Mental health Good practice guide May 2010

Click to go to Æ Meeting the psychological and Document map emotional needs of homeless people Introduction Section 1: Non-statutory guidance on dealing with complex psychological and An outline of emotional needs from the National Mental Health Development Unit the key issues and the Department for Communities and Local Government Section 2: Case studies Section 3: Acknowledgments Definitions and We are very grateful indeed to the many colleagues around the country weblinks who contributed so much to this guide. Section 4: Particular thanks are offered to: Guidance and good practice Dr Nick Maguire, Chartered Clinical Psychologist and Deputy Director, PG Dip/Cert in Cognitive Behaviour Therapy, University of Southampton Section 5: Research Robin Johnson, RJA Consultancy Section 6: Panos Vostanis, Professor of Child and Adolescent Psychiatry, University of Leicester Glossary

For further information on any aspect of the good practice guide please contact: [email protected]

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Document map This document is interactive and has been linked for easy navigation and use. Link through pages using the document map below or the colour coded menus. Introduction

Section 1: Introduction J New Directions Team Assessment 35 An outline of The purpose of the guide 4 J Homeless Link Outcomes Programme 42 the key issues Schemes for young people 44 Who is this guide for? 4 Section 2: J Intensive Fostering – Youth Justice Board 44 How to use the guide 5 Case studies J Family liaison pilots – Youth Justice Board 45 Section 1: An outline of the key issues J High support hostels – Depaul UK 46 Section 3: The national policy context 8 J Kids Company, London 49 Definitions and Importance of agencies working together 11 J The Zone, Plymouth 51 weblinks New research and practice from pilot projects 13 High support schemes for adults 53 Section 4: Issues for accommodation and support providers 15 J 90 Lancaster Street, Multiple Needs Unit, Guidance and Importance of well-trained frontline staff 19 Birmingham 53 good practice The Psychologically Informed Environment J Home Base – Community Housing and Therapy 55 Section 5: approach (PIE) 20 J St George’s Crypt, Leeds 57 Research Drugs and alcohol 21 J Leeds NFA Health Centre 59 Best practice tips 22 J Lifeworks – St Mungo’s psychotherapy service 60 Section 6: Section 2: Case studies J Leicester Homeless Mental Health Service 63 Glossary Clinical assessment tools 24 J The Old Theatre, Broadway, London 66 J Leeds Holistic Framework 25 Staff capacity building and support 68 J New Directions Assessment – J Coaching Skills Training Course – Foyer Foundation 68 South West London Mental Health NHS Trust 28 J Westminster Cognitive Behaviour Therapy Project 69

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Document map J The Department of Health's Knowledge and Section 4: Guidance and good practice Understanding Framework 71 The psychologically informed environment (PIE) 88 Introduction J Behaviour Support Service, Brighton and Hove 72 Reflective practice 91 J Art of Defusing training, Bedford 75 Personalisation pilots and invest to save 92 Section 1: J Novas Scarman psychological skills training 76 J 1. Case studies from around England 93 An outline of J Framework Housing Association, Nottingham 78 J 2. The case for investment 101 the key issues J Young People in Focus: J 3. Longitudinal studies and evidence 108 Section 2: health and wellbeing scheme 80 Working with people with complex needs 109 Case studies Section 3: Definitions and weblinks CBT project, Derby Road, Southampton 113 Section 3: The use of medication 116 Psychological disorders which can predict Definitions and homelessness – some key definitions 81 Childhood experiences 116 weblinks J Complex trauma 80 Collaboration models for complex trauma and Section 4: J Personality disorder 80 severe social exclusion 117 Guidance and J Post traumatic stress disorder 81 Section 5: Research good practice J Conduct disorder 81 Cognitive and behavioural therapeutic interventions J Oppositional disorder 82 to tackle homelessness – research synopsis 122 Section 5: J Persistent, pervasive problems 82 How psychological factors related to traumatic Research J Co-morbidity 83 experience and personality disorder are Section 6: associated with chronic homelessness 131 J Attachment 83 Glossary J Emotion regulation 84 Research synopsis 138 Psychological techniques and approaches – Section 6: Glossary useful weblinks 86 Glossary of acronyms 142

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Introduction Click to go to Æ Document map The purpose of the guide Who is this guide for? The purpose of the guide Introduction This guide describes effective ways of recognising The good practice guide is designed to assist: Who is this guide for? and meeting the psychological and emotional needs • Supported accommodation key workers and managers How to use the guide Section 1: of people who have experienced homelessness, are Local authority housing options teams and managers An outline of sleeping rough or living in insecure accommodation, • the key issues in particular young people and rough sleepers with • Supported accommodation providers histories of complex trauma (see below for a definition • Day centre staff Section 2: of complex trauma). The guide outlines the national • NHS homelessness healthcare services Case studies policy context, the research evidence which informs Social workers developing practice, and explores the issues for service • Section 3: Drug and alcohol workers providers and commissioners. • Definitions and Prison and probation housing advice staff • weblinks The guide describes the common psychological • Offender managers problems associated with complex trauma and offers • Assertive outreach teams Section 4: examples of treatment models available. The case Health staff in A+E departments Guidance and studies describe a variety of existing services for rough • good practice Hospital discharge coordinators sleepers and young people which address emotional and • psychological problems. These illustrate the wide range • Psychiatrists and psychologists Section 5: of techniques and approaches that are commissioned • GPs and practice managers Research across the country, with contact details. For further • Health visitors information on any aspect of the guide please contact: Section 6: Community Psychiatric Nurses (CPNs) [email protected] • Glossary • Local commissioners of housing, health or support services • Local councillors We hope you find it useful.

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Introduction Click to go to Æ Document map How to use the guide The purpose of the guide Introduction The guide is divided into six sections: Who is this guide for? How to use the guide Section 1: An outline of Section 1: An outline of the key issues Section 3: Definitions and weblinks the key issues The national policy context A look at some of the key definitions of • • Section 2: • Importance of agencies working together different psychological disorders which can predict homelessness Case studies • New research and practice from pilot projects Some useful weblinks to give you more Issues for accommodation and support providers • Section 3: • information on psychological techniques Definitions and Importance of well-trained frontline staff and approaches • weblinks • The Psychologically Informed Environment approach (PIE) Section 4: Guidance and good practice Section 4: • Drugs and alcohol Some very helpful papers that outline more on Guidance and The Psychologically Informed Environment (PIE) and good practice Section 2: Case studies reflective practice – as well as some strong stories about individual clients and good practice around the UK. Section 5: There are four groups of wide-ranging case studies The psychologically informed environment (PIE) Research showing good practice in action that cover: • Reflective practice Section 6: Clinical assessment tools • • Personalisation pilots and invest to save Glossary Schemes for young people • • CBT Project at Derby Road, Southampton High support schemes for adults • • The use of medication Staff capacity building and support • • • Childhood experiences

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Introduction Click to go to Æ Document map Section 5: Research The purpose of Some key papers (presented in their original form) that the guide Introduction offer top-level research to help commissioners explore a Who is this guide for? wide range of issues surrounding complex trauma. How to use the guide Section 1: • Collaboration models for complex trauma and severe An outline of social exclusion the key issues • Cognitive and behavioural therapeutic interventions to tackle homelessness – research synopsis Section 2: • How psychological factors related to traumatic Case studies experience and personality disorder are associated Section 3: with chronic homelessness – a paper Definitions and • Bio-psychosocial influences in complex trauma and weblinks repeat homelessness: the evidence base and the implications for future research and practice – Section 4: a synopsis Guidance and good practice Section 6: Glossary Section 5: Acronyms spelled out. Research Section 6: Glossary

