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Complex Needs and Homelessness Presentation
1. www.homeless.org.uk Let’s end homelessness together
Jo Prestidge
Innovation and Good Practice Project Manager
Homeless Link
Innovative approaches to
supporting homeless people
with complex needs
2. www.homeless.org.uk Let’s end homelessness together
• Complex needs and homelessness
provision
• Complex needs and complex
trauma
• Psychologically Informed
Environments
• Trauma Informed Care
• Housing First
In this workshop….
3. www.homeless.org.uk Let’s end homelessness together
Amicus Horizon
What we know…
• Rough sleeping has increased by 51% in last two years
• 47% of accommodation projects report reduced funding, number of bed
spaces declining
• 33% living in accommodation projects have complex needs, 32%
affected by mental health problems and 31% affected by drug problems
and 23% alcohol problems.
• 73% of accommodation projects turned people away because their
needs were too high or too high risk to staff and residents (67%)
• Risk to self, non-engagement, balance with other clients (reasons for
refusal)
4. Question…
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What is your experience of working
with people with multiple and complex
needs?
How do they present to your service?
5. Complex needs
Hard Edges (2015) – 85% of those in touch with
criminal justice, substance misuse and
homelessness services in the UK have
experienced trauma as children (not
representative of women).
‘Women with extensive experience of physical
and sexual violence are far more likely to
experience disadvantage in many other areas of
their lives, including disability and ill health,
substance dependence, poverty and debt, poor
living conditions, homelessness and
discrimination’. Hidden Hurt, Agenda (2016)
www.homeless.org.uk Let’s end homelessness together
6. Trauma and Homelessness
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• Goodman et al (1991) – psychological trauma and homelessness is linked.
Losing one’s home, living in the ‘shelter system’ or experiencing trauma
(particularly women) before homelessness. Homeless people display two of
the symptoms of PTSD; social disaffiliation and learned helplessness.
• Nick Maguire et al (literature review) – strong link between homelessness
and complex trauma. Makes the argument that psychological interventions
are needed.
• ‘People with a history of complex trauma, including the chronically homeless,
may behave in a range of ways that suggest underlying difficulties with
trusting relationships, and with managing their own emotions in the face of
perceived adversity’. (PIE good practice guide, CLG, 2012)
7. Trauma:
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1. Trauma is pervasive
2. The impact of trauma is very broad and touches many life
domains
3. The impact of trauma is often deep and life-shaping
4. Violent trauma is often self-perpetuating
5. Trauma is insidious and preys particularly on the more vulnerable
among us
6. Trauma affects the way people approach potentially helpful
relationships
7. Trauma has often occurred in the service context itself
8. Trauma affects staff members as well as consumers
Fallot and Harris 2009
8. Psychologically Informed Environments (PIE)
www.homeless.org.uk Let’s end homelessness together
• Recognition high levels of personality disorder
and complex trauma in homeless population
• Royal College of Psychiatry
• Enabling Environments and PIPEs
• DCLG guidance 2012
• Framework for use by homelessness services
• A service which considers the emotional and
psychological needs of their clients
9. PIE framework
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Managing
relationships
Environment
and spaces
Training
and support
Psychological
framework
Monitoring
outcomes
Reflective
Practice
10. Use of PIE
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Waterloo project
St Mungos
Newcastle and Gateshead
St Basils
Commissioners
PIE Link
PIE training
11. Me, PIE and the big apple
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• Pan London Personalised Budgets
project for entrenched street homeless
people
• Go into crisis once housed
• Challenging and destructive
behaviour
• Won’t engage at all
• Tons of training, totally missing
something!?
