The needs of vulnerable people: Complex Trauma and Repeat Homelessness CIH 11 th March, 2011 Dr Nick Maguire Clinical Psychologist University of Southampton Helen Keats Specialist Advisor Communities and Local Government

Overview Theory and Practice What is Complex Trauma? Complex Trauma in homelessness Research evidence Model Literature Review Treatment implications Interaction of person and environment Case study

Complex trauma and homelessness Many people in the homeless population have suffered abuse in childhood This leads to a pattern of behaviours, emotions and cognitive experience termed complex trauma

What is Complex Trauma? A number of terms used interchangeably Type II Trauma Disorders of Extreme Stress Not Otherwise Specified (DESNOS; DSM-IV (APA, 1999)) Complex Trauma Complex PTSD Often contrasted with Post-Traumatic Stress Disorder (PTSD) Cognitive and mood disruption Attention and sensitisation to threat, emotion dysregulation, nightmares, flashbacks, rumination

Complex Trauma Term describes observations of: Alterations in emotion and impulse regulation Dissociation Changes in self-perception Difficulties relating to others Somatisation Alterations in belief systems held by the individual

Causes PTSD – single event E.g. RTA, combat, violence Complex trauma – sustained exposure to traumatic experience Mainly in childhood Some examples of hostage situations, sustained exposure to combat If in childhood, disruption to fundamental processes Attachment processes Interpersonal issues in adulthood Emotion regulation (general)

Diagnosis Association with diagnosis of personality disorder Borderline Personality Disorder (BPD) Weak concepts in terms of validity and reliability Some argue that BPD should be recast as complex trauma But association only; not 100%

Complex Trauma in Homelessness Observe many CT issues (symptoms) Impulse control Negative self-perceptions Interpersonal problems Physical problems Emotion dysregulation Behaviours Drug and alcohol abuse Promiscuity Self-harm Violence Coping strategies?

Attachment (Mikulincer and Shaver, 2003) Avoidant Anxious

Evidence Research at UoS 55% - 59% hostel and street homeless populations reach diagnostic levels of PD Two studies 100% report some incidence of abuse and / or neglect Most common is physical abuse Around 60% report sexual abuse

Evidence Evidence of the roles of… Emotion dysregulation Victimisation (self) Shame Maladaptive coping styles (externalising) …mediating the relationship between childhood abuse and antisocial behaviours Leads to a model (formulation) of these historical, psychological and homelessness factors

Psychological, emotional and behavioural pathway to repeat homelessness Childhood abuse / neglect Emotion dysregulation Experiential avoidance Maladaptive coping style (externalising) Rumination Shame, guilt Drug and alcohol use Asocial and antisocial behaviour Lack of social and practical functioning skills Repeat tenancy breakdown Triggers : Release from prison Relationship breakdown Discharge from armed services Loss of tenancy Modelling Attachment problems

Psychological, emotional and behavioural pathway to repeat homelessness Childhood abuse / neglect Emotion dysregulation Experiential avoidance Maladaptive coping style (externalising) Rumination Shame, guilt Drug and alcohol use Asocial and antisocial behaviour Lack of social and practical functioning skills Repeat tenancy breakdown Triggers : Release from prison Relationship breakdown Discharge from armed services Loss of tenancy Modelling Attachment problems

Literature review: Complex Trauma and Homelessness Searched the academic literature, identified 155 papers dealing with trauma in the homeless population

Results: Links between complex trauma and homelessness Strong and consistent evidence supporting an association between homelessness and complex trauma But, complex relationship between traumatic experience, mental health issues, behavioural factors and homeless status Few empirical studies and very few longitudinal studies

Mental health and homelessness Mixed evidence of higher rates of anxiety, depression and PD than non-clinical populations; rates are comparable with psychiatric populations Mixed evidence in terms of health services use Higher rates of hospitalization Psychological illnesses tend to remain untreated

Interventions Evidence of effective interventions is very poor in terms of breadth, sophistication and definition of issues. Evidence from the trauma and PD literatures suggests that a number of psychological interventions are useful Residential settings for delivery of interventions are important No overwhelming evidence for one form of therapy or setting over another

Conclusions Complex trauma is demonstrated as a significant issue implicated in the causation and maintenance of repeat homelessness Childhood / adolescent experiences implicated The research programme needs definition and more sophisticated designs and methods The role for interventions is clear, but again the research programmes need to become more sophisticated

How is this manifest? Many antisocial and self-destructive behaviours, many apparently inexplicable Relationship difficulties Anger problems (emotion dysregulation) Difficulties dealing with authority E.g. Housing providers, benefits agencies etc. Behaviours lead to repeated eviction Criminal and antisocial behaviours, e.g. Drug use Abandonment

So what do we do? Psychological interventions needed to underpin tenancy support and practical interventions Address the issues underpinning behaviours leading to eviction or abandonment Interventions should address Emotion dysregulation and coping behaviours Drug and alcohol abuse Self-harm Attachment and interpersonal problems Cognitive activity Self-perception (beliefs about self) Rumination Flashbacks and nightmares Setting for delivery important

Psychologically Informed Environments (PIEs) Hostels and other residential settings may be psychologically informed Staff taught and supervised within a consistent psychological framework Increase resilience of staff, increase the possibilities of facilitating change for clients.

Evaluation of projects Empirical culture necessary to drive up quality of services Evidence-generating practice Three levels of evaluation Policy Service Individual

23 Good Practice Guide Non-statutory guidance on dealing with complex psychological and emotional needs National Mental Health Development Unit Department for Communities and Local Government

Good Practice Guide Seeks to draw together evidence of good practice in dealing with complex mental health issues Evaluated Demonstrable outcome Provides evidence for commissioners Provides an organic platform for quality service delivery

Setting up a PIE: How to Guide Defines a psychologically informed environment Details the activity and approach E.g. Reflective practice for staff, use of a psychological framework To some extent considers the physical environment Although behaviours of staff more important

Person and environment Given complex needs and difficulties described, what do we need to do in terms of environment to enable change in individuals?

The need to engage... Form of tenancy Investment in physical environment – ongoing Wears out quickly Eviction protocols Substance use and abuse protocols Staffing ratios, responsibilities and cover Support for staff, expectations

Case study 108 Derby Road Collaboration Health Homelessness charity Housing association Street homeless prevention team Small, four bed hostel Engage most excluded group of men

Summary Complex trauma to some extent accounts for some of the ways in which vulnerable people deal with the world These problems interfere with tenancy sustainment We can to some extent address these issues with psychological interventions The setting in which these interventions are provided is important

Complex Trauma and Rough Sleeping End