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Section 1: An outline of the key issues Click to go to Æ Document map The causes of homelessness can be complex. For some The prevalence of personality disorders in the general The national people it may result from social or mental health population varies according to the way it is measured, policy context Introduction difficulties, often undiagnosed. Tackling homelessness but it is generally acknowledged that around 10 per effectively for these groups will require agencies cent may reach diagnostic levels.1 However, it is Importance of agencies integrating accommodation with psychologically estimated that this rate rises to 60 per cent of adults working together Section 1: informed health and support services. living in hostels in England.2 New research An outline of the and practice from key issues Recent research suggests that behaviour which can Rough sleepers and young people who have experienced pilot projects increase the likelihood of homelessness may be homelessness generally experience higher rates of Section 2: Issues for associated with mental health problems such as: mental health problems than the general population. Case studies accommodation and These are people who, with a few exceptions, will not be • personality disorder support providers Section 3: post-traumatic stress disorder accessing mainstream mental health services and they • can present challenges to which conventional mental Importance of Definitions and • complex trauma; or health services have not on the whole responded well. well-trained weblinks conduct disorders in children. frontline staff • In some cases, primary health care may be engaged, Section 4: though good practice here is far from universal. The Psychologically Guidance and What is complex trauma? Informed Environment good practice The term ‘complex trauma’ does not seek to convey a approach The behaviour observed in people with personality medical diagnosis, but rather a set of experiences which Section 5: disorder can be described as reactions to and may underpin emotional, cognitive and behavioural Drugs and alcohol Research ways of coping with the traumatic experience patterns seen in adulthood. This guide deliberately tries Best practice tips of difficult childhoods. It may, therefore, be to avoid the polarised argument about homelessness Section 6: more useful to describe personality disorder as being either the fault of the individual or the fault of Glossary ‘complex trauma’, in other words, a reaction to society, but rather sees homelessness as resulting from an ongoing and sustained traumatic experience. an interaction of the two in some vulnerable groups. This description will be used in the guide. Please note there are more detailed definitions of personality disorders later in this section. 1 For example, Eksellius et al, 2001. 2 Maguire et al, in prep.

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Section 1: An outline of the key issues Click to go to Æ Document map The national policy context The national policy context Introduction Importance of agencies It is important to emphasise that not all people who Experiencing a traumatic childhood may mean working together have experienced homelessness will have suffered people develop problems in later life, particularly Section 1: traumatic childhood experiences or would be diagnosed with attachment, emotion regulation and New research An outline of the as experiencing complex trauma. However, there interpersonal skills (see definitions section for more and practice from key issues is growing evidence that a significant proportion – on personality disorders). These may underpin many pilot projects Section 2: particularly of those with very complex needs such as of the emotional and behavioural issues which Issues for Case studies entrenched rough sleepers or young people who have cause and perpetuate homelessness and lead to accommodation and endured sustained traumatic experiences before facing further mental health problems, drug and alcohol support providers Section 3: homelessness – may suffer from complex trauma. misuse. These problems can also be compounded Definitions and by further trauma in adult life, thus perpetuating Importance of weblinks Developing services that acknowledge the psychological the cycle of homelessness. Without addressing the well-trained frontline staff and emotional needs of people with complex trauma trauma it can prove difficult to help people stabilise Section 4: issues is likely to produce positive outcomes for their lives and find and keep accommodation. The Psychologically Guidance and those people who may have been adversely affected Informed Environment good practice by the experience of homelessness but who may In recognising the psychological and emotional approach not have such complex and entrenched problems. needs of people who are homeless or living in Section 5: Drugs and alcohol Adopting a psychologically skilled approach will insecure accommodation, there are clear Research not only provide positive outcomes with those who implications for the commissioning of Best practice tips have received a medical diagnosis, but also with services and for the training and support of Section 6: those clients who may have learnt ineffective and key working and resettlement staff. Glossary destructive coping strategies which affect their ability to maintain healthy relationships or accommodation.

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Section 1: An outline of the key issues Click to go to Æ Document map is a need for joined up input and support from primary Cross-government working with The national care services, including support to general practitioners, New Horizons policy context Introduction emergency health services and specialist mental health The approach taken in this guide to meeting the Importance of agencies services engaging with this client group, to enhance the emotional and psychological needs of people who have working together capacity within accommodation services to meet these Section 1: experienced complex trauma and who are homeless or needs. It is important that we appreciate the complexity New research An outline of the living in insecure accommodation is intended to support of the challenge for service provision, the support that and practice from key issues the vision of New Horizons the cross-government homelessness and health services need when working pilot projects programme for improving mental health and well being. Section 2: with people experiencing complex trauma; and the www.newhorizons.dh.gov.uk/index.aspx Issues for need for partnership working between agencies. Case studies accommodation and New Horizons sets out a twin-track approach to support providers Section 3: There are a number of national policy developments improving population mental health and enhancing Definitions and that underpin the development of new approaches Importance of the quality and accessibility of mental health care. weblinks to tackling emotional and psychological issues and well-trained Both elements of this approach can be applicable to homelessness, as part of tackling health inequality frontline staff people who are socially excluded, where the range of Section 4: and improving public health. risk factors leading to social exclusion can also leave The Psychologically Guidance and people at greater risk of mental ill-health and needing Informed Environment good practice New and increased flexibility for to access mental health care. Addressing these issues approach Section 5: commissioners and providers can include intervening early to prevent people needing Drugs and alcohol The removal of the ringfence around Supporting to access services at a stage of crisis: through proactive Research People funding creates new and increased flexibility employment or housing support, for example; and also Best practice tips Section 6: for commissioners and providers. It enables them to through changing service specifications across multi- extend their range into areas of need where they are agency service pathways to ensure that all services in Glossary often the first to engage with and the best placed to social care, acute and primary health care, housing; work with people experiencing complex trauma. leisure and employment are responsive to the needs of www.communities.gov.uk/news/corporate/1075788 people who use them.

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Section 1: An outline of the key issues Click to go to Æ Document map Importance of agencies working together The national policy context Introduction

There is an increasing recognition in the UK about the These local commissioning arrangements to meet the Importance of agencies importance and cost benefits of preventive services. newly-identified needs will enhance the capacity and working together Section 1: the potential for innovative approaches such as: New research An outline of the Joint Strategic Needs Assessment • practice-based commissioning and and practice from key issues pilot projects Responsibility for the assessment of health needs fits social prescribing Section 2: within the remit of the local primary care trust (PCT) • to be able to intervene earlier Issues for Case studies working in partnership with other agencies, most • greater needs-led flexibility. accommodation and notably local authorities. The statutory framework support providers Section 3: for needs assessment within a local area is the Joint The impetus of World Class Commissioning in the Importance of Definitions and Strategic Needs Assessment (JSNA) which is led by NHS, the outcomes of JSNAs across local authorities well-trained weblinks local authorities with input from primary care trusts. and primary care trusts and the transformation frontline staff www.dh.gov.uk/en/Publicationsandstatistics/Publications/ programme for adult social care have also helped Section 4: PublicationsPolicyAndGuidance/DH_081097 to sharpen the commissioning focus on a range of The Psychologically Guidance and socially excluded groups, including people who are Informed Environment good practice The JSNA in turn feeds into the local planning system homeless or living in insecure accommodation or approach Section 5: through the mechanism of Local Area Agreements individuals who may have experienced difficulty Drugs and alcohol (LAAs). In an area of commissioning such as complex accessing services by virtue of diagnoses such Research Best practice tips trauma it would be good practice for agencies to work as personality disorder or complex trauma. together in the needs assessment phase and in taking Section 6: forward commissioning plans for new services to meet Inclusion Health – Improving Primary Care for Socially Glossary the identified needs. Equally, existing services could be Excluded People is a practical guide aimed at supporting refocused to reflect the recognition of complex trauma PCTs to commission improved access to high quality as an issue for clients. www.dh.gov.uk/en/SocialCare/ primary care services for socially excluded people. Socialcarereform/Localareaagreements/index.htm www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_114067