• Transatlantic Practice Exchange
• Center for Urban Community Services,
NYC
12. What is Trauma-Informed Care?
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SAMHSA Treatment Improvement Protocol 57:
‘TIC is an intervention and organisational approach that focuses on how trauma
may affect an individual's life and his or her response to behavioural health
services from prevention through treatment. There are many definitions of TIC
and various models for incorporating it across organisations, but a “trauma-
informed approach incorporates three key elements:
(1) realising the prevalence of trauma;
(2) recognising how trauma affects all individuals involved with the service,
organisation, or system, including its own workforce; and
(3) responding by putting this knowledge into practice”
(SAMHSA, 2012)’
13. Trauma Informed Care
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(Hopper, Bassuk, & Olivet, 2010)
Strengths -
Based
Approach
Emphasis on
Safety
Opportunities
to Rebuild
Control
Trauma
Awareness
14. ACE study
Adverse childhood experiences
Early life trauma events may include one
or more of the following:
Emotional abuse
Physical abuse
Sexual abuse
Emotional neglect
Physical neglect
Domestic violence between parents
Drug/alcohol using parent(s)
Parent(s) with mental illness
Lost parent through separation/divorce
A parent in prison
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15. ACE study 1995-1997:
Adverse childhood experiences
As the number of ACEs increases, so does the risk for the following (if 4 or more
ACEs):
7 x more likely to experience alcoholism and/or alcohol abuse
260% more likely to experience chronic obstructive pulmonary disease
460% more likely to experience depression
1220% increased risk of suicide attempts
Health-related quality of life
Illicit drug use
220% more likely to experience Ischemic heart disease
240% higher risk of stroke
240% higher risk of hepatitis - Liver disease
Poor work performance and financial stress
190 % increased risk of cancer
160% increased risk of diabetes
(Info taken from a Nadine Burke-Harris presentation)
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16. 2015:
The national survey of ACE Wales
14% had ACE score of 4+ and compared to those with 0 ACE score were…
4 times more likely to be a high-risk drinker
6 times more likely to have had or caused unintended teenage pregnancy
6 times more likely to smoke e-cigarettes or tobacco
6 times more likely to have had sex under the age of 16 years
11 times more likely to have smoked cannabis
14 times more likely to have been a victim of violence over the last 12 months
15 times more likely to have committed violence against another person in the
last 12 months
16 times more likely to have used crack cocaine or heroin
20 times more likely to have been incarcerated at any point in their lifetime
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17. Trauma- Informed Support
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• A philosophy underpinning organisations and service delivery
• Seeing everything through the lens of trauma
• Not trauma specific – much broader approach
• Creating safety – first stage of trauma recovery (Judith Herman)
• Aims to prevent retraumatisation, ‘do no harm‘ and recognises
widespread impact of trauma (clients and staff)
18. Vicarious Trauma
It is common for support providers to be
impacted when working with survivors of
trauma
Workers may develop symptoms in
response to being exposed to the trauma
This is known as vicarious or secondary
trauma and it can be overwhelming and
lead to burn out
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19. The Benefits
For service users:
Feel safe
Empowered to take control
Increased engagement
Aware that symptoms are a result of trauma
Can begin recovery
Not retraumatised by services
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For staff:
Increased understanding
Increased compassion and hope
Increased resilience
More able to cope with
challenges
Don’t see things in such a black
and white way
Reduced burnoutFor organisations:
Clear values and philosophy
Increased retention of service users
Increased engagement
Improved outcomes
Increased retention of staff
Reduced staff sickness and absence
Insightful and compassionate places
to work
20. www.homeless.org.uk Let’s end homelessness together
Amicus Horizon
Case Study:
• Black male, early 40’s
• Accommodated but not complying with rules
• Using numerous services but not allowing people to
support him meaningfully
• Always agitated and verbally aggressive
• Made accusations and threats towards staff and other
service users regularly
• Possible psychosis as delusional ideas
• ‘Victimised’ and defensive
21. www.homeless.org.uk Let’s end homelessness together
Amicus Horizon
Case Study:
• He, I and others were ‘hyper-aroused’
• Quiet safe place to meet
• Grounded him
• Introduced him to a model
• Agreed how behaviour would be managed
• Provided him with resources he could use and refer to in
order to ground himself and process events
• Number of incidents/complaints reduced
22. TIC in England
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• TIC and PIE!
• Training the sector
• Women’s criminal justice sector
• Agenda
• Young Minds
• Where else?
23. www.homeless.org.uk Let’s end homelessness together
• Unlike traditional staircase approach
• Permanent offer of a home
• No conditions other than maintaining
tenancy
• Flexible, person-centred support
• International evidence base
What is Housing First?
24. That sounds like floating support..
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25. Where is it being used?
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• Widely adopted across the US
• Central to national homelessness
strategies in some countries
• Growing in popularity across other
European countries
• A number of services and pilots in
England and devolved nations
• Service models vary depending on
context
26. Support teams structure
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• Assertive Community Treatment
- multi-disciplinary
- ‘mini welfare state’
• Intensive Case Management
• Depends on operating context – what
other services are available, funding
streams
• UK – a role for both?
