability, domestic violence transitional housing (DVTH) has become a frequent service model aiming to address needs related to longer-term housing and economic stabilization for survivors and their minor children (Klein et al., 2021). While threats to family health and economic stability are both linked back to experiences of violence, little is known about survivors’ needs and accompanying approaches of DVTH programs related to survivors’ and family physical and mental health. The current study seeks to understand DVTH service providers’ perspectives on the needs and paired services of DVTH service recipients around physical and mental health.

Background

IPV is highly prevalent in the United States, with 37% of women and 30% of men experiencing lifetime IPV (Smith et al., 2018), with a higher risk of abuse for transgender and gender-diverse individuals (Closson et al., 2024; Kattari et al., 2022). In addition to adult survivors of IPV, many children are exposed to IPV in the home, resulting in nearly one in four children witnessing IPV while growing up (Hamby et al., 2010). Furthermore, IPV and child maltreatment frequently co-occur (Hamby et al., 2010). High rates of IPV experiences and exposure are of concern across the social ecology, with impacts including negative physical and mental health, as well as worse economic and housing outcomes, for IPV survivors and their children. IPV has profound negative physical health outcomes, with survivors reporting poorer perceptions of their health, headaches, chronic pain and disorders, sleeping and eating problems, and comorbidities of Type 2 diabetes (e.g., cardiovascular issues, kidney failure, circulatory issues) (Cho et al., 2023; Dillon et al., 2013; Schultz et al., 2021; Stockman et al., 2015). Other health concerns associated with IPV include reproductive and sexual health problems such as gynecological pain, unintended pregnancies, STIs including HIV, infertility, and miscarriage, among others (Dillon et al., 2013; Hutchinson et al., 2023; Stockman et al., 2015). These issues extend to maternal health for those who experience IPV during pregnancy, with negative outcomes including fetal injuries, preterm birth, low birth weight, and maternal mental health issues (Agarwal et al., 2023). Children exposed to IPV are at higher risk for a variety of negative health-related outcomes including increased morbidity, obesity, out-of-date or lack of immunizations, emergency room visits, health and behavioral health care needs, respiratory and hearing functioning issues, nutritional deficits, and more overall health problems (Campbell et al., 2021; Holmes et al., 2022; Jofre-Bonet et al., 2024).

The consequences of IPV extend beyond physical harm, negatively impacting emotional well-being and mental health. Reports of depression, anxiety, self-harm, post-traumatic stress disorder (PTSD), and overall poor mental health are particularly high and common for survivors (Dillon et al., 2013; Reyes et al., 2023; Schultz et al., 2021; Shuman et al., 2022; Stockman et al., 2015). Indeed, a meta-analysis found that 64% of survivors reported PTSD, 48% major depression, and 18% suicidality (Golding, 1999), with two to five times the increased odds of these same mental health outcomes for IPV survivors compared with those without IPV experiences (White et al., 2024). Likewise, substance misuse and abuse are significantly associated with experiences of IPV (Cafferky et al., 2018; Reyes et al., 2023; Schultz et al., 2021) as survivors often use substances to cope with IPV and associated trauma (Gezinski et al., 2021). Specifically, 36% to 94% of women with opioid addiction report IPV experiences over their lifetime (Stone & Rothman, 2019), and IPV victimization is significantly associated with seeking treatment for alcohol use (Schonbrun et al., 2013). These findings highlight the complex relationship between mental health, substance use, and trauma, emphasizing the importance of addressing IPV survivors’ mental health concerns, and underscoring the connection between IPV services and mental health needs. IPV and mental health impacts also have relational implications for children and families, with IPV being linked to harsh parenting and attachment disruptions in particular among survivors with PTSD (Chiesa et al., 2018; Greene et al., 2018).

Economic impacts related to IPV, including reduced housing stability, can further exacerbate family health challenges and increase risk for on-going violence exposure. There is a strong negative relationship between IPV experiences and economic impacts including overall material hardship (O’Connor & Nepomnyaschy, 2020; Voth Schrag, 2014) and economic self-sufficiency (Postmus et al., 2012). Furthermore, economic abuse within relationships with IPV impacts survivors’ ability to secure new housing or maintain their existing housing and may lead to homelessness (O’Campo et al., 2016); the risk of homelessness due to IPV extends to survivors who are pregnant and postpartum (Chan et al., 2021). Indeed, one in five women who are unhoused report IPV as the main reason they are homeless (Jasinski et al., 2002), and housing is the most in-demand, yet unmet, need of IPV survivors (National Network to End Domestic Violence [NNEDV], 2019; Rollins et al., 2012; Wood et al., 2019). One study found that for more than 2 years, 36% of IPV survivors with children experienced one or more episodes of unstable housing, and 11% experienced homelessness (Gilroy et al., 2016). In addition, for IPV survivors with children who reported homelessness or unstable housing, when compared with those with stable housing, both maternal mental health and child functioning suffered (Gilroy et al., 2016). Furthermore, economic abuse with relationships with IPV impacts survivors’ ability to secure new housing or maintain their existing housing (O’Campo et al., 2016).