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Section 1: An outline of the key issues Click to go to Æ Document map Frequently, the complex challenges socially excluded www.dh.gov.uk/en/Publicationsandstatistics/ The national people face can mean that many lead chaotic lives. Publications/PublicationsPolicyAndGuidance/DH_114067 policy context Introduction The challenge facing commissioners and providers Importance of agencies is how to work with excluded people to ensure that A key factor in improving outcomes for people with working together all opportunities are optimised to help stabilise their a personality disorder is the response they receive Section 1: care needs, and to support them into pathways to from staff. There has been a great deal of stigma New research An outline of the recovery wherever possible. Traditional services tend to attached to a diagnosis of personality disorder and and practice from key issues engage poorly with socially excluded people and vice this often translates to discrimination and exclusion. pilot projects Section 2: versa. They frequently experience barriers to accessing Staff, especially those in non-specialist settings, Issues for Case studies primary care and maintaining the relationships with working with people with such a diagnosis can often accommodation and providers that lead to continuity of care. By addressing lack awareness, skills and training to cope effectively support providers Section 3: these issues there is potential to secure not only better with what can be perceived to be challenging health outcomes for those who need our help the most, and risky behaviour. Specialist practitioners often Importance of Definitions and but also to deliver better value. work in isolation, lacking the support networks well-trained weblinks frontline staff to deal effectively with high-need clients. Section 4: Inclusion Health is the latest in a series of best practice The Psychologically Guidance and guides which have been produced by the Department Dispelling myths and stereotypes Informed Environment good practice of Health, primary care team in support of the There is a need to dispel myths and stereotypical beliefs approach implementation of the primary care and community Section 5: about untreatable, unsuitable, undeserving or hard-to- Drugs and alcohol services strategy, Our vision for primary and community reach clients, and this paper outlines new research on Research care. This guidance is also linked with the Cabinet underlying needs and examples of effective practice to Best practice tips Office, Social Exclusion Task Force and Department correct the negative terminology. In order to address Section 6: of Health new short study Inclusion Health. the problem the Department of Health and the Ministry Glossary This study outlines how improvements in health care of Justice commissioned a comprehensive training and for the most excluded groups in society can be development programme for personality disorder, the accelerated to ensure high quality services are available Knowledge and Understanding Framework. to all, and sets out a series of actions to drive these www.personalitydisorder.org.uk/training/kuf/awareness changes at a national level. This guide can be found at

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Section 1: An outline of the key issues Click to go to Æ Document map New research and practice from pilot projects The national policy context Introduction

In the past, it was thought that problems associated provides guidance for commissioners by reviewing Importance of agencies with personality disorder were untreatable. Evidence what is known about personality disorder, government working together Section 1: from a number of pilot projects funded by the policy, clinical approaches and learning from the New research An outline of the Department of Health and two sets of guidelines pilots, and sets out a series of recommendations. and practice from key issues from the National Institute for Clinical Excellence www.dh.gov.uk/en/Publicationsandstatistics/ pilot projects (NICE) issued in 2009 is changing that. Publications/PublicationsPolicyAndGuidance/ Section 2: Issues for http://guidance.nice.org.uk/CG78 DH_101788 Case studies accommodation and support providers Section 3: Ground-breaking therapeutic programmes are making Making public money work harder Definitions and real and lasting improvements to families, prisoners, through ‘health check’ pilots Importance of ‘untreatable’ psychiatric patients and others who well-trained weblinks There are strong spend-to-save arguments for health, frontline staff experience extreme social exclusion. This guide Section 4: outlines many examples of effective practice emerging the criminal justice system and the homelessness The Psychologically Guidance and within housing services (see Section 2: Case studies sector in favour of tackling complex trauma, Informed Environment good practice and CBT project, Derby Road, Southampton). particularly in excluded and vulnerable groups. This can be achieved by partnership working approach Section 5: through the LAA process and by looking at Drugs and alcohol Applying the learning from the pilots ways of joining up individual local funding Research The challenge now is for commissioners to apply streams to achieve better outcomes. Best practice tips the learning from the pilots and the developing Section 6: evidence base to ensure that people experiencing Total Place is a new approach to local public service Glossary complex trauma are treated by skilled and specialist delivery, encouraging local partners to put the citizen staff working together across agencies. Recognising at the heart of service design in delivering service Complexity, commissioning guidance for personality improvements and savings. The Total place report, disorder services from the Department of Health, published alongside the 2010 Budget, draws on the

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Section 1: An outline of the key issues Click to go to Æ Document map findings of 13 pilots that worked closely with central The national government to map the totality of public spending in policy context Introduction their area, identify national-level changes to support Importance of agencies local collaboration and discern opportunities for working together genuine, cross-organisational service transformation Section 1: in chosen themes. These themes included housing, New research An outline of the tackling alcohol and drug use, children’s health and well and practice from key issues being, mental health services and reducing reoffending. pilot projects Section 2: A report of the findings of the pilot stage is available Issues for Case studies at www.hm-treasury.gov.uk/psr_total_place.htm accommodation and support providers Section 3: Importance of Definitions and well-trained weblinks frontline staff Section 4: The Psychologically Guidance and Informed Environment good practice approach Section 5: Drugs and alcohol Research Best practice tips Section 6: Glossary

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Section 1: An outline of the key issues Click to go to Æ Document map Issues for accommodation and support providers The national policy context Introduction Importance of agencies Ongoing difficulties for people who have Additional problems of those experiencing working together Section 1: experienced complex trauma complex trauma New research An outline of the The evidence from practitioners and recent research Many people experiencing complex trauma will have and practice from key issues suggests that people with a history of complex additional problems, for example: learning difficulties, pilot projects trauma are likely to have ongoing difficulties related physical or other mental health problems or re- Section 2: to issues such as attachment and loss, emotional offending. They may not be in regular contact with Issues for Case studies disregulation and impulsivity, dependence, avoidance, a GP or mental health services or have any formal accommodation and rejection, mistrust or hostility. A better awareness psychiatric assessment of diagnosis established. They support providers Section 3: of these issues can help services to recognise these may use emergency departments for the majority of Importance of Definitions and vulnerabilities early on, and take steps to engage the their healthcare needs. For example, new research by well-trained weblinks individual through some sensitivity to likely problems. the Social Exclusion Task Force and Department of frontline staff Health found that homeless people are 40 times more Section 4: With those for whom complex trauma has likely to be unregistered with a GP and five times more The Psychologically Guidance and become entrenched – those who might, for likely to use A&E when they could not speak to a doctor Informed Environment good practice example, be given a diagnosis of personality than the general public. www.cabinetoffice.gov.uk/ approach Section 5: disorder – it may be helpful to be aware of the media/346574/inclusion-health-evidencepack.pdf Drugs and alcohol advice currently given by mental health services Research on working with those with personality disorder. Current advice suggests that supportive and Best practice tips Section 6: www.dh.gov.uk/en/Publicationsandstatistics/ collaborative relations with the client are more effective Publications/PublicationsPolicyAndGuidance/ than technical or coercive interventions. This supports Glossary DH_4009546 the experiences of many housing resettlement staff that user-defined outcomes are the strongest basis on which to build. Use of person-centred approaches such as the ‘Outcomes Star’ can give this a specific focus. (See case study on Homeless Link Outcomes Programme).

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Section 1: An outline of the key issues Click to go to Æ Document map People with complex trauma who have experienced response, until they are sure that trust is well placed. The national homelessness may behave in a range of ways that It is estimated that 55-60 per cent of adults in policy context Introduction suggest underlying difficulties with relationships, or supported accommodation have a diagnosable Importance of agencies with managing their own emotions. Some people may personality disorder, in many cases resulting from working together for example: neglectful and abusive early experiences. This can result Section 1: • self-harm or have an uncontrolled drug and/or in anti-social and violent or disruptive behaviour which New research An outline of the alcohol problem is hard for frontline staff to manage and which, in some and practice from key issues cases, can lead to exclusion or eviction. pilot projects • appear impulsive and not consider the consequences Section 2: of their actions Issues for Such outwardly disruptive behaviour is only one Case studies appear withdrawn or socially isolated and reluctant accommodation and • possible manifestation of an underlying difficulty in support providers Section 3: to engage with help which is offered managing relationships. Equally problematic can be Definitions and exhibit anti-social or aggressive behaviour high dependency or avoidant behaviour, or very erratic Importance of • weblinks lack any structure or regular daily routine and inconsistent responses to stressful situations well-trained • frontline staff • not have been in work or education for significant and demands, with irresponsible and sometimes Section 4: periods of time melodramatic behaviour. There are many possible The Psychologically Guidance and presentations of dysfunctional and self-defeating have come to the attention of the criminal justice Informed Environment good practice • attitudes (reactions and ways of thinking) that can give system due to offending. approach a clue to underlying and deep-seated emotional and Section 5: psychological difficulties which need to be addressed. Drugs and alcohol Some people may have had unsatisfactory experiences Research Best practice tips of housing, health or care and support services in Section 6: the past; and some may now be wary of all forms of authority or bureaucratic systems, despite the good Glossary intentions of the service provider. Some may be reluctant to reveal the full extent of their problems until they are reassured that their trust will not be betrayed, others may need to challenge services to test the

