1. Rebuilding Shattered Lives Peter Cockersell Director of Health and Recovery

2. St Mungo’s About 2000 beds: hostels to self-contained flats, including registered care Specialised drug, alcohol, mental health, dual diagnosis; older, women’s, and sexworkers’ projects Street outreach, 2 day centres, employment, training, substance use, health, and psychotherapy London, Reading, Oxford, Oxfordshire, Bath, Bristol, Hitchin, Welwyn Garden City…

3. 3 Shattered lives Population 1 - 4% schizophrenia 5 – 13% personality disorder 11% anxiety disorders and depression 1.3% have attempted suicide Homeless People 16 – 30% schizophrenia 50 – 70% personality disorder 50 – 80% anxiety disorders and depression 42% have attempted suicide

4. 4 Shattered lives: women 66% have a mental health problem 55% have a substance dependency >50% have physical health problems >50% have experienced violence or abuse from family/partner 41% rough sleepers have been involved in prostitution 45% are mothers

5. Shattered lives: children 47% experience of neglect/emotional abuse 34% early loss of parents through abandonment, separation or divorce 31% early loss of parents through death (including murder and suicide) 27% sexual abuse High levels of parental alcoholism, drug use, and domestic violence

6. 6 Behaviours associated with complex trauma Self-harm Uncontrolled drug or alcohol use Impulsive, careless of the consequences Withdrawn, reluctant to engage Anti-social Isolated Aggressive Lacking daily structure or routine Inability to sustain work or education Bullying, or being a victim Offending Unstable relationships

7. 7 Seeking help 70% had sought help: 11% got help Majority have histories of compound and complex trauma, not simple diagnoses More people have more than one condition than have only one Almost no access to psychotherapy, only drugs

8. 8 Client perspective I did not access much of mental health services (they would not let me), but I used up hundreds of thousands of pounds of other budgets such as housing, social services and substance misuse “ ”

9. Psychologically Informed Environments (PIEs) Recognition of range of mental health problems encountered by homelessness staff Services need a degree of psychological awareness and support PIEs focus on the psychological and emotional needs and capacities of clients and use the psychological and emotional resources of staff and clients to create a positive dynamic of change PIEs use a therapeutic framework to develop clear and consistent responses to clients PIEs are not simply about containing challenging behaviour, but changing it

10. Places of conscious change PIEs aim to create: an empowering and calming environment where people can feel emotionally as well as physically safe, and can gain an understanding of their behaviour and an ability to take responsibility for themselves

11. 11 Rebuilding shattered lives Dual diagnosis PIE Intensive engagement 1 – 1’s with specialist substance use worker Individual psychotherapy for clients; reflective practice for the staff No rehospitalisations; 17 of 18 moves were into less supported accommodation Lifeworks psychotherapy Individual psychodynamic psychotherapy 100% improvement on Outcomes Star axes 75% improvement on Wellbeing Impact Assessment Measure 3x more likely to move from pre-contemplation to active on Cycle of Change

12. 12 Key ingredients of St Mungo’s PIEs Psychological Framework Social Spaces Staff Training and Support Managing Relationships Access to psychotherapy

13. Managing relationships Complex trauma arises from abusive relationships Healing relationships need to be managed, and take care, and time Relationships have an impact on both/all parties Group dynamics affect individual group members’ relationships Setting up PIEs is also about managing relationships

14. Staff support and training Clinical supervision Reflective practice Training: Attachment, psychological perspectives Motivational interviewing, psychological techniques The Escape Plan, client perspectives Recovery, enabling management Corporate Commitment and Framework Client access to psychotherapy

15. Psychodynamic psychotherapy Based on relational dynamics in the here and now, while recognising the impact of the past in the present Does not require diagnosis or pathologisation of clients, and recognises the reality and validity of their experiences Therapy is flexible, client-led and non-directive Works on linking thinking and emotions, and the regulation of affect Evidence of effectiveness

16. 16 Client perspective I didn’t want to go initially, thought I didn’t need to see a shrink. I gave it a go and the first few sessions were very informal, unthreatening. I grew to trust her, told her things I haven’t told anyone else. A lot of tears were shed, she didn’t drag it out of me, she listened. I got shit out of my system that I’d been carrying around a long time. There was an underlying burden in my heart that she knew what to do with. Everything I said wasn’t written down and I loved that. It was properly confidential. It was a hard one but it was a good one and if it wasn’t for her I’d be floating down the Thames now. “ ”

17. 17 Client perspective ‘It became a really important stable part of my life when each week I had this appointment no matter what else happened and I would move heaven and hell to go there. When you look at your life and have someone else look at it you are able to analyse things from a fresh perspective. Things you thought were one way might not always be what they seem. They have a tendency not so much to have hidden meanings but you discover things you think are unrelated, are patterns and from those patterns you are able to make better decisions.’ (rough sleeper) “ ”

18. Further information www.groundswell.org.uk/The_Escape_Plan_Report.pdf www.groundswell.org.uk/The_Escape_Plan_Report.pdf www.homelesshealthcare.org.uk www.rebuildingshatteredlives.org Peter.cockersell@mungos.org