Housing instability broadly intensifies health impacts of IPV for families (Gilroy et al., 2016) and can increase risks for engagement with child welfare systems (Bai et al., 2022; Marcal, 2018) and family separation (Shinn et al., 2017). Furthermore, housing instability can increase the risk of ruptures in the parent-child bond (Shinn et al., 2017), through increased family stress and mental health conditions (Jacoby et al., 2017; Rollins et al., 2012). Furthermore, housing instability creates safety risks for those experiencing IPV, creating vulnerability for repeated violence (Sullivan et al., 2023). As such, the last several decades have brought housing related programming for survivors of IPV and their children to the forefront in efforts to both reduce violence exposure and address impacts including those to family health and well-being. Such programming includes emergency shelter, housing voucher programs, and transitional housing (Baker et al., 2010; Klein et al., 2021). Transitional housing is a time limited (no more than 2 years) model that couples low or no cost housing with supportive services for survivors, and sometimes their children (Backes et al., 2024). Transitional housing for IPV survivors typically offers services focused on social and health needs, along with instrumental support on addressing legal concerns and economic remedies for stabilization. Typical services provided in transitional housing include case management, housing advocacy, material assistance, counseling, and financial assistance (Backes et al., 2024). Transitional housing programs frequently house survivors together with their children in individual units (Backes et al., 2024), and previous qualitative work has indicated that transitional housing may offer survivors time to focus on parent and child needs post-IPV, especially when supportive services are offered in trauma-informed manner (Wood, Backes et al., 2022). Previous research has found that primary advantages of DVTH for survivors over other housing approaches include increased security due to co-location with DV services agencies, lengthier stays allowing for greater stabilization in economic well-being, and the ease of access to other DV program services (e.g., counseling, advocacy) (Clark et al., 2019). Crucially, previous studies of DVTH service recipients highlight the importance of the availability of navigation support across a range of systems, including legal support, counseling, and children’s services are crucial for reducing violence exposure in the long term for DVTH residents, as well as increasing hope and minimizing trauma symptomology (Bennett et al., 2004; Clark et al., 2019; Sullivan & Virden, 2017). Having a program like DVTH for 1 year, and up to two if necessary, afforded survivors time to begin healing from the trauma, put long-term security measures into place (e.g., legal protection orders, divorce, relocating), obtain new or better-paying employment, and save money for the future. Those in the greatest current danger and/or with the most psychosocial needs were especially appreciative of this type of assistance and would not have traded it for Rapid Rehousing, even if Rapid Rehousing rental assistance were equivalent to DVTH. These findings indicate DVTH may be a good fit for those with multiple housing barriers and ongoing safety needs.

Advocates in DVTH programs use a range of approaches to identify survivor and family needs and provide options for addressing those needs, ranging from community-based referrals to informal support to agency provided legal, counseling, or economic support (Klien et al, 2021). In the United States, advocates frequently work under a voluntary service model outlined in federal statute which requires services to be provided without string attached—in other words, programs do not mandate one set of services in order for a survivor to receive another set of services (Wood, Voth Schrag, et al., 2022).

Despite the frequent use of DVTH as a model for families exposed to violence, there has been little written on the health needs and experiences of families participating in this service. While it is well documented that families exposed to IPV have significant health needs, there is scant information about how transitional housing programs seek to address those needs, especially among families at the intersection of housing insecurity and safety concerns stemming from IPV. To address these research gaps, the current study aims to understand the perspectives of DVTH service providers on the mental and physical health needs and experiences of families residing in DVTH programs. Using semi-structured interviews with 22 staff in DVTH across the United States, this study sought to examine staff perceptions related to (a) family health needs and experiences in DVTH; (b) staff advocacy approaches to address health needs, and (c) barriers experienced in addressing such needs.

Method

Study Design

Staff members working in direct practice positions or immediate supervisory positions in DVTH programs were recruited to participate in qualitative interviews focused on program dynamics, survivor experiences, and programmatic impact. Recruitment materials were shared with targeted agencies with DVTH programs across six states in the United States. Agencies were identified based on recommendation from state coalition partners, or based on their engagement with the larger exploratory sequential longitudinal evaluation from which this study is drawn. States were targeted to include a diversity of program structures, funding approaches, and political landscapes. Interested staff contacted the study team to participate, and interviews were conducted via video conference or phone. Qualitative interviews were conducted by four study team members, all of whom are PhD-level social workers with practice and research experience related to domestic violence services and advanced training in qualitative methods and analysis. A total of 22 interviews were conducted with DVTH program staff members, with the majority being advocates or case managers in DVTH programs. Example job titles include “Program Director of Supportive Housing” “Housing Advocate” “Transitional Supportive Housing Advocate” and “Transitional Housing Director.” The vast majority identified as female, with ages ranging from mid-20s to mid-60s. Their agency tenure ranged from 1 to 20 years, with most falling between 2 and 6 years. Interviews lasted an average of an hour, and were audio recorded and transcribed verbatim for analysis. Participants received a $25 gift card as a thank-you for their time. All study procedures were approved by the institutional review board (IRB) of the participating universities prior to the beginning of data collection activities.