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Section 1: An outline of the key issues Click to go to Æ Document map The national Particular issues for 16-17 year-olds policy context Introduction There are particular issues to consider around Their behaviour may also increase their chances of Importance of agencies 16-17 year-olds who have experienced homelessness losing their accommodation and becoming homeless working together Section 1: and who may have had traumatic and abusive again. Not recognising or working with their childhoods. On top of the problems of adolescence experiences of trauma means there is a risk of those New research An outline of the which affect young people generally, they may also young people disengaging from services, resulting in and practice from key issues pilot projects exhibit behavioural problems, of lesser (oppositional) a potential lifetime of homelessness Section 2: or higher severity (conduct disorder), with the latter and exclusion. Issues for Case studies usually being associated with antisocial behaviour. accommodation and (Please also see the definitions section.) In some Emotional and social maturity younger than support providers Section 3: cases the behaviour may not get diagnosed at all, but chronological age Importance of Definitions and labelled as anti-social or just ‘being difficult’. An additional difficulty for staff working with weblinks young people is that the young person's emotional well-trained frontline staff These problems can lead to and compound the and social maturity may be much younger than their Section 4: experience of homelessness for these young people. adulthood chronological age. This developmental The Psychologically Guidance and It can make it much more difficult for them to: discrepancy is particularly prominent among Informed Environment good practice achieve a successful transition into adult life young people who have experienced complex approach • trauma, and can be compounded by the additional Section 5: hold down a tenancy Drugs and alcohol • problems faced by adolescents in transition Research • remain in education to adulthood. Best practice tips • make healthy relationships; or Section 6: • find a job. Glossary

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Section 1: An outline of the key issues Click to go to Æ Document map People who have experienced homelessness and who The high prevalence of personality disorder and The national experience complex trauma can prove: complex trauma among clients of some homelessness policy context Introduction services means that hostel staff and resettlement • difficult to engage with Importance of agencies workers can often find themselves engaged in quite demonstrate volatile, irresponsible, risky or working together • psychologically sophisticated and demanding work, for Section 1: antisocial behaviour; and which they should be properly recognised, trained and New research An outline of the • use drugs and alcohol. supported. It is important for staff and commissioners and practice from key issues to understand that this approach complements pilot projects They may behave and think in particular ways which Section 2: but does not replace access to mainstream clinical Issues for perpetuate their problems. This makes key working psychology services by clients. Case studies very hard and at times frustrating for both client accommodation and and worker. support providers Section 3: Importance of Definitions and Without effective, psychologically informed input well-trained weblinks by staff and/or therapists as an integral part of case frontline staff Section 4: management or key working with clients, there The Psychologically is unlikely to be any resolution of their problems. Guidance and Informed Environment Accommodation on its own, even coupled with support, good practice approach will very rarely enable people experiencing complex Section 5: trauma to deal with negative self-belief or emotional Drugs and alcohol Research disregulation and change how they behave. Best practice tips Section 6: Glossary

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Section 1: An outline of the key issues Click to go to Æ Document map Importance of well-trained frontline staff The national policy context Introduction Importance of agencies People who are homeless or insecurely housed are services, such as those outlined in the Case studies are working together among those most in need of psychologically informed provided, they generally have a high level of take up, Section 1: help, but are also among those least able to access good attendance and strong positive outcomes. New research An outline of the mainstream clinical psychology services. The skills and practice from key issues and awareness of frontline health and support staff to pilot projects More effective services at relatively low cost Section 2: this issue are central here, and staff training and staff through staff training Issues for support are equally important, in order to develop Case studies Managers and commissioners alike need to consider accommodation and individual resilience and address burn out and high support providers Section 3: staff turnover. The capacity and the opportunity to how far staff development, training and supervision reflect upon experience and for staff to support each may, in the long run, produce more effective services at Importance of Definitions and other in learning to manage challenging behaviour, can a relatively small cost. Resilient services need to provide well-trained weblinks a careful mixture of flexibility and consistency, and the frontline staff also make a significant difference to the resilience of Section 4: the organisation in coping with the emotional impact use of reflective practice is generally acknowledged to The Psychologically Guidance and of such demanding work. lead to constructive changes in daily routines and the best use of facilities. Informed Environment good practice approach Section 5: Psychological training and The organisation of the frontline service over and above Drugs and alcohol the skills, resilience and activities of individual staff, Research awareness training Best practice tips There are now a number of well-evidenced models can have a significant impact on the extent to which Section 6: the service can manage challenging or frustrating of psychological training and awareness raising that Glossary can be offered to frontline staff in a variety of non- behaviour. Equally, the physical design of a building can specialist settings in order to improve awareness of the have a significant impact on behaviour and influence issues around complex trauma. There are also tools positive relationships, as has been well demonstrated by for self-help with proven effectiveness that can assist the Homes and Communities Agency’s Places of Change non-specialist staff. Where accessible psychological Programme. www.homesandcommunities.co.uk/places_ of_change 18 Mental health Good practice guide

Section 1: An outline of the key issues Click to go to Æ Document map The Psychologically Informed Environment approach The national policy context Introduction Importance of agencies People who have been homeless often come to expect It is striking that many of the case studies describe working together rejection and, therefore, find it difficult to trust those opportunities for tiered or staged involvement, Section 1: who are there to help them and talk openly about so that the warier client can develop trust and New research An outline of the important issues in their lives. The psychologically eventually engagement more fully, but on their and practice from key issues informed environment (PIE) can be created in a own terms. This will require careful and appropriate pilot projects Section 2: service such as a hostel or day centre where the social pacing of interventions, and can be a slow process. Issues for Case studies environment makes people feel emotionally safe. A Many services make good use of peer support, accommodation and PIE is an approach rather than a place, and an example and aim to work with the informal social networks support providers Section 3: of what the Royal College of Psychiatrists terms an that supported accommodation will inevitably Definitions and ’enabling environment’. PIEs can be developed within produce. We need to be aware that for some people, Importance of weblinks existing commissioned services, wherever appropriate this may offer the only sense of community they well-trained frontline staff training and development enables staff to respond have. User-led services that work to encourage Section 4: effectively to people with psychological needs and engagement but not reproduce dependency will The Psychologically Guidance and longstanding emotional problems. This includes trying be more effective than those that overlook the Informed Environment good practice to understand people’s behaviour, helping them to be social dimension of person-centred services. approach involved with others in a genuine way, and to take as Section 5: Drugs and alcohol much responsibility for themselves as possible. Tackling complex trauma requires a combination Research of approaches and therapies. Both the physical Best practice tips environment and the approach to clients by staff can Section 6: A PIE will aim to use the potential for change have a significant effect. Engagement and consistency Glossary that resides in all human beings in the pursuit of approach are central to this, as is appropriate staff of some wider or future goal, whether it be the training and support. reduction of re-offending, a positive attitude to learning, or engagement with treatment and therapy.

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Section 1: An outline of the key issues Click to go to Æ Document map Drugs and alcohol The national policy context Introduction Importance of agencies It is crucial that access to services is not conditional on It is also important that working relationships between working together Section 1: abstinence from drugs or alcohol. This is particularly staff from different services are good, in order to New research An outline of the important with people who experience complex trauma help ensure that the difficult relationships that some and practice from key issues and who also use drugs or alcohol as self-medication, vulnerable individuals may experience do not become pilot projects sometimes described as dual diagnosis. Until the rerun as repeated patterns of conflict between agencies Section 2: underlying causes of the complex trauma are diagnosed and services. Joint training events, link-workers, Issues for Case studies and treated, the substance misuse is highly likely to colocation, information-sharing meetings, case accommodation and continue. Denying access to either accommodation or conferencing and other such bridging mechanisms can support providers Section 3: mental health services because of continued substance be helpful in building and maintaining better working Importance of Definitions and misuse is likely to result in rough sleeping and ill health. relationships that work more seamlessly to meet well-trained weblinks However this has to be balanced with the need for complex needs. frontline staff services to ensure the safety of staff and residents. Section 4: www.dualdiagnosis.co.uk The Psychologically Guidance and www.dh.gov.uk/en/Publicationsandstatistics/ Informed Environment good practice Publications/PublicationsPolicyAndGuidance/ approach Section 5: DH_062649 Drugs and alcohol Research It is important to distinguish between those who use Best practice tips Section 6: drugs and alcohol as way of coping with complex trauma and those whose drug and alcohol use may Glossary largely be recreational though still problematic. Robust assessment, joint working and communication between professionals will assist with identification of underlying complex trauma and referral to appropriate services.

