Abstract
Traumatic experiences are highly prevalent among people experiencing homelessness who face structural inequities, which may impact engagement in research. Research staff (“staff”) working with people experiencing homelessness are under-equipped to cope with structural inequities and the trauma present in participants’ lives, even if they are well-trained in the regulatory aspects of the research process. Six staff involved in tobacco cessation intervention research with people experiencing homelessness described their experiences and highlighted areas of training to integrate trauma-informed and resilience-building approaches to support field staff and people experiencing homelessness. We identified three themes: (a) impact of trauma on the research process; (b) the importance of engagement with community partners and participants; and (b) the need for a field worker’s guide. Staff described being the bearers of participants’ traumas, while also coping with their own vicarious traumatization. Staff believed they would benefit from a fieldworker’s guide that includes best practices for engagement with community partners as well as trauma-informed approaches like training in trauma-informed care and tools to address vicarious traumatization. Resilience-building approaches include real-time debriefing to celebrate successes and troubleshoot problems in the field. Training in resilience-building can be integrated as part of the general training required of all research staff prior to conducting intervention research studies with people experiencing homelessness. These approaches may need institutional support to be integrated into standard research workflows. In doing so, they may not only safeguard research staff and participants but also promote research as a means to dismantle inequities by being inclusive, safe, and empowering.
Background
Community-engaged research is founded on the principles of inclusion, with community partners and members contributing their knowledge and lived experiences to co-create interventions that benefit their community. Community-engaged intervention research is critical to eliminate health disparities for people experiencing homelessness who face structural inequities and intergenerational trauma that influence their engagement in the research process (Miller et al., 2023; Rubin et al., 2021).
Research staff (“staff”) receive training in the regulatory aspects of conducting community-engaged intervention research but receive no training or support to cope with structural inequities or the trauma present in participants’ lives. This gap leaves staff under-equipped to address real-life challenges of fieldwork and highlights a need for trauma-informed and resilience-building approaches to support staff and people experiencing homelessness (Edelman, 2023).
The trauma-informed approach includes realizing the presence of and widespread impact of trauma, recognizing signs and symptoms of trauma, responding in practice and policy, and preventing re-traumatization (Center for Substance Abuse Treatment [CSAT], 2014). Resilience-building is inherently tied to being trauma-informed (Edelman, 2023). However, resilience is often framed as an individual trait or characteristic, without consideration of structural inequities that contribute to adversity. Resilience-building for social justice was “developed to address these concerns with the intention to encompass the potential for marginalized people to challenge and transform aspects of their adversity, without holding them responsible for the barriers they face” (Hart et al., 2016). The resilience-building for social justice approach gives people the chance to not only overcome adversity but also transform systems that promote adversity (Hart et al., 2016). In this study, we describe staff’s field experiences with people experiencing homelessness and highlight areas of training to integrate and operationalize trauma-informed and resilience-building approaches into research practices.
Method
Six staff who were involved in tobacco cessation intervention research reported their experiences working with study participants experiencing homelessness (“participants”). These interventions took place in homeless shelters, permanent supportive housing for formerly homeless adults, and in safety net clinics serving people experiencing homelessness. Staff met for three 2-hr sessions to write about their experiences in the field including case scenarios, personal perspectives, and best practices around engagement with community partners and participants, and then coded each other’s written reports. Through a process of consensus coding and thematic analysis of the written reports, staff identified themes relevant to their experiences and trauma-informed and resilience-building tools they would benefit from while conducting community-engaged intervention research (Boyatzis, 1998). The tobacco cessation intervention research studies are approved by the University of California, San Francisco Institutional Review Board (IRB # 20-33214, 20-33166, and 20-9865). The work that involved staff perspectives to develop trauma-informed and resilience-building approaches was considered exempt by the IRB.
Results
Impact of Trauma on the Research Experience
Bearer of Participants’ Traumas
Staff witnessed firsthand and heard about participants’ traumatic experiences. Many were survivors of physical and emotional abuse. Participants described experiences of racism and discrimination around obtaining housing or employment, daily struggles with structures that contradicted their basic needs and hindered opportunities as well as challenging interactions with housing and/or shelter personnel. Staff were bystanders to these interactions and occasionally in positions of having to intervene with participants. In these scenarios, staff were not only bearers of participants’ traumas, needing to learn how to respond in real-time, but also, at times, coping with the intersection of their own lived experiences of trauma or housing insecurity with the research process. One staff reported, “At times I get very emotional when listening to [participants’] stories because it reminds me of my childhood navigating the streets and the feelings of hopelessness, and it makes me even sadder knowing that these systems are still in place.”