Measures

A semi-structured interview guide was developed by the study team based on key study aims and a review of relevant literature. Domains queried across the interview include staff roles and programmatic designs, survivor experiences with violence and DVTH programming, staff experiences working in DVTH programs, and recommendations for practice and policy. For the current study, relevant questions include: What health and mental health concerns do survivors in domestic violence transitional housing report most often to you? What are the main needs for domestic violence transitional housing residents and their children? Do you have any specialized domestic violence transitional housing services for under-served or marginalized groups of survivors?

Analysis

Qualitative interview data were analyzed using techniques of thematic analysis (Braun & Clarke, 2020, 2021), which has been highlighted as an appropriate approach for understanding perceptions and experiences in applied research. The research team began with a phase of data familiarization, which included reviewing interviewer memos and transcripts in their entirety. The team then developed a set of initial codes using a combination of inductive and deductive approaches. An initial codebook was developed by the first, third, and fourth authors, and checked through a process of parallel coding by the first and third authors. The team conducted a flexible coding period across the 22 transcripts, with refinements to the codebook made via negotiation to consensus. Initial themes were generated by the first author. A second phase of targeted coding across codes that were identified as relevant to the current research aims, including codes related to: Mental Health Needs and Services, Children’s Needs and Services, Physical Health Needs and Services, Mental Health Goals and Impacts of DVTH, Substance Use, Disability, and Children’s Service Goals and Impacts was employed by the first and fourth authors to develop themes related to survivor and family health and mental health need and experiences. Quality criteria employed include triangulation of analysts, reflexive memo-ing, and an ethical approach (Tracy, 2010). Refined themes are presented below along with participant quotations to enhance participant voice in findings and thick description.

Results

Across interviews, service providers discussed what they perceive as the major health related needs of survivors and their children in DVTH. They also highlighted key advocacy strategies they employ to help survivors meet these needs, as well as service-related barriers that prevent effective services in this area. Finally, they shared reflections on the experiences and trajectories of survivors and children in DVTH related to health and mental health.

Service Provider Assessment of Survivor Health Needs

Survivors and their children coming into DVTH have both chronic and acute health and mental health needs, which shape their experiences. When asked about the most frequent needs survivors present with, service providers highlighted a range of trauma-related mental health needs such as PTSD, anxiety, and depression. Physical health concerns and substance misuse challenges were frequently tied to coping, experiences of injury, and psychosomatic responses to trauma. For example, service providers highlighted traumatic brain injuries: “You know, we’ve seen a lot of traumatic brain injuries” (Participant 5), and some underscored a link between physical health needs, injuries due to IPV, and mental health need:

Um, chronic pain, um, spinal damage. Um, we’ve had people who maybe come in with injuries from their experiences like, um, traumatic head injuries—or traumatic brain injuries, I mean. Um, and of course—I guess I will say super common is, um, mental health in a variety of ways, just because it, it pretty much comes with what people experienced, whether that’s the only reason it’s there or if they have even more experiences that contribute to that. (Participant 21)

One advocate reflected on the way that having time and space to assess their situation in a DVTH program sometimes led to new identification of health need, sharing “You know, some people come here, and they don’t realize, like, until later on, oh, they have a disability, or a neurodivergency, or something that makes it even harder to work” (Participant 9). Across the board, mental health impacts of trauma were central to provider’s assessment of survivor and family needs, with providers often expressing that their first aim was to address mental health challenges in a DVTH setting to set the stage for making progress on a range of other health and well-being goals:

And, so, if I can treat the PTSD [post-traumatic stress disorder] and sort of stabilize her schizophrenia diagnosis, or symptoms, or her bipolar symptoms or, or she can more clearly be treated on the- by- for those and her psych and we can sort of collaborate, then we’re definitely gonna do that. So, from a mental health place, our goal is to just welcome her in and be able to understand her mental health needs more, and then be able to collaborate and work on the stability when the management of those symptoms, if not decrease, um, and getting rid of them hopefully in a lot of ways. (Participant 23)

Providers repeatedly highlighted the ways that survivors’ mental health needs coincided with substance misuse, especially for survivors who were managing trauma symptoms. As Participant 26 shared: “I would say probably over 70% of the population that we’re serving have either co-occurring mental health diagnoses or substance use, um, disorders or both, uh, along with domestic violence and trauma.” Across interviews, participants drew this connection between mental health need and substance misuse, often linking this challenge to the need to balance individual and communal safety in communal living situations, or in challenges with leases or program expectations in scattered site DVTH programs.