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Section 1: An outline of the key issues Click to go to Æ Document map Best practice tips The national policy context Introduction Importance of agencies working together Section 1: Getting started 2 Make sure that multi-agency risk management New research An outline of the Some best practice tips to help service providers follows risk assessment, to ensure that homeless people with complex trauma are not excluded and practice from key issues and commissioners adapt existing services or pilot projects develop new ones which address the issues from accommodation or support services. Section 2: surrounding complex trauma in an often chaotic Issues for Case studies client group whose behaviour can be perceived as 3 Work with homeless people with complex accommodation and very challenging. trauma with their presenting behaviour support providers Section 3: rather than restricting access to appropriate Importance of Definitions and Build requirements into service specifications services until behaviours change. well-trained weblinks for providers of direct services and relevant frontline staff assessment team functions to: Section 4: 4 Develop, and include in contractual The Psychologically Guidance and arrangements, clear care pathways and a Informed Environment good practice 1 Train and support staff to recognise and consistent, psychologically informed approach approach work with the behavioural, emotional from all agencies, statutory and non- Section 5: Drugs and alcohol and cognitive issues that are problematic statutory, working locally with people who are Research for people with complex trauma. homeless or in insecure accommodation. Best practice tips Section 6: Glossary

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Section 2: Case studies Æ Click to go to Document map These case studies offer examples of how psychologists The findings and recommendations in these Clinical diagnose personality disorder and how service providers case studies are those of the authors and do not assessment tools Introduction necessarily represent the views or proposed policies can assess the emotional and psychological needs of Schemes for of CLG or NMHDU. their clients. There are also case studies that look in young people more depth at how services can support young people – Section 1: and adults with high-support needs. High support An outline of schemes for adults the key issues Staff capacity Clinical assessment tools Home Base, Community Housing and Therapy Section 2: • building and support Case Studies • Millon Clinical Multi-axial Inventory; • St George’s Crypt, Leeds Personality Diagnostic Questionnaire • Leeds NFA Health Centre Section 3: • The Leeds Holistic Framework • Lifeworks, St Mungo’s psychotherapy service Definitions and • New Directions Assessment – South West London • Leicester Homeless Mental Health Service weblinks Mental Health NHS Trust The Old Theatre Broadway London • Section 4: • Homeless Link Outcomes Programme Staff capacity building and support Guidance and Schemes for young people good practice • Coaching Skills training course – • Intensive fostering – the Youth Justice Board Foyer Foundation Section 5: • Family Liaison pilots – the Youth Justice Board • Westminster Cognitive Behaviour Therapy project Research • High support hostels – Depaul UK • Knowledge and Understanding Framework, • Kids Company, London Department of Health Section 6: • The Zone, Plymouth • Behaviour support service, Brighton and Hove Glossary • Art of defusing training, Bedford High-support schemes for adults • Novas Scarman psychological skills training • 90 Lancaster Street, Multiple Needs Unit, • Framework Housing Association, Birmingham Nottingham

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Section 2: Case studies Æ Click to go to Document map Clinical assessment tools Clinical assessment tools Introduction Schemes for In clinical assessments, the prevalence rates of • The PD diagnoses are based on the Diagnostic young people personality disorder (PD) can vary greatly depending on and Statistical Manual (DSM-IV) published by the Section 1: the form of assessment used. American Psychiatric Association. The MCMI has High support An outline of been criticised for being over-inclusive in its schemes for adults the key issues The broad spread of signs and symptoms mean that diagnosis of PD. www.psychcorp.co.uk/product. Staff capacity Section 2: diagnosis is often difficult and unreliable. There is aspx?n=1316&skey=4364 building and support Case Studies evidence that studies which rely on formal psychiatric diagnosis produce highly-variable results. There are, Personality Diagnostic Questionnaire Section 3: however, a number of clinically-developed self-report (PDQ-4) Definitions and measures which give an indication of the presence/ weblinks absence of PD and its severity, two of which are • This is a 99-item true/false questionnaire extensively used in clinical practice to screen people suffering covered below. Section 4: from PD. It is also extensively used in research. Guidance and Millon Clinical Multiaxial Inventory The PDQ is also based on the Diagnostic Statistical Manual (DSM-IV) categories of PD. good practice (MCMI-III) • The newest version has a clinical significance scale Section 5: This is a 175-item true/false questionnaire that is • which attempts to address the problem of false Research extensively used in clinical and research settings. positive diagnosis. • It has subscales which identify the presence of Section 6: specific types of PD according to an 85th percentile Not yet formally researched, but proven effective in Glossary cut-off. practice, the PDQ is the assessment framework used • It also has subscales to identify depression, anxiety, for the personality disorder Managed Network, drug and alcohol problems and post-traumatic stress and NIMHE/DH PD pilot. disorder (PTSD). www.pdq4.com

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Section 2: Case studies Æ Click to go to Document map Leeds Holistic Framework Leeds Holistic Framework for Clinical Understanding Complex Needs assessment tools Introduction Not yet formally researched, but proven effective Consider and discuss the following with the client: Schemes for in practice, the Leeds Holistic Framework is the young people Section 1: assessment framework developed by Ray Middleton 1 Environment from Community Links for the Leeds personality High support An outline of disorder Managed Network – one of the Where they LIVE schemes for adults the key issues Describe what it is like where the client lives. NIMHE/DH PD pilots. • Staff capacity Section 2: www.commlinks.co.uk How would they describe it? building and support • How safe and secure is it where they live? Case Studies This assessment tool is used by key workers at What they DO with their lives Section 3: Community Links in Leeds and enables them to identify a Living skills: can/do they cook/shop/clean/ Definitions and and understand the emotional and psychological needs manage money? weblinks of their residents. It is completed as part of the process b Meaningful use of time: study/voluntary of agreeing a support package and regularly reviewed. work/paid work/hobbies? Section 4: Who do they MEET? (social networks) Guidance and Its strength is that it does not use technical language, good practice but asks questions in a way that is readily understood • Describe the people the client meets regularly? by individuals with such difficulties. It also helps to • How do they view these people? Section 5: What influence do others have on the client? identify problems without any suggestion that these • Research problems are a matter for healthcare, social care or support services. 2 Beliefs and thoughts about: Section 6: Themselves (their identify) Glossary It is particularly useful for services that may be • How would the client describe himself or herself? commissioned and funded by diverse funding streams. • How do they think and feel about themselves? • How does the client think other people see them? The questions in the Leeds Holistic Framework are outlined in more detail opposite.

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Section 2: Case studies Æ Click to go to Document map Other people • Self-harm? Clinical • How would the client describe the other people • Physical health? assessment tools Introduction they meet? What risks are there of them harming someone • Schemes for else or offending? The ‘way the world works’ young people Section 1: How does the client think their ‘world works’? Reviewing/reflecting on the outcomes of plans • High support An outline of (e.g. is it dangerous/unfair etc – this is a hard and actions schemes for adults the key issues question so you can say you ‘do not know’!) • How much does the client reflect on their actions and consider how effective their plans have been? Staff capacity Motivation to change and take responsibility Section 2: How much do they learn from experiences? (Do building and support How motivated to change are they in order for • Case Studies • they adjust their plans based on past experiences?) their life to get better? Section 3: To what extent do they see themselves as • 4 Building relationships: responsible for their own problems? Definitions and Co-operating weblinks 3 Problem-solving strategies: • What is the client like at asking for, Section 4: and co-operating with, help? Assessing a problem In what ways does the client help others? Guidance and • List some of the problems the client has at the • good practice moment. Conflict • Does the client tend to exaggerate or minimise • What conflicts crop up for the client? Section 5: their problems? (What does the client get cross about?) Research How do they tend to react to their problems? • Ways of communicating Section 6: Planning a solution What is the client like at listening to and • Glossary • Does the client plan solutions to problems? understanding others? What are they like at • Are their plans realistic and achievable? communicating? • Does the client avoid solving problems? • Does the client think other people listen to and understand them? Taking risks • What risks are they vulnerable to?

