The Effects of Implementation of Art Therapy within the Homeless Population McKinsey Medlin Honors College, University of North Carolina Wilmington Abstract This proposal intends to build a partnership with the Good Shepherd Center in Wilmington, North Carolina, to create an 8-week intensive Visual Thinking Strategies (VTS) art therapy program. This program will address the mental health needs of those experiencing homelessness and provide a healing environment for all levels of trauma. A literature review has been conducted to view the effectiveness of similar programs and the need for these resources in the New Hanover County region. These findings indicated that the Good Shepherd center has considerable potential to be the leading facility to implement this program within the New Hanover County region. Keywords: VTS, therapy, homelessness, trauma Introduction There is a population that is very prevalent in the United States of America and is often very overlooked. This population of individuals gets driven past without a second thought in whatever conditions the climate decides to bring that day. The unhoused population is rapidly growing due to the housing crisis, rising unemployment rate, rising medical costs leading to debt, and numerous other interdisciplinary factors. Although there are shelters to relieve some of the struggles of homelessness, that does not remedy the mental damage that an unhoused individual faces. Due to circumstances, homeless people are more at risk for mental illness, substance misuse, and trauma. Unfortunately, resources that can help are not available without insurance, money, transportation, and/or technology to access telehealth services. This creates a ripple effect and a continuous cycle of mental damage to a person. Although some shelters offer in-facility mental health services, residents deserve an opportunity to express themselves in untraditional ways. Using art as a healing practice has been used in all cultures for years and has greatly evolved. Art therapy is used in practice to improve cognitive skills, self-esteem, resilience, and social skills and reduce negative attitudes and emotional conflicts. Furthermore, the Visual Thinking Strategies (VTS) process can be implemented with similar benefits to art therapy. Once a facilitator can guide participants, a VTS program can be carried out in various settings. Regarding unhoused population(s), this would allow VTS sessions to be held in shelters where residents could participate in discussions surrounding art. Literature Review THE EFFECTS OF IMPLEMENTATION OF ART THERAPY WITHIN THE HOMELESS POPULATION 2 A National View of the Homelessness Crisis According to the State of Homelessness: 2021 Edition, in January 2020, over 580,000 individuals were dealing with homelessness in America. Of that population, 70% comprised individuals, with the remaining 30% accounting for families or those with children dependents. Diving even further into the population, special attention is given to certain subgroups such as unaccompanied youth (under 25 years old), chronically homeless, and veterans. Due to this investigation shows that men are more likely to experience homelessness as out of 10,000 men, 22 are homeless, and that number is only 13 for women (“State of Homelessness,” 2021). Additionally, the unsheltered homeless carry some staggering statistics in America’s temporary shelters. Systems and programs to provide shelter cover 61% of those experiencing homelessness. However, children almost always have priority in those situations leaving only 10% of families with children without shelter. This leaves a large gap within age groups supported by these programs. The unaccompanied homeless youth lack essential shelters, as 50% of that population remains unsheltered. However, individuals (not with a family) are arguably at the most risk as 51% live in places not intended for human habitation (sidewalks, subway cars, parks, downtown, etc.). Integrated View of the New Hanover County/ Wilmington Homeless Population Homelessness is defined as anyone residing in a setting that is not meant for human residency, an emergency shelter, or transitional housing between these places (“Changes in Definition of ‘Homeless,’” 2012). The Ten-year Plan to End Chronic Homelessness and Reduce Homelessness in the Cape Fear Region (2008) discusses the root causes of homelessness in New Hanover County and surrounding areas and lays out the staggering statistics of attempts to assess the needs. For many, the reason for current or chronic homeless stems from at least one of the following: “unemployment, underemployment, lack of affordable