Staff Strategies for Health Needs

Participants identified a range of invitational approaches that they employ to encourage survivors to work on health-focused needs in DVTH programs. Because of the voluntary service model that most DVTH programs operate within, they rarely discussed mandated treatment or treatment requirements, but instead talked about the ways they work with survivors to identify and address health related challenges and create environments in which healing is possible. Key themes that emerged including the way that programs provide space and choices to support survivor agency, autonomy, and individual decision making around their health needs, and ways that staff try to create the safest environments possible in which survivors and their family can address their health and mental health needs, including relational, environmental, and substance focused safety.

Giving Space and Choices for Health Decisions

Many service providers discussed that, particularly at the outset of a survivor’s time in DVTH programming, it was important to give them the space and opportunity to identify their health needs and choose the treatment approach that would work for them. Participant 23 highlighted the way that, at first, participants often want to focus on “[getting] settled into their new place. And so, they don’t really want to immediately start services at, at, at, um, at outreach. They want to see how it goes, see where they settle.” Similarly, Participant 26 highlighted that, while “they’ll say, like, I know I need it, but it’s just one of those things they don’t want to do right now. It’s always like, you know, I’ll do that later,” they understand that it is important to take a moment after exiting a traumatic situation before “having to like face and work through those feelings, I imagine can be super overwhelming.” Rather than pushing for immediate engagement in services, they try to keep lines of communication open so that a client who, for example, may need medication for health reasons, can access the care they want, when they want. A survivor-defined approach to health care decision making purposively centers the client’s experiences and needs, often in the aftermath of a lack of bodily and mental autonomy from an abusive partner.

Participants also talked about trying to take that open and nonjudgmental approach when working with survivors who are using substances. Advocates acknowledged that substance use is often a coping mechanism for those with histories of trauma, and that programmatic rules related to substances can be a barrier if they are not well managed. One participant highlighted how they help create space for survivors to have a choice to seek substance use treatment without mandating it:

We’ll just sit down with them and say, “Hey, you know, this seems to be like a big problem, and we have these resources if you want to do outpatient, or if you wanna do inpatient. And if you go, we’re not gonna take away your apartment, it’s still gonna be there. We’ll make sure nothing happens with that.” Um, just make sure that they know that they’re supported and they have options and things aren’t just gonna be taken away from them if they follow through with therapy or if they decide not to. (Participant 20).

Creating the Safest Possible Environment

Staff often highlighted how they viewed their task as supporting and enhancing the safety of the environment in which survivors and their families were living, thereby facilitating their attention on longer-term health and well-being goals. Staff discussed seeking to enhance relational and physical/environmental safety by addressing potential traumatic reminders, ensuring safe environments, and considering the community context of services. Staff also saw their job as balancing safety from and around substances with the needs of survivors who use substances as a coping mechanism for trauma related mental and physical health challenges.

Relational & Environmental Safety

Staff indicated they try to build trust and safety for survivors both in terms of their own relationships with residents and, particularly for those in co-located transitional housing, between residents. The realities of communal living when many residents have trauma related challenges came up as a major challenge, and one which service providers attempt to address to promote trauma recovery in the DVTH environment. As Participant 9 shared:

Like one person, when they feel elevated or there’s a conflict, might like raise their voice ‘cause they want their voice heard and they’re—they have some trauma response of not having their voice heard. And another person, a raised voice is super scary. So, like, we’re also navigating how like people’s, um, like trauma responses, conflict with each other in the building and trying to solve those conflicts and help people work their way through those conflicts themselves as well.

Staff uses de-escalation and nonviolent communication strategies to build connections with residents as well as to ensure their own safety and the safety of others when they interact with folks dealing with acute crises. Some programs include home visits as an approach to build safety and support survivors who are managing mental or physical health challenges. As Participant 21 shared:

We do a lot of home check-ins and visits, so we kinda have an idea if someone is living with a diagnosis or having a crisis and we just kinda jump in ‘n see what we can do. Um, all of our staff has been trained in some nonviolent de-escalation.

Service providers underscored that an important part of building relational safety for families living in DVTH was keeping an on-going awareness of the dynamics between survivors and others in their home or between survivors in shared living spaces. By managing these relationships, and creating environments of relational safety, staff felt they were able to support survivors in focusing on healing and recovery, moving into spaces where they could take advantage of mental or physical health supports or address their felt needs.

Participant 20 talked about the importance of DVTH staff efforts to build rapport and trust in helping to heal relational trauma:

I think it’s the time that allows for the treatment of relational trauma. . .So we have more time to truly, not, not just build rapport. Like, I think building rapport and trust is obviously really important, but it’s enough time to have consistent interactions, consistent predictability, and consistency- consistent. And, and also, which happens a lot of times with survivors in our transitional living, we have some sort of moment of conflict. Some sort of misunderstanding, some sort of. And so, then we get to . . . have that moment of repair and like in a healthy way, address the conflict that happened, recover from the co- and that’s that reparative, um, relational interactions from the trauma that they experience before of like, “Oh, y’all didn’t get mad at me and kick me out?” No, let’s talk about what happened. And so, I think from a time place, like, that repair in how I understand relationships and how I interact with others, um, is a huge part of it.