Death and Disability Among Participants
Because we conducted our studies during the COVID-19 pandemic and opioid epidemic, staff were often faced with participants’ untimely deaths from these causes. Suicidal attempts were also common among members of unhoused communities. Participants’ premature deaths often left a void among the remaining members of their community. One staff reported meeting a participant who was “eager to refer friends from the building to our study. I learned that he passed away suddenly, and the building [that he lived in] felt the crush of his loss.” Staff reported exhaustion and a sense of despondency from grief. One staff felt that the “constant reminder of death was debilitating despite efforts for growth and change.”
Study Procedures can be Triggering
While we aimed to conduct our research in community settings that were private, privacy was not a guarantee and contributed to participants’ reticence to engage in all study procedures. Some participants found the study’s questions on mental health and substance use behaviors to be triggering. Staff described that “people’s traumas can be triggered by anything,” including the type of questions, the context of the conversation, and the location of data collection. Triggering questions not only frustrated participants and impacted their engagement and retention in the study but also compromised staff safety and burnout.
Importance of Engagement With Community Partners and Participants
Nontransactional Engagement With Partners
Staff emphasized the need to “build relationships in a way where we are not coming in to do the work, but we are actually working with [partners] to do the work,” and that “relational,” not “transactional” engagement was one of the hallmarks of strong partner engagement. Long-standing relationships with community partners developed over the years through an alignment of goals facilitated study procedures. There were instances when staff had to modify research protocols to meet the needs of participants and community partners such as offering participants flexibility in attending study visits or meeting in locations that were convenient to them or offering partners flexibility in the timeline for launching study procedures.
Staff described different levels of partner engagement. The executive leadership and senior administrative staff in an organization were essential to obtaining buy-in for the overall study and were involved in securing funding along with the study investigators. Ground-level, front-line staff in shelters, housing sites, or clinics were critical to recruitment and retention efforts. Staff reported that “partnerships cultivated by simply having a positive presence and rapport with program staff [at a site] can increase the efficacy of a study and interest to potential participants.” However, turnover among front-line staff posed challenges to developing long-term allies in the field.
Soliciting Feedback From Community Partners and Participants
Staff solicited feedback from participants and front-line staff in multiple ways. Quarterly community advisory boards with front-line staff were a useful mechanism to relay information about the study and obtain feedback on study procedures. However, in the absence of incentive structures that supported front-line staff to attend those meetings, their engagement in community advisory boards was variable. At the participant level, we used incentivized, informal group discussions to engage with participants on study procedures and obtain feedback while the study was ongoing. These discussions encouraged participants’ views on study procedures that they may not have felt comfortable sharing in a questionnaire or interview.
Need for Fieldworker’s Guide
As field researchers, “staff are not trained to address medical or social needs, be the bearer or receiver of difficult news, but that is what they end up needing to be.” Staff discussed the need for education and training and a fieldworker’s guide that addressed safety and trauma in the field. To support staff and participants, trauma-informed and resilience-building for social justice-informed approaches can provide a framework to understand the intersection of structural inequities and research participation and provide tools to cope in real-time with the many manifestations of trauma as it intersects with research practices (Table 1) (Isobel, 2021; Miller et al., 2023).
Field Worker’s Guide—Trauma-Informed and Resilience for Social Justice Approaches to Support Staff Conducting Field Work With People Experiencing Homelessness
Trauma-Informed Approaches
Trauma, despite its high prevalence, is often hidden in society. Most participants in our studies had a lifetime traumatic experience (Kushel et al., 2023). Trauma-informed approaches recognize the importance of attending to trauma experiences in research participation and engagement. To operationalize trauma-informed approaches, staff need training in delivering and integrating trauma-informed care and research practices into research workflows (CSAT, 2014).
Training in trauma-informed care
Given the connection between trauma and tobacco use, staff acknowledged that interventions must be trauma-informed and they would benefit from training in trauma-informed care. Staff participated in a day-long training in trauma, addiction, mental health, and recovery, designed for mental health and substance use providers (National Association of State Mental Health Program Directors [NASMHPD], 2023). This training provided information on how trauma manifests including recognizing verbal and nonverbal cues (e.g., minimal eye contact or fidgeting), ways to discuss trauma, and tools to cope with trauma in real-time. Staff participated in role-playing activities, and learned about relaxation techniques to implement in real-time with participants (e.g., drawing, or the use of fidgets, breathing techniques), ways to discuss trauma without re-triggering and re-traumatizing participants, and ways to avoid potentially sensitive topics. Such training should be routinely offered to research staff before starting community-engaged intervention field research.