housing, substance abuse/addictions, mental illness, physical disabilities, veterans’ post-traumatic stress disorder, lack of access to affordable health care and family break-up” (“Plan to End Homelessness in the Cape Fear Region,” 2008, p. 5). Under these conditions, the majority fall under the category of suffering from mental illness. This might not be the cause of their homelessness but is a result of their current situation. Of those who have reported, 22% of the homeless population in New Hanover County is a victim of serious mental illness, with over half not receiving treatment. Additionally, a significant number of individuals that are discharged from mental health institutions, prison systems, and hospitals end up homeless within the urban regions of New Hanover County (“Plan to End Homelessness in the Cape Fear Region,” 2008). Furthermore, an in-depth review of the interaction between affordable housing and homelessness is identified in Bowen’s National Research, Housing Needs Assessment (2021). Since 2000, the population size of New Hanover County has increased by 78,375, which is 15.6% more than the North Carolina increase. This positive trend has been predicted to continue from 2020-2025 in Wilmington, with a 7% increase within those five years. A section of this population does come from students at the two local colleges in the area: Cape Fear Community and the University of North Carolina Wilmington. Due to having educational institutions in the area, the percentage of those with a high school diploma and/or bachelor’s degree is significantly higher than the overall state of North Carolina. However, this county’s educated workforce can often outshine the 6,460 adults without a high school diploma. Those lacking a diploma find it more challenging to find steady employment and livable wages, resulting in struggles for secure housing. THE EFFECTS OF IMPLEMENTATION OF ART THERAPY WITHIN THE HOMELESS POPULATION 3 The rapidly growing New Hanover County population creates barriers to employment, housing needs, and accessibility to organizations that provide financial assistance. Visual Thinking Strategies About Visual Thinking Strategies provides insight into the goals and benefits of VTS work which was co-developed by Abigail Housen and Philip Yenawine. VTS acts as a guide to jumpstart participants into deep thinking, especially about topics they might not usually create time to explore. This can be implemented within almost all subjects, but art is utilized specifically to facilitate discussion. Participants can improve their written and visual literacy, collaborative interactions, and cognitive skills to increase confidence in their abilities (University of College Cork, n.d). While VTS has tremendous qualities within a personal setting, a group experience can provide its learning environment. This problem-solving process allows participants to pursue a willingness to share their thoughts without fear. This creates a non-judgmental environment that can allow people to question openly, listen to multiple viewpoints, question narratives, and think deeply. The facilitator of this discussion is tasked with keeping this space positive by utilizing optimistic approaches and ensuring everyone feels welcome. This ensures that each participant’s perspective is heard to appreciate how it affects others. VTS produces growth in all forms and proves benefits in even vulnerable populations (University of College Cork, n.d). Art Therapy Within Vulnerable Populations Frank Marangos (2020) discusses the multi-complexity of homelessness and the intricate healing properties of artwork. Images, paintings, sculptures, etc., hold power within their form. These works can give insight into the sheer emotion of hope or despair within their forms. Just as art holds this power that is up to individual interpretation, many see homelessness the same way. To the ignorant, homelessness is viewed as a personal choice to not work hard enough or a position granted to those who have experienced poor life circumstances. To others, it is a multi-dimensional problem that requires dedication, an open mind, and a highly complex support system (Marangos, 2020). As the American Art Therapy Association defines it, art therapy is “a human service profession in which clients, facilitated by the art therapist, use art media, the creative process, and the resulting artwork to explore their feelings, reconcile emotional conflicts, foster self-awareness, manage behavior, develop social skills, improve reality orientation, reduce anxiety, and increase self-esteem” (“About Art Therapy,” 2022). This kind of work can foster healing