Building safety so that survivors can pursue mental and physical health and was also tied to the built and designed environments of DVTH programs. Participant 19 provided a concrete example of how changing program rules helped to build such an environment:

We did, we did change things a little bit and this has been really helpful, is you can now have a pet. So, it used to be like “no pets.” And then it was like, uh, “Okay, you can have a pet, just no pit bulls.” . . . And it could be anything, a cat, a dog, a snake, as long as you get your therapist to say. So, we have found that that’s been helpful, that they have this dog or this cat or something that, you know, that they can love on, that kinda gives them relief.

Similarly, participants discussed the ways that program expectations around visitors and guests was part of their attempt to build relational and physical safety for participants, reducing the chance of trauma triggers in the environment and building a space in which survivors could heal from trauma. Environmental aspects including security cameras (e.g., Ring cameras), gates, and on-site staff were all efforts both to secure DVTH facilities and to build environments in which survivors could establish the psychological safety needed to pursue their own physical and mental health goals. Participant 23 noted the way that how participants interacted in and with their spaces seemed to be impacted by their experiences of trauma:

Um, so one of the things that we have found through the years is trauma symptoms can very much be expressed in living conditions. And so then you have somebody who’s overwhelmed living in a very cluttered and overwhelming space. We’ve also seen a lot of, um, you know, you move into shelter and you lose so much in leaving your home. And so the desire to gain things and have things that are yours, that is, is very, very powerful. And of course, we understand that.

Safety and Substances

One area of considerable difference among participants was the programmatic approach to survivors with co-occurring substance use. In nearly every case, participant and program safety was cited as the motivation for how programs dealt with co-occurring substance misuse, but the steps were sometimes diametrically opposed. In some cases, programs had zero tolerance rules or sober living arrangements, which preempted survivors from entering DVTH if they were using. This was often tied to the communal aspect of parts of the program. As one staff person shared, “We have an expectation of, ummm, of course, communal living, right? So, there are certain goals, like we can’t have any alcohol, we can’t have any drugs, um, we can’t have any visitors” (Participant 23). Other programs, usually noting the link between substance use and trauma coping, took different approaches. Participant 5 shared:

There’s no rule saying that you have to remain sober in this program because. . . sometimes people come in and they do struggle with addiction because of what they’ve been through. So, we wanna make sure that we’re able to still provide them that support that they need and still, you know, offer them resources.

Some participants talked about building safety planning around substances into their general participant safety plan. For example, Participant 20 talked about the communal environment being a potential protective factor:

If they were to overdose, there are people around and they can get them help. So, we try to at least get them out of like the worst of it before we put them in housing if we can. Um and then after that, you know, just be consistent with them, checking in with them, seeing if they’re okay. Uh, we can do some safety planning with them, ask them things about, like, what the signs are that they’re using again or that they might use again so that we can look out for that and help them through it.

Some programs sought to walk a balance of approaches, as described by Participant 26:

So, both in our emergency shelter, in our transitional housing, we don’t have any kind of rule that you have to be sober or clean. Um, we don’t, you know, deny somebody services just because they have like a co-occurring substance use situation. However, we do have the rule that you don’t have drugs or alcohol on the property, and that’s both in shelter and in our transitional housing program. So, if an advocate came to meet with you to do a case management session and, you know, notice that there were substances or alcohol, um, in the apartment, then that, you know, might lead to a conversation. Um, and, you know, we’d offer referrals and resources based on that. Um, so, yes, there is that rule.

Barriers to Meeting Health Needs: Service Mismatch

While service providers were clear on the importance of addressing mental and physical health needs over the course of DVTH programming, they also underscored the challenges survivors and programs face in trying to make strides in these areas, particularly relating to gaps in service availability or a lack of alignment between survivor needs or preferences and community capacity. Many participants linked a lack of mental health services in their communities to survivors being unable to access care. Participant 9 discussed the way that community capacity was impacting survivors from their agency, stating:

I can get people referrals to counseling places in the area, but a lot of them are so, like, overbooked or they’re not accepting clients or, you know, or, you know, the online therapies are super expensive, or they’re not covered in the insurance.

Other participants noted that survivors have often had negative experiences with helping systems, which pose a barrier to getting supports in the present. Participant 15 shared:

We see a lot of, of need for medical care, mental health care, substance use treatment. Um, not, not always a lot of desire for those services or a desire to use the resources that exist, right? So it might be that it’s hard to access the public care and may have had negative experiences using those systems in the past. And so, what we’ll hear is sometimes a need for support, but looking for types of support that either don’t exist or that they can’t figure out how to gain access to.