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Section 2: Case studies Æ Click to go to Document map 5 Managing emotions: 6 Reflections and connections: Clinical Discuss what connections you or they can make assessment tools Anger • Introduction between the five areas. What does the client get angry or cross about? Schemes for • How you think and feel about this client? How does the client react when they get angry? • young people • • What your role and limits are in relation to Section 1: Anxiety/fears the client? High support An outline of • What does the client get anxious, schemes for adults the key issues fearful or worry about? Contact: [email protected] Staff capacity How does the client react when anxious? Section 2: • building and support Case Studies Low mood/enjoying life activities • What causes the client to get low in mood Section 3: or fed up? Definitions and • What activities does the client enjoy doing? weblinks Other emotions (e.g. guilt, loneliness, shame, Section 4: grief, emptiness, excitement, envy, stress…) What other emotions does the client experience? Guidance and • good practice Addictions and impulsive acts • Does the client use any of the following to cope with Section 5: thoughts, feelings or lack of feelings? (i.e. do they Research misuse any of these mood-altering activities?) • Over- or under-eating alcohol/drugs/gambling/ Section 6: misusing sex/work addiction/ Glossary • Exercise/self-neglect/self-harm/cutting/burning/ overdosing others • Do these activities cause the client any problems? • Does the client want to stop or reduce these activities? [Y/N]

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Section 2: Case studies Æ Click to go to Document map New Directions Assessment – actually be serving based on real case studies. At initial Clinical meetings it was clear that while all members could assessment tools Introduction South West London Mental Health identify potential clients for the new team there was a Schemes for NHS Trust range of perspectives. young people Section 1: Snapshot summary Early discussions and a review of the relevant research High support An outline of showed that a high proportion of people with multiple schemes for adults the key issues The New Directions Team aims to provide an early needs tended to have mental health problems, often Staff capacity Section 2: intervention for residents from the London Borough of in combination with substance use or personality building and support Case Studies Merton who are not engaging with frontline services, disorder. While local case studies were being developed, resulting in multiple exclusion, chaotic lifestyles and a brief review of the literature about people who Section 3: negative social outcomes for themselves, their families did not engage, or were rejected by mental health and communities. The team reports to a multi-agency services, was also carried out to identify key individual Definitions and partnership group. characteristics. weblinks Section 4: Background What we do and how we do it Guidance and good practice During the development phase a local ‘Chaos Index’ Development of the Chaos Index was agreed to help identify individuals or groups that The multi-agency partnership was keen for the Chaos Section 5: the New Directions Team (NDT) could target. Index to focus on behaviours. The local case studies Research were analysed to ascertain consistent behaviours and It was important from the start to understand the to understand the level of impact of these behaviours. Section 6: different perspectives of the multi-agency partnership Standardised assessments were drawn on to support Glossary which included social services, primary care, mental the development of the Chaos Index but the essential health services, housing, youth inclusion services, the element was ensuring that the index reflected the range police, drug and alcohol services, Jobcentre Plus, the of behaviours identified through the local case studies Learning and Skills Council and the volunteer centre thus reflecting the local population of Merton. and find out who they considered the new team would

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Section 2: Case studies Æ Click to go to Document map To ensure reliability and consistency in assessment, it The pilot showed that the Chaos Index was easy to use Clinical was agreed the team manager would carry out all the and understandable. However, there were concerns assessment tools Introduction Chaos Index assessments of referrals to the NDT team. about people who were potentially marginal especially Schemes for when services considered the scoring of a person could young people Piloting the Chaos Index change within a short period of time. For example, a Section 1: The Chaos Index was piloted across several of the person might be leading a chaotic lifestyle resulting High support An outline of agencies from the multi-agency partnership including in current negative social outcomes, but because they schemes for adults the key issues the police, mental health services, alcohol/drug services were engaged with frontline services they were scoring Staff capacity Section 2: and the youth inclusion services. A key aim of the pilot ‘2’ on the ‘engagement with frontline services’ criterion building and support Case Studies was to establish an eligibility threshold on the index for which would not make them eligible to continue the referral to the NDT. assessment – or, therefore, the NDT. However, agencies Section 3: thought that this situation could change and the person Definitions and Each agency carried out the piloting as a desktop could score 3 or 4 within a short period of time thus weblinks exercise based on existing knowledge of clients in making that person potentially eligible for the NDT Merton. They also considered clients they thought service. This concern has been addressed through ways Section 4: should be eligible for the NDT and those people they of working between the NDT and other agencies. Guidance and thought would not. Agencies were also asked to good practice comment on the index including: Some members of the steering group and several of the • how easy it was to use agencies who piloted the index suggested the name Section 5: should be changed to a less pejorative term. Nobody how understandable it was Research • wanted an individual who had been assessed under the • whether there were criteria that were missing Chaos Index to see this as a ‘badge of honour’! Section 6: • whether the anchor points on the index were correct; Glossary and The name of the assessment was changed to the • whether the distance between the anchor points New Directions Team assessment. were sensible and understandable.

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Section 2: Case studies Æ Click to go to Document map Outcomes from the pilot – and further review • the eligibility threshold was set at the right level; and Clinical Following the piloting a threshold for eligibility to the • the team was targeting people who were not assessment tools Introduction NDT was set at a score of 22 or above. It was agreed engaging with frontline services. Schemes for that the threshold and the NDT assessment (the former young people Section 1: Chaos Index) would be reviewed after six months. Review of NDT assessment after six months The aim of the review would be to check whether: Thirty referrals were made during the six-month High support An outline of • the NDT assessment worked in practice and had operational period. The highest number of referrals schemes for adults the key issues face validity came from the police. Staff capacity Section 2: building and support Case Studies

Section 3: Table 1: Referral sources and numbers, accepted referrals, gender and ethnicity Definitions and weblinks Referral Total Gender Ethnicity Accepted Gender Ethnicity source referrals (% male) (% white) referrals (% male) (% white) Section 4: Police 13 38 85 9 33 100 Guidance and Probation 1 100 100 1 100 100 good practice General hospital 1 100 100 0 - - Section 5: Adult mental health 3 67 33 2 50 50 Research Older people team 1 100 100 0 - - Housing 2 100 50 2 100 50 Section 6: Drug services 4 75 75 2 50 50 Glossary YMCA 2 50 50 1 100 100 Faithin Action 1 100 100 1 100 100 Physical disability team 1 0 Not stated 1 0 Not stated A relative 1 0 100 1 0 100 TOTAL 30 57 82 20 50 89

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Section 2: Case studies Æ Click to go to Document map Of the referrals not taken on by the team a total of seven Does the NDT assessment work and have Clinical were not appropriate: four did not score above ‘2’ on the face validity? assessment tools Introduction We also looked at how the NDT assessment works in initial question of ‘engagement with frontline services’ Schemes for which ended the assessment process and three people operation and whether it has face validity by looking at: young people Section 1: were not residents of the London Borough of Merton. the assessments scores for the six-month period • High support An outline of Only four people did not meet the eligibility threshold the feedback from the NDT team manager in terms • schemes for adults the key issues of 22 points. It had been agreed that borderline scores of whether: would be discussed. One assessment scored ‘21’ and it the criteria and anchor points in the assessment Staff capacity Section 2: was decided, based on the person’s circumstances, to • reflected the behaviours of the referrals made to building and support Case Studies take them onto the caseload of the team. the NDT team; and local agencies had provided feedback that the Section 3: The NDT assessment does not appear to discriminate in • criteria and anchor points were not reflective of Definitions and terms of gender (57% referred and 50% of the accepted local circumstances or key behaviours had weblinks caseload are male) or ethnicity (82% referred and 89% been omitted. of the accepted caseload were white). The high referral Section 4: and acceptance rate for white people is consistent with • The feedback received at the multi-agency partnership meetings. Guidance and agencies that support homeless and vulnerably housed good practice people across London3. Section 5: Research Section 6: Glossary