environments and be an effective treatment for those with developmental, cognitive, medical, social, and/or psychological disability. Furthermore, art therapy allows individuals to dig deep into the hands-on, creative art process to create tools such as problem-solving, impulse control, focus, positive self-image, and a sense of calmness. These skills are necessary to guide individuals through the transition out of homelessness to interviews and eventually permanent housing. Within this process, participants can choose whichever medium speaks to them the most and work through their emotional past and trauma while in a safe space. These creative practices are a humanizing method that can facilitate group discussions and uncover undeniable growth (“Benefits of Art Therapy,” 2020). Marian Faa (2019) puts perspective on the link between homelessness and trauma by sharing an individual’s story and connecting a growing crisis with art. Ursula Tate, now 21, was only 15 years old when she escaped an abusive relationship. However, she had no idea the further trauma she would endure from the stress of never knowing where she would sleep at night and her constant exposure to issues such as substance misuse. Her story, among others, helps researchers THE EFFECTS OF IMPLEMENTATION OF ART THERAPY WITHIN THE HOMELESS POPULATION 4 link homelessness with trauma. A 2014 study showed that 97% percent of individuals who were homeless at some point had been subjected to multiple traumatic events. This important study shows that mental health worsens after an individual loses stable housing (Cash et al., 2014). Melissa Andrews, an art therapist, took an interest in these findings and created an 8-week art therapy program to encourage healthy neural pathways to begin again. This art had a common theme of growth, love, happiness, and dreams. Participants showed significant progress with communication and self-expression. This calls for action in implementing programs like this one to become a norm. Applied Design To implement this design, there needs to be a strong community relationship between the Good Shepherd Center, local artists, and the Cameron Art Museum. The Good Shepherd center is the leading and largest homeless shelter in the New Hanover County region, with over 118 overnight beds. Within a yearly period, they provide 160,000 meals to residents and others in the community with food insecurity (“Sheltering the Homeless,” n.d). Its mission statement is “to feed the hungry, shelter the homeless, and foster transition to housing” (“Our Mission, n.d, p. 1). This shelter has integrated mental health and substance misuse services that all residents can utilize. With on-staff physiologists and mental service professionals, this would be an ideal facility to house a VTS program. Within the Good Shepherd Center, there are multiple resources offered to the community. In addition to mental health resources, there is also a well-established walk-up medical clinic, day shelter, night shelter, and the SECU lakeside reserve. The night shelter opened in October 2005 and can house individuals and families through a check-in process. Volunteers can provide educational opportunities, social support, and plans for creating long-term housing in this setting. The SECU lakeside reserve was created with Lakeside Partners of Wilmington Inc. The reserve is a 40 one-bedroom unit, permanent supportive housing featuring affordable rent, transportation, counseling, and life-skills training (SECU Lakeside Reserve, n.d). Finally, the day shelter is characterized as a haven for all. It provides basic needs such as bathrooms, showers, phone/ mail service, case management, mental health referrals, etc. This drop-in center allows even the most fragile to have the comfort of support from staff (“Sheltering the Homeless,” n.d). This is where trust can grow between the homeless and community members; therefore, steps toward stability can be taken. The day shelter would be ideal for hosting the proposed VTS program. This setting would allow most participants to join and open the opportunity to those who cannot obtain overnight stays at the time. This approach could impact a larger community and even encourage more people to utilize the day shelter. Bringing in more needy individuals also allows them to receive medical and mental health care. Additionally, this setting provides total freedom for participants; therefore, no one feels pressured into the engagement. The eight-week VTS proposed program would utilize classic VTS sessions, expressive art creation, and follow-up conversations about emotions that have arisen. Providing art supplies would be a