Designing trauma-informed study procedures
When designing research questionnaires and interview protocols, the way questions are presented and asked is important (Isobel, 2021). Communicating the possibility that questions may be distressing, and normalizing emotions can validate trauma survivors’ experiences. A trauma-informed approach to data collection acknowledges the lived experiences of trauma, recognizes the manifestations of trauma, and provides tools in real-time to help cope with distress (Edelman, 2023). When staff are trained in trauma-informed approaches, they can validate emotions of distress or anger and offer space, agency, and choice to continue, which may mitigate the frequent invalidation that people with traumatic experiences face. However, when staff are not equipped to offer this support and research questions are triggering or traumatizing, then procedures may become unethical and potentially harmful.
Best practices for data collection include conducting study procedures in a space of familiarity and relative privacy, providing breaks in between, and offering the option to skip questions or topics. Staff need to be comfortable with the range of emotions expressed by participants and be ready to re-direct and/or help participants regulate their emotions, stay grounded and present on the task at hand, and provide examples of ways to provide agency or power back to the participant to mitigate re-traumatization (Isobel, 2021). Throughout this process, staff may have shared emotions with participants. While shared emotions may strengthen a connection with a participant, they should not dominate the interaction with participants (Isobel, 2021). In these scenarios, empathy and/or compassion and validation or boundary setting may be more appropriate.
An implementation manual of standard operating procedures that provides guidance for common situations in the field can be helpful. The manual would provide tools to help staff develop awareness of their own positionality and intersectionality and how that might impact participants’ engagement with research (Isobel, 2021). It may include tools to ensure that participation is not coercive, oppressive, or further strengthening structures of power and position. The document may include tools to cope with participants’ reactions, prompts to acknowledge participants’ trauma, and considerations for safety in the field. These may include visual prompts for participants and staff such as mindfulness practices (deep breathing and centering), or material prompts such as paper and pencils or fidgets which may alleviate triggers. A best research practice might be to develop and consistently update the manual or standard operating procedures as a “living document” and shared activity among staff to build community and to develop tools that are specific to the population and current times.
Addressing vicarious trauma
Staff experience vicarious trauma and need structures to debrief and share their own experiences to mitigate the trauma’s effects. Research protocols that can help reduce vicarious trauma include allotting structured time for data collection during the day, pairing up staff to recruit and enroll, distributing data collection tasks among the team, and integrating breaks to process events of the day. The pressures of data collection and the need to meet recruitment targets must be balanced with staff’s own personal safety and ability to cope with vicarious traumatization.
Resilience-Building for Social Justice Approaches
To build resilience in staff conducting research with people experiencing homelessness, we highlight the (a) importance of debriefing and (b) the need for structured resilience-building training.
Debriefing
Debriefing is integrated in hospital-based care, particularly after traumatic or critical events, and can play a similar role in social justice-informed research methods (Arriaga et al., 2020). Debriefing integrates an organizational approach that capitalizes on the inherent resilience present in teams while providing space to share errors, troubleshoot problems, and celebrate successes. Celebrating successes is critical to building resilience among the research team. Fostering a communication structure such as real-time chat groups and/or time to talk after events take place in the field is critical for staff to feel heard, appreciated, and supported. Providing time during weekly meetings to discuss challenging scenarios or situations and to troubleshoot them together can be integrated as best practice for resilience-building.
Resilience-building training
Resilience-building training should begin during onboarding. Resilience is an interaction between the individual and the environment and includes personal (e.g., optimism) and environmental resources (e.g., social support). Some aspects of resilience can be modified and improved by interventions. Interventions for resilience-building may be brief or intensive interventions and in group or individual-based formats; however, there is no consensus on the duration of the training and effect sizes of resilience interventions (Kunzler et al., 2020). Approaches may include cognitive behavioral therapy through modifying cognitive processes to prevent maladaptive patterns. One form of cognitive behavioral therapy is problem-solving therapy which may provide tools for resourceful problem-solving in the field, which may then improve psychological adaptations to stress by increasing active coping and resilience. Mindfulness therapy, which is a focus on the present moment and its accompanying emotional and physical states (e.g., thoughts, emotions, physical feelings) can also be helpful as staff learn cognitive flexibility to accept and adapt to negative situations and emotions that might arise in the field (Kunzler et al., 2020). These approaches may be integrated as a one-time session during onboarding and/or at regular intervals to provide space for staff to discuss specific situations that arise in the field.
Implications for Practice
It is critical to integrate trauma-informed and resilience-building approaches into community-engaged research practices. Institutional compliance for research needs to go beyond human subjects training and integrate trauma-informed and resilience-building training for field staff engaging in community-engaged research. Such training will enhance staff well-being while improving research practices. In doing so, trauma- and resilience-informed research practices will support evidence generation that is inclusive, safe, and informed by staff and participants representing our impacted communities.