3 Broadway (2008) Street to Home: Annual report for London 1 April 2007 – 31 March 2008. London: Broadway

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Section 2: Case studies Æ Click to go to Document map The assessment scores Clinical Of the 20 clients taken onto the caseload, all met the The average scores and ranking provide a sense of assessment tools Introduction threshold of the first question (scoring 3 or 4) on the the ‘typical client’ the team is serving. The ranking Schemes for engagement with frontline line services which was the highlights that ‘risk to others’ was the highest scoring young people first step in the eligibility to the team. Table 2 shows criterion for all the clients followed by ‘risk from others’. Section 1: the breakdown scores by criteria for all 20 assessments The lowest scoring criterion was ‘intention to High support An outline of accepted by the team and shows that in terms of each self-harm’. schemes for adults the key issues criterion there was a wide range in the behavioural Staff capacity Section 2: anchor points scored within the assessment process building and support Case Studies (as one would expect). Section 3: Definitions and Table 2: Scores for the total caseload of the team (n=20) weblinks

Criterion Range Average Rank Section 4: Engagement with frontline services 3 – 4 3 N/A* Guidance and Intention to self-harm 0 – 2 1 9 good practice Unintentional self-harm 0 – 4 3 6 Section 5: Risk to others 2 – 6 4 2 Risk from others 0 – 8 6 1 Research Stress and anxiety 2 – 4 3 3 Section 6: Social effectiveness 1 – 4 2 8 Glossary Alcohol / drugs abuse 0 – 4 3 5 Impulse control 1 – 4 2 7 Housing 1 – 4 3 4

* Engagement with frontline services is not ranked as all clients have to achieve a score of 3 or more to be eligible to continue the assessment.

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Section 2: Case studies Æ Click to go to Document map Feedback from the NDT team manager Checking that the NDT assessment targets the Clinical The ongoing feedback from the NDT team manager is right group of people assessment tools Introduction that the criteria and anchor points work and appear The average and ranking scores from Table 2 provides a Schemes for correct. In addition, there has not been any feedback behavioural profile of an average or ‘typical’ client who young people from local agencies to contradict this. was referred and accepted onto the NDT team caseload Section 1: in the first six months of operation. Box 1 illustrates the High support An outline of Feedback from the multi-agency partnership group behavioural profile of a ‘typical’ client on the caseload. schemes for adults the key issues The multi-agency partnership concluded (at the Staff capacity Section 2: steering group in August 2008) that the assessment building and support Case Studies appeared to be identifying the target group of people and that the assessment seemed to work effectively Section 3: within the context of Merton. Definitions and Looking at the eligibility threshold weblinks Excluding the 7 inappropriate referrals, only 4 people Section 4: did not meet the eligibility threshold for the NDT Guidance and assessment. One person was a borderline score and good practice was taken on by the team based on the person’s circumstances. The remaining three total scores for the Section 5: assessment were 18, 15 and 20. Research Based on this review it would seem that the original Section 6: eligibility threshold set at 22 points, with the caveat Glossary that there will be a discussion on borderline cases, was the correct threshold.

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Section 2: Case studies Æ Click to go to Document map Conclusion Clinical Box 1: Behavioural profile of a 'typical' NDT client assessment tools Introduction An individual who is non-compliant with routine They regularly use alcohol or abuse drugs which Schemes for activities or reasonable requests, does not follow a causes significant effect on functioning resulting in young people Section 1: daily routine though may keep some appointments. aggressive behaviour to others. The individual has a High support An outline of high risk to their physical safety as a result of self- schemes for adults the key issues They are subject to the probable occurrence of abuse neglect, unsafe behaviour or inability to maintain a or exploitation from others and pose a risk to the safe environment. Staff capacity Section 2: property of others and/or pose a minor risk to the building and support Case Studies physical safety of others. In response to stress the They have temper outbursts and/or aggressive person has very limited problem-solving skills and behaviour of moderate severity and have had at Section 3: becomes hostile and aggressive to others. least one episode of behaviour that is dangerous or Definitions and threatening. They have marginal social skills that weblinks They have high housing support needs and are either sometimes create interpersonal friction or appear Section 4: at immediate risk of losing their accommodation or inappropriate. They pose minor concerns about the living in short-term/temporary accommodation. risk of deliberate self-harm or a suicide attempt. Guidance and good practice Section 5: Based on this review it would appear that the NDT The NDT assessment in operational use is achieving the Research assessment is targeting the group of people whom the original aim in being able to target residents from the multi-agency partnership were aiming to reach out to London Borough of Merton who are not engaging with Section 6: when originally bidding for the pilot project. frontline services, resulting in multiple exclusion, chaotic Glossary lifestyles and negative social outcomes for themselves, families and communities. The NDT assessment works, has face validity and the original threshold set for eligibility to the team seems to be correct.

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Section 2: Case studies Æ Click to go to Document map New Directions Team Assessment Criterion 1, engagement with frontline services, tests Clinical the basic eligibility for New Direction team, if a score assessment tools Introduction of 0 – 2 is achieved then the person is not eligible to Instructions Schemes for complete the assessment or be considered for the team. The New Directions Team assessment is used young people Section 1: in assessing whether someone referred to the Client Name High support An outline of New Directions Team is appropriate for the service. schemes for adults the key issues Date of birth The assessment will not be the only criterion to be used Staff capacity Section 2: Address in determining service eligibility, and certain vulnerable building and support Case Studies groups of people will be given priority: Section 3: • care leavers, particularly those with multiple risk factors e.g. school exclusion Definitions and Home telephone weblinks • young offenders • prisoners facing release from HMP Wandsworth Mobile Section 4: • repeat offenders or former prisoners with drug/ Referrers name, organisation and contact details Guidance and alcohol problems good practice people with particularly pronounced housing • Section 5: difficulties Research The items in the assessment are rated on a 5-point Person carrying out assessment Section 6: response format with 0 being a low score and 4 being Glossary the highest score, There are two criteria where 0 is the lowest score and 8 is the highest. There are 10 criteria in Date total each with 5 anchor points.

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Section 2: Case studies Æ Click to go to Document map Select ONE statement that best applies to the person 2 Intentional self-harm Clinical being assessed. Base all scores on the past one month assessment tools Introduction 0 = No concerns about risk of deliberate self-harm or suicide attempt Schemes for 1 Engagement with frontline services young people Section 1: 1 = Minor concerns about risk of deliberate self- High support An outline of 0 = Rarely misses appointments or routine harm or suicide attempt activities; always complies with reasonable schemes for adults the key issues requests; actively engaged in tenancy/ 2 = Definite indicators of risk of deliberate self- Staff capacity Section 2: treatment harm or suicide attempt building and support Case Studies 1 = Usually keeps appointments and routine 3 = High risk to physical safety as a result of activities; usually complies with reasonable deliberate self-harm or suicide attempt Section 3: requests; involved in tenancy/treatment Definitions and 4 = Immediate risk to physical safety as a result of weblinks 2 = Follows through some of the time with daily deliberate self-harm or suicide attempt routines or other activities; usually complies Section 4: with reasonable requests; is minimally Guidance and involved in tenancy/treatment good practice 3 = Non-compliant with routine activities Section 5: or reasonable requests; does not follow Research daily routine, though may keep some appointments. Section 6: Notes 4 = Does not engage at all or keep appointments Glossary

If score for ‘Engagement with frontline services’ is 0 – 2 please stop, end of assessment If score is 3 or 4 please continue Æ