Other participants similarly noted that there may be a disconnect between their perception of what survivors might need or want from services and the extent to which survivors are interested in or able to engage with those services. Participant 7 talked about trying to support survivor mental health in situations in which services might be available, but survivors are not engaging with them, saying:

Mental health is where I feel like we’re struggling in order to either refer, get our clients there, or to get their meds filled. So, a lot of their mental health is not being addressed right now. And that could be, I mean, for me specifically and the people I’m working with, it’s, A, they, they’ll set up an intake appointment, for example, like [mental health agency] where . . . they have received their medications from before. A, they will sleep through their appointment, they won’t make it, they’ll leave their appointment, or they just missed it for some reason. Um, then when we refer them to the pop-up community care that’s on site that could also fill their medication, same things are kinda happening. So it’s more of follow through on their end.

Advocates’ Perceptions of the Mental Health Journey of DVTH Participants

Service providers discussed the patterns they observed in survivors living in DVTH programs, recognizing a series of similar experiences related to mental and physical health and well-being for survivors living in DVTH. This includes a sense that the space provided by DVTH allows survivors to engage in a reexamination of their goals, including their health-related goals, a series of peaks and valleys in the healing journey, and a path toward stability and maintenance in the area of mental and physical health.

Breathing Room to Think About Goals

Service providers were clear that the space provided by DVTH programming for survivors to take stock and evaluate is a crucial component of positive health outcomes for survivors. Participant 26 shared:

So, I think that it offers them a little bit of breathing room, um, in a supportive, safe environment where they can continue to heal and work on themselves without feeling like they’re [on the clock to leave]. Um, and so I think that it allows people to kind of take a beat and maybe think about what decisions are actually best for them.

Providing that space gives survivors a chance to build patterns and goals that work for them and their families. As Participant 11 articulated:

I think people realize their own strengths here. They have the opportunity to do that, um, because everybody has, has strengths. So, they find—and I think finding out that you have more strengths than you thought you did. And so, they get a chance to breathe and to, to not have to worry so much about that. So, I think it’s a place for them. I think it’s just a place to start rebuilding and, you know, to, to, um, to have the basic things respected and, and to be, you know, I think to have somebody actually care. I think that that’s really the first thing.

Service providers frequently shared the importance of providing space for processing and understanding the trauma that survivors have been through and their goals for building safety and security moving forward. As Participant 9 said,

Um, and it’s like once you get here, you know, a lot of people are like running on that like adrenaline, like just like running on survival mode, and then once you get here, you’re in a safe building. It’s like that time to process everything hits people.

Participant 13 reflected on how DVTH and the advocacy relationship within DVTH creates space for survivors to identify their trauma experiences and resulting needs, leading to healing:

The trauma, the mental health, the little pieces, and they’ll say, “I don’t know why I do this.” And so that opens up to- it opens us up for conversation about what has happened in the past, what’s happening now, how the two could be- but that’s huge. Uh, we’ve had- I have one participant that spent the first three months doing- trying to do all the shoulds and oughts and needs to, you know. “I should get my G.E.D.,” you know? “I should, um, I, I should get a job. I should get the PPO [Personal Protection Order]. I should file for divorce. I should, I should, I should, I- I need, I need, I need.” And after three months, she finally trusted me enough to say, “[Participant’s name], I think I need to just stop and get my mental health in order.” And she spent the next eight- 6 to 8 months, um, seeing a psychiatrist, seeing her counselor weekly. And, um, it was the best thing she coulda done.

Peaks and Valleys of Impact

Across interviews, service providers underscored that healing is not a linear journey for survivors in DVTH, and that there were some predictable times of highs, such as program entrance, and lows, including in the post-entrance phase and nearing program end. Participant 6 talked about how space can lead to loneliness and regression in symptoms. After the high of getting into DVTH and having space, overwhelm can quickly set in, and being prepared as DVTH staff to address this is an important component of their work. They shared:

So, in my experience, entering [transitional housing program] is like the most hopeful, happiest of times. Because in entering, they know that they have qualified, and they know they’re gonna get up to a year of stable living. . . . But loneliness and isolation can set in pretty quickly for a lot of our new clients. . . I think in shelter, because it’s so crisis oriented, I’m just sort of thinking about what’s my next step, what’s my next step? They get over here and they really start feeling that loss and grief of “I left this place and now I’m all alone,” you know, kind of thing. . .We start to really want to support them in feelings of loneliness and isolation, um, and then, sort of that clinical coping and management of symptoms.

Advocates spoke of the solitude and loneliness of DVTH as a universal experience for survivors which impacts their journeys and can create emotional challenges. Participant 22 shared:

I would say the thing that I’ve seen kind of universally, again, has been um being alone. It’s that they are uh the, the solitude of independent living ‘cause we’re dealing with all the practical stuff of “What does that mean?” You know, “How do I do that?” And then, it’s still, you know, the loss of relationship um with an abuser. So it’s fear of the abuser, but still mourning the loss of the relationship and being alone a lot of the times with children, and, you know, it’s just your responsibility.