weekly task to ensure that residents can create art that is meaningful to them. The program would be a personal experience, and sharing would never be necessary for privacy reasons. The VTS sessions would surround different images every time, with many donated by local artists. An art piece brought into the facility can create a much different environment than art shown on a computer screen. Residents can feel important and worthy if given the environment to show them they are. Part of that environment is ensuring that they receive the best opportunities THE EFFECTS OF IMPLEMENTATION OF ART THERAPY WITHIN THE HOMELESS POPULATION 5 to explore art in a healing and healthy way. This importance is why allowing participants to explore a museum setting is critical in developing skills through art. The final two VTS sessions of the program would utilize transportation from volunteers and potentially adequate funding to rent 15- passenger vans. The sessions at the museum would be a refreshing environment change after the participants have had time to build relationships with volunteers, their peers, and ultimately themselves. It is important to note that environmental changes are only beneficial when people have had time to process their work throughout the program and have built enough self-confidence to feel worthy of the new environment. The hope is that allowing participants to tour the museum without other community guests would be the last building block to prove the importance of their role in the community. Presenting individuals, who are often looked over and judged, an opportunity to experience beauty in a private space is an important step in their recovery. Each session would be different, and the program would get more intense as the weeks progressed. This may create difficult feelings to arise, as residents heal through different levels of trauma that have been endured. The hard emotions are not glamorous, but they are necessary for a successful program with the intent to provide stability and emotional success to residents. Figures 1-4 reflects the progression of potential images used for VTS sessions. The topics of family, growth, childhood, and nature are likely to arise in these conversations. The connection between trauma exposure and homelessness is reflected in Figure 5. The interdisciplinary nature is evident, as trauma exposure can lead to mental health issues, social disparities, and homelessness. However, this pathway can also be reversed as homelessness, as noted before, leads to further levels of trauma, especially in substance abuse exposure. Furthermore, there is no argument that social disparity and homelessness go hand-in-hand. The graphic displays how individuals experiencing homelessness are in desperate and in chronic need of support through shelter resources and mental health services. The steps to recovery from the cycle of trauma and homelessness are mapped out in Figure 6, with the inner circles showing the first milestones in the process. Within the work of VTS and the program proposed, the work would take place within the first two tiers. To begin moving forward with recovery, individuals must first feel safe, which is where the haven of the day shelter helps to fit into the picture. Furthermore, the process of VTS sessions provides participants with a connectedness to art, society, and other aspects displayed in each unique work. The ability to discern emotions based on viewing patterns and dig deep into an image brings on skills of self- efficiency. This instills confidence in individuals to think for themselves and feel self-assured in their capacity to relay their thoughts to others. Diving into the second tier of recovery, there is a need for necessary steps towards healthy social connections through developing problem-solving skills, reaction management, and logical thinking tactics. Being in a group setting, while discussing artwork and creating self-expression pieces is the perfect environment for growth in these areas. Discussions are open but still loosely guided, and participants are encouraged to collaborate on many occasions. Finally, VTS is a proven method to improve problem-solving, reasoning, critical thinking, and visualization skills. The building blocks and social support from others will allow participants to eventually transition into more structured treatments, which the Good Shepherd Center offers. The third tier is out of the control of the proposed program, but hopefully, it will foster a smooth transition. Although the hope is for an easy recovery, that is often not the reality. Figure 7 highlights that recovery is not linear, but the newly