27. The principles
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1. People have a right to a home
2. Flexible support is provided for as long as
is needed
3. Housing and support are separated
4. Individuals have choice and control
5. An active engagement approach is used
6. The service is based on people’s
strengths, goals and aspirations
7. Harm reduction approach is used
28. Use in England
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33 LA areas
current
Projects in
33 LA areas
50/50
PRS & RSL
Not all for
rough
sleepers
Not all LA
funded
Crisis
feasibility
study
Another 12
planning
(not inc. SIB)
29. Does it work?
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• Consistent trends despite
context
• Tenancy sustainment
• Health and wellbeing
• Substance misuse
• Anti Social Behaviour and
ineffective service use
International evidence base:
30. Other things to mention
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• Homelessness and mental illness
• Autism
• Acquired Brain Injury
• Supporting drug users
• Homeless Health Needs Audit
• Making Every Adult Matter
• Agenda
31. More Information:
Any questions?
Jo Prestidge
joanne.prestidge@homelesslink.org.uk
020 7840 4420
@joanneprestidge
To book the training visit:
http://www.homeless.org.uk/events/training or email
training@homelesslink.org.uk
www.homeless.org.uk Let’s end homelessness together
Editor's Notes
5% of women experience extensive abuse in life course (vs 1% men) – 3% experience extensive physical violence from partner in adulthood
Gender specific services?
Loss of safety/fear of extreme physical harm and loss of control/overpowered and overwhelmed
PTSD main symptoms (from minor affect to disabling):
Avoidance
Nightmares/flashbacks
Hypersensitivity
Dissociation
Rule of 1/3 traumatised:
3 people experience an event. 1 is non-plused, one is ‘life is wonderful’, one is damaged.
Not everyone that experiences early abuse or neglect will present with symptoms of personality disorder/other conditions. This depends on resilience.
Resilience: a secure attachment to someone else, support network, age at onset of trauma and numbers of trauma, what happens when they tell someone of the trauma
Multiagency working group on community mental health – discussions arose
Guidance – PIE to enable people to make changes in their lives, relationships seen as key tool for change
Homelessness staff have most contact but are least qualified
Managing relationships – help staff and clients self manage their emotional and behavioural responses to triggering events
Psych framework – services to have shared understanding of, and response to, the people they support
Training and support – allowing staff to move away from crisis management to working in a planned and therapeutic way
Physical and social environment – adapated to improve space for engagement and support
Eval of outcomes – evaluate effectiveness for ongoing improvement and evidence impact
A philosophy underpinning organisations and service delivery
Seeing everything through the lens of trauma
Not trauma specific – much broader approach
Creating safety – first stage of trauma recovery (Judith Herman)
Aims to prevent retraumatisation, ‘do no harm‘ and recognises widespread impact of trauma (clients and staff)
Researches found these four key themes across trauma-informed homelessness services
There are other principles too – but these are critical.
This research created the definition of TIC.
Trauma awareness – all staff have some understanding of trauma and impact
2. Emphasis on safety – service providers and managers focus on creating safe environments and relationships
3. Opportunities to rebuild control – service users are empowered to take control of their recovery
4. Strengths-based approach – services users are seen as people rather than problems and their strengths are acknowledge and encouraged
The ACE (Adverse Childhood Experience) study involves more than 17,000 Americans who are surveyed through their health insurance company and a gov health organisation
It asks them how many of these things they experienced in childhood and then assesses them against later-life health and wellbeing
It shows that ACEs are a major risk factor for leading causes of illnesses and death in the US. Traumatic experiences are transformed from psychosocial experience into organic disease, social malfunction and mental illness
This study also showed that ACEs are common
Trauma informed support – provides an opportunity to restore balance in a persons life.
This is not about “fixing someone” rather about providing safe space and not re-traumatising the individual
Trauma specific services = psychologist on site
Trauma and psychologically informed services – grounding, CBT etc
Pre-treatment approach – providing safe environment for people. Not responsible for treatment!
Staff and service user wellbeing – supervision; peer support, reflective practice etc (vicarious trauma)
Start of recovery, establishing safety – see your resource pack re Judith Herman book (1992) – Trauma and Recovery Recommend you read this. Defines stages of recovery – safety is the first stage – your key role in services. Ask work to purchase this resource for you!
Secure relationships/secure base
Preparing people to be ready
‘clinical parenting’ – providing the safe relationship that has been missing. Reflect back to this morning!
Focuses on impact on workers too – check in with self too! How am I feeling? How is this impacting on me, my relationships with colleagues and clients?
Ask the group:
What things do humans find traumatising?
Looking for experiences which relate to: abuse, violence, neglect, bereavement, natural disasters
ACTIVITY 2
Looking for discussions around:
The nature of the event
The resilience of the person involved
Natural, manmade, interpersonal
Support worker – secondary trauma
Trauma that sticks: often manmade/interpersonal – what we are talking about today
Natural trauma – no blame/injustice