Participants also discussed that, as survivors move toward the end of their time in DVTH, they experience increasing pressure related to housing and economic stability, and potential disruptions to social support, all which may contribute to increased anxiety symptoms and point to the ending of DVTH services as a potential moment of increased mental or physical health risk. As Participant 23 shared,

In my experience, the end does sort of- there’s a mixture of, of course, excitement, um, but there’s a lot of anxiety and a lot of increase in anxiety symptoms. . . And so the anxiety of that, of “Where am I gonna go? What’s this gonna look like?” Can be strong. But even- you know, I have a client who left yesterday. She’s leaving into her own apartment. Um, we actually have her set up with [community agency], which is an agency that’ll come in and decorate her apartment with her. And so, you know, even the furniture stuff is not really something- we, we helped her with an air mattress to support her until [community agency] can get her the beds and the mattresses. Um, so all of those things are sort of in place, but there’s a lot of anxiety of just change, right? Loss because “I’m losing the supportive and now I’m really gonna be somewhere on my own.” Um, and so I think that that anxiousness of being alone or being by myself is a huge thing that I hear from clients.

Clearly, symptom reduction is a goal and aim of many survivors in DVTH. These interviews highlight that program entrance is a time when survivors might see a reduction in symptomology, as they have space for processing and increased feelings of environmental and relational safety. They also highlight that recurrences should be expected and planned for across a DVTH journey.

Achieving Stability and Maintenance

When discussing the trajectory of mental and physical health for DVTH participants, service providers highlighted improvements over time, as well as a hope that survivors can move toward health maintenance approaches as they end their stay in DVTH. In discussing how participants move on from a period of highs and lows in the first year in DVTH, Participant 6 shared:

Usually at that time, I think they feel like they’ve kind of hit a stride or a, a level of normalcy. So, most of our clients will sort of have let—had decreased their PTSD [post-traumatic stress disorder] symptoms, um, or symptoms, um, and be sort of stable in that. And they also feel like they’re sort of managing their advocacy goals, right? So, it’s sort of this sort of stable management time period.

Participant 26 talked about what this period of stability toward the middle of DVTH means for survivors in other areas of their life, sharing: “I’m just continuing to move forward and wait for this. I’m kind of- I’ve taken those big steps into a lot of my goals.” By providing survivors with this time of stability, they are able to muster resources that they can deploy in the future to support their health and well-being as well as their future safety needs. As Participant 20 shared:

I think it’s partially just about giving them a little bit more time, uh, to process things and to prepare themselves for being out in the community, uh, ‘cause they can only be in shelter for so long, but that’s not really enough time, most of the time, to fully like process what happened to them, to save up money, to support themselves and their kids, and things like that. Um, and then a lot of it, too, is just that they’ve been cut off from things for so long that it’s useful to have somebody that they can reach out to and say, “Well, what can I do in this situation? What- who can I reach out to? What are my resources?” Um, and also just to help them, like, establish a support system again. We are part of that support system, but let’s think about who else we can make connections with for once you’re out of this program.

Discussion

Mental and physical health considerations are a central part of DVTH services and assessment, and are an essential component in the program’s ability to support participants in achieving their goals. Our findings emphasize the prevalence of health and mental health challenges among residents including PTSD, anxiety, depression, brain injuries, and substance abuse. Given their prevalence, participants highlighted the importance of including health considerations in advocacy focused on maintaining long-term stability among DVTH residents, and discussed the various practices employed to support these goals, including fostering relational and environmental safety while giving residents the time to heal from the abuse they endured. Advocates prioritized health needs viewed as central to the survivors they were working with (“survivor driven health goals”). Barriers related to community infrastructure and service structure and limitations were particularly highlighted, with advocates noting that survivors experience waves of health and mental health impact over the course of a longer housing stay, which often includes important initial time for healing and new risks and setbacks as the program comes to an end.

Our findings emphasize the link between housing and mental health. Housing provides residents the time they need to recover from abuse, after living in survival mode for extended periods of time. Safety measures like gates, cameras, and security guards allow residents to relax their vigilance. Prolonged subsidized housing allows them to focus on their healing rather than worrying about the immediate physical needs of themselves and their kids. At the same time, staff also strive to ensure environmental safety in housing complexes. Specifically, participants talked about how relational trauma and substance abuse can negatively impact residents’ sense of safety.