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Section 2: Case studies Æ Click to go to Document map 3 Unintentional self-harm 4 Risk to others Clinical assessment tools Introduction 0 = No concerns about unintentional risk to 0 = No concerns about risk to physical safety or physical safety property of others Schemes for young people Section 1: 1 = Minor concerns about unintentional risk to 1 = Minor antisocial behaviour High support An outline of physical safety 2 = Risk to property and/or minor risk to physical schemes for adults the key issues 2 = Definite indicators of unintentional risk to safety of others Staff capacity Section 2: physical safety building and support 3 = High risk to physical safety of others as a result Case Studies 3 = High risk to physical safety as a result of of dangerous behaviour or offending/criminal Section 3: self-neglect, unsafe behaviour or inability to behaviour maintain a safe environment Definitions and 4 = Immediate risk to physical safety of others as weblinks 4 = Immediate risk to physical safety as a result of a result of dangerous behaviour or offending/ self-neglect, unsafe behaviour or inability to criminal behaviour Section 4: maintain a safe environment Guidance and good practice Section 5: Research Section 6: Notes Notes Glossary

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Section 2: Case studies Æ Click to go to Document map 5 Risk from others 6 Stress and anxiety Clinical assessment tools Introduction 0 = No concerns about risk of abuse or exploitation 0 = Normal response to stressors from other individuals or society Schemes for 1 = Somewhat reactive to stress, has some coping young people Section 1: 1 = Minor concerns about risk of abuse or skills, responsive to limited intervention High support An outline of exploitation from other individuals or society 2 = Moderately reactive to stress; needs support in schemes for adults the key issues 2 = Definite risk of abuse or exploitation from other order to cope Staff capacity Section 2: individuals or society building and support 3 = Obvious reactiveness; very limited problem Case Studies 3 = Probably occurrence of abuse or exploitation solving in response to stress; becomes hostile Section 3: from other individuals or society and aggressive to others Definitions and 4 = Evidence of abuse or exploitation from other 4 = Severe reactiveness to stressors, self- weblinks individuals or society destructive, antisocial, or have other outward manifestations Section 4: Guidance and good practice Section 5: Research Section 6: Notes Notes Glossary

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Section 2: Case studies Æ Click to go to Document map 7 Social effectiveness 8 Alcohol / drug abuse4 Clinical assessment tools Introduction 0 = Social skills are within the normal range 0 = Abstinence; no use of alcohol or drugs during rating period Schemes for 1 = Is generally able to carry out social interactions young people Section 1: 1 = Occasional use of alcohol or abuse of drugs with minor deficits, can generally engage in High support An outline of without impairment give-and-take conversation with only minor schemes for adults the key issues disruption 2 = Some use of alcohol or abuse of drugs with Staff capacity Section 2: some effect on functioning; sometimes 2 = Marginal social skills, sometimes creates building and support Case Studies interpersonal friction; sometimes inappropriate inappropriate to others Section 3: 3 = Uses only minimal social skills, cannot engage 3 = Recurrent use of alcohol or abuse of drugs in give-and-take of instrumental or social which causes significant effect on functioning; Definitions and conversations; limited response to social cues; aggressive behaviour to others weblinks inappropriate 4 = Drug/alcohol dependence; daily abuse of alcohol Section 4: 4 = Lacking in almost any social skills; inappropriate or drugs which causes severe impairment of Guidance and response to social cues; aggressive functioning; inability to function in community good practice secondary to alcohol/drug abuse; aggressive behaviour to others; criminal activity to support Section 5: alcohol or drug use Research Section 6: Notes Notes Glossary

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Section 2: Case studies Æ Click to go to Document map 9 Impulse control 10 Housing Clinical assessment tools Introduction 0 = No noteworthy incidents 0 = Settled accommodation; very low housing support needs Schemes for 1 = Maybe one or two lapses of impulse control; young people Section 1: 1 = Settled accommodation; low to medium minor temper outbursts/aggressive actions, High support An outline of housing support needs such as attention-seeking behaviour which is schemes for adults the key issues not threatening or dangerous 2 = Living in short-term/temporary Staff capacity Section 2: accommodation; medium to high housing 2 = Some temper outbursts/aggressive behaviour; building and support Case Studies moderate severity; at least one episode of support needs behaviour that is dangerous or threatening 3 = Immediate risk of loss of accommodation; Section 3: 3 = Impulsive acts which are fairly often and/or of living in short-term / temporary Definitions and moderate severity accommodation; high housing support needs weblinks 4 = Frequent and/or severe outbursts/aggressive 4 = Rough sleeping / "sofa surfing" Section 4: behaviour, e.g. behaviours which could lead to Guidance and criminal charges / Anti Social Behaviour Orders good practice / risk to or from others / property Section 5: Research Section 6: Notes Notes Glossary

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Section 2: Case studies Æ Click to go to Document map Scoring Outcome Clinical assessment tools Introduction Please insert the assessed score against each criterion Referral accepted: YES NO Schemes for point and add up the total score. young people Section 1: If not accepted what advice guidance has been given High support An outline of Criterion Score to referrer? schemes for adults the key issues 1 Engagement with frontline services Staff capacity Section 2: building and support Case Studies 2 Intentional self-harm 3 Unintentional self-harm Section 3: Definitions and 4 Risk to others weblinks 5 Risk from others Section 4: 6 Stress and anxiety Guidance and good practice 7 Social effectiveness Section 5: 8 Alcohol / drug abuse Research 9 Impulse control Section 6: 10 Housing Glossary

© South West London & St George's Mental Health NHS Trust TOTAL SCORE / 48 Contact: [email protected]

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Section 2: Case studies Æ Click to go to Document map Homeless Link Outcomes Programme • increase awareness of good practice in outcomes Clinical approaches assessment tools Introduction Snapshot summary • improve services for vulnerable people who may be Schemes for at risk of homelessness within other sectors; and young people Section 1: The aim of the Homeless Link Outcomes Programme is enable the sector to improve its services through • High support An outline of to support organisations to improve their services to good outcomes data. end homelessness. schemes for adults the key issues Staff capacity Section 2: We see the programme as a major opportunity The Outcomes Star System building and support Case Studies to promote the value of an outcomes approach in The Homeless Outcomes website has comprehensive helping services to focus on the needs, potential and guides for staff and clients in how to use the star. Section 3: development of each individual person. Organisations can create and then store stars online. Definitions and The website content is all free. weblinks Background Section 4: Homeless Link has run the Outcomes Programme The website also allows the reporting of outcomes for individuals, projects or for the organisation as a whole. Guidance and which includes the Outcomes Star tool and the online good practice Outcomes Star System since June 2008. It also allows you to: • show service users a picture of their progress at the Section 5: touch of a button The Outcomes Star is widely recognised as an example Research of good practice. • summarise your outcomes in a simple visual format; and Section 6: Through our outcomes programme we aim to: • benchmark your performance with other similar Glossary • encourage organisations to have a shared philosophy organisations. of an outcomes approach • enable homelessness agencies to access and use outcomes measurement tools that meet their needs

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Section 2: Case studies Æ Click to go to Document map The Outcomes Star was developed by Triangle All the information about the Outcomes Star System is Clinical Consulting, originally for St Mungo's, and was at: www.homeless.org.uk/outcomes-star-system assessment tools Introduction subsequently widely tested and revised for the Schemes for London Housing Foundation. Contact: [email protected] young people Section 1: High support An outline of The Outcomes Star schemes for adults the key issues Staff capacity Section 2: building and support Case Studies

Section 3: Definitions and weblinks Section 4: Guidance and good practice Section 5: Research Section 6: Glossary

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Section 2: Case studies Æ Click to go to Document map Schemes for young people Clinical assessment tools Introduction Schemes for These case studies offer examples of schemes young people designed to meet the emotional and psychological What we do and how we do it Section 1: needs of young people who are homeless or at risk The programme offers intensive care for up to 12 High support An outline of of homelessness, including those in contact with the months for each individual, as well as a comprehensive schemes for adults the key issues criminal justice system. programme of support for their family. The scheme is Staff capacity Section 2: based on the Multi-dimensional Treatment Foster Care building and support Case Studies Intensive Fostering – (MTFC) model which has been used successfully with offenders in Oregon since the 1980s. This model is Section 3: based on a system of points and levels which reward Youth Justice Board Definitions and appropriate behaviour. weblinks Snapshot summary A support team is employed to work with: Section 4: The Intensive Fostering programme, funded by the Youth the child or