learned coping abilities will be an asset on the journey. The homeless population, especially in the New Hanover County region, desperately needs integrated mental health services, including seemingly untraditional methods. Visual thinking THE EFFECTS OF IMPLEMENTATION OF ART THERAPY WITHIN THE HOMELESS POPULATION 6 strategies (VTS) use collaboration, free thinking, and the healing powers of art to build coping skills within participants. A program designed specifically for those pre-determined by society to experience some level of trauma would implement VTS, expressive art creation, and partnership. The importance of this work is shown through model programs and relevant research into the link between trauma and homelessness. While this population may require a delicate touch, there is a significant impact in the art of effort. THE EFFECTS OF IMPLEMENTATION OF ART THERAPY WITHIN THE HOMELESS POPULATION 7 References About Art Therapy. (2022). Retrieved from https://arttherapy.org/about-art-therapy/ Bowen National Research. (2021). Housing Needs Assessment. Retrieved from https://planning.nhcgov.com/wp-content/uploads/2021/04/Bowen-Housing-Needs-Assmt- FINAL.pdf Cash, R., O’Donnell, M., Varker, T., Armstrong, R., Di Censo, L., Zanatta, P., Murnane, A., Brophy, L., & Phelps, A. (2014). The Trauma and Homelessness Service Framework. Report prepared by the Australian Centre for Posttraumatic Mental Health in collaboration with Sacred Heart Mission, Mind Australia, Inner South Community Health and VincentCare Victoria. Changes in the HUD Definition of "Homeless". (2012, January 18). Retrieved from https://endhomelessness.org/resource/changes-in-the-hud-definition-of-homeless/ Creativity and recovery: The Mental Health Benefits of Art therapy. (2020, July 29). Retrieved from https://www.rtor.org/2018/07/10/benefits-of-art-therapy/ Faa, M. (2019, August 09). Using Art to Tap into Trauma. Retrieved from https://www.abc.net.au/news/2019-08-09/art-therapy-helps-healing-from-homeless- trauma/11391270 SECU Lakeside Reserve. (n.d.). Retrieved from https://www.goodshepherdwilmington.org/project/lakeside-reserve/ Marangos, F. (2020, January 22). Arts therapy for the homeless. Retrieved from https://homeboca.org/arts-therapy-for-the-homeless/ Our Mission. (n.d.). Retrieved from https://www.goodshepherdwilmington.org/inside-gsc/our- mission/ Sheltering the Homeless. (n.d.). Retrieved from https://www.goodshepherdwilmington.org/project/sheltering-the-homeless/ State of Homelessness: 2021 edition. (2021, August 16). Retrieved from https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of- homelessness-2021/ Ten Year Plan to End Chronic Homelessness and Reduce Homelessness in the Cape Fear Region. (2008). Retrieved from https://b.3cdn.net/naeh/e381c1839d25b07037_8lm6rktdu.pdf THE EFFECTS OF IMPLEMENTATION OF ART THERAPY WITHIN THE HOMELESS POPULATION 8 University of College Cork. (n.d.). About Visual Thinking Strategies. Retrieved from https://www.ucc.ie/en/vts/about/ THE EFFECTS OF IMPLEMENTATION OF ART THERAPY WITHIN THE HOMELESS POPULATION 9 Figures Figure 1 Image Example used in proposed VTS session Note. Levitan, I. (1889). Golden Autumn, Village [Canvas Oil Painting]. Wiki Art. https://www.wikiart.org/en/isaac-levitan/golden-autumn-village-1889 THE EFFECTS OF IMPLEMENTATION OF ART THERAPY WITHIN THE HOMELESS POPULATION 10 Figure 2 Image Example used in proposed VTS session Note. Kahlo, F. (1938). Girl with Death Mask [Metal Oil Painting]. Wiki Art. https://www.wikiart.org/en/frida-kahlo/girl-with-death-mask-she-plays-alone-1938 https://www.wikiart.org/en/frida-kahlo/girl-with-death-mask-she-plays-alone-1938 THE EFFECTS OF IMPLEMENTATION OF ART THERAPY WITHIN THE HOMELESS POPULATION 11 Figure 3 Image Example used in proposed VTS session Note. Portinari, C. (1944). Os Retirantes [Painting]. Wiki Art. https://www.wikiart.org/en/candido-portinari/os-retirantes-1944 https://www.wikiart.org/en/candido-portinari/os-retirantes-1944 THE EFFECTS OF IMPLEMENTATION OF ART THERAPY WITHIN THE HOMELESS POPULATION 12 Figure 4 Example Image used in proposed VTS session Note. Kahlo, F. (1931). Portrait of Luther Burbank [Masonite oil Painting]. Wiki Art. https://www.wikiart.org/en/frida-kahlo/portrait-of-luther-burbank-1931 THE EFFECTS OF IMPLEMENTATION OF ART THERAPY WITHIN THE HOMELESS POPULATION 13 Figure 5 Aid in examining the intersectionality of trauma exposure, homelessness, and mental health struggles Figure 6 Model of recovery for long-term unhoused individuals THE EFFECTS OF IMPLEMENTATION OF ART THERAPY WITHIN THE HOMELESS POPULATION 14 Figure 7 Recovery Progression stages with the integration of support agencies