Implications for Practice

Important implications arose from these interviews related to the range of approaches programs take to working with survivors with co-occurring substance use and misuse. Within these DVTH programs, wide variation was observed in agencies’ approaches to substance use, with a range of programmatic approaches from sober-living to harm reduction. Given high rates of co-occurrence between IPV victimization and substance use, and the frequency of substance use as a coping strategy for trauma symptoms, particularly in light of limited other options, this range of approaches is likely impacting survivors’ service use. Survivors in geographic regions with multiple service agencies may be unaware of differences in approach to substance use, which could impact their decision making related to seeking help. Furthermore, a lack of transparency around the approach to this issue could either reduce help seeking or create barriers for survivors after service engagement. Agencies can consider harm reduction strategies and close collaboration with substance misuse treatment facilities to provide opportunities to reduce survivor distress and expand service access for survivors and their families, especially given the wide range of DVTH service models. In Canadian shelter programs, Hovey et al. (2020) found that many program use harm reduction or other non-abstinence based approaches, which could provide examples for broader DV housing services. These programs operate in a policy context with requirements for providing services for survivors using substances, which many states do not have, and tend to include shared housing and shorter time limits. Adaptation of these approaches to longer term, individual housing based DVTH model requires close attention. Furthermore, consideration could be given to the appropriate placement (in site-based housing, for example, or in community units that meet their needs) for those in active recovery compared with those choosing to use harm reduction strategies to manage substance use and misuse. Gilroy and colleagues (2016) argue that we must develop new models of DV housing to meet the complex set of challenges facing families fleeing domestic violence. Addressing substance use in a more comprehensive, compassionate, and effective way could be an important aspect of such a new model. Drawing from studies of examining substance use approaches in DV shelter could provide a framework for DVTH practitioners to adapt to their unique contexts.

Furthermore, these interviews highlight the ways in which small community-based service organizations, which comprise the crucial backbone of IPV services in the United States, are reliant on other community-based organizations for providing important aspects of survivor care. Similar to other findings drawing on the roles that DV agencies play in their community contexts (Harris & Hodges, 2019), this study findings that this reliance on community-based solutions can limit agencies in their ability to address physical and mental health challenges, as waiting lists, funding limits, and session limits all impact accessible treatment. Programs can benefit from assuming that DVTH families come with complex physical and mental health challenges and having both community based referrals and internal program knowledge to draw from in terms of addressing such challenges. However, issues related to capacity and access to mental and physical health supports are rampant across service sectors, particularly for individuals facing economic insecurity and those with personal or cultural histories of challenging interactions with service systems. Wholesale expansion of quality mental and physical health care, particularly for economically vulnerable individuals, would significantly benefit survivors in DVTH.

Similar to the findings of Wood et al. (2022). An important implication of these data is that advocates observe somewhat predictable variation in survivor and family health and mental health, which could be planned for and expected in service provision. Particularly, survivors may experience an initial respite as they access housing stability and privacy for the first time, followed by periods of trauma symptomology. This may include increased mental health challenges and somatic symptoms, as they begin to stabilize and have the new opportunity to reflect on and acknowledge the trauma they have experienced. Rather than expecting a linear path to healing for survivors, DVTH provides enough space and time that survivors can do deeper trauma work, but this may lead to periods of renewed vulnerability or symptomology. Advocates can anticipate, provide psychoeducation, and normalize these experiences for survivors in ways that recognize the depth of trauma they have experienced and recognize that they are doing difficult trauma work which can include times of increased distress. Having access to emergency mental health supports, along with normalizing that healing from trauma is not a linear path of symptom reduction may be important advocacy points for DVTH programs. Supporting advocates as they witness such ebbs and flows in healing is also a critical component of effective supervision and organizational resilience for longer-term advocacy work.

Participants also recognized that the end of DVTH can be an especially risk-filled time for survivors as they face increased economic pressure, reduced social support, and potentially accompanying increases in mental health symptomology. They spoke specifically of this being a time of unique risk, and also opportunity for survivor-advocate alignment. Because there is clear evidence that social supports can help buff negative mental and physical health outcomes for survivors of violence (Schultz et al., 2021), DVTH program can particularly work to increase social supports for survivors at crucial points in the DVTH journeys- particularly mental health and child focused supports as they first enter transitional housing and economic and social supports again as they approach the end of DVTH programming. Ogbe et al (2020) found in a systematic review that there is strong support for focus on community networks and community support as a model for enhanced mental health outcomes for survivors. These approaches may be particularly appropriate for longer-term service models like DVTH.

Limitations and Future Research

Like all research, our study has limitations. First, this study is a cross-sectional, qualitative analysis of DVTH service providers. To fully understand the impact of DVTH on survivors’ mental and physical health as well as safety, future research should involve both qualitative and quantitative, longitudinal studies with survivors themselves, tracking the effects of DVTH over time. Such research could specifically examine some of the conditions frequently mentioned by participants in this study including, substance use, PTSD, anxiety, depression, and physical health concerns. In addition, the participants were from only six states in the United States, meaning not all states or regions are represented, nor housing approaches used outside of the United States. While efforts were made to recruit participants from diverse states, and from different regions in the United States including the South, Great Lakes, and Midwest among others, state level differences and emerging funding realities shape each programs’ contexts to a great degree. However, the participating advocates do represent a mix of urban and rural agencies, providing greater applicability. Future studies should aim for a more diverse representation of states, including U.S. territories, to better understand how the needs of IPV survivors within DVTH may vary by location.

Conclusion

DVTH Programs, and the advocates that work in them, play a crucial role in supporting survivor and family stability and safety in the wake of violence. Advocates focus on survivor identified goals related to health and mental health, providing support and linkage in line with the desires of survivors and their family members. Expanded service availability, as well as opportunities for targeted supports could further this impactful service model and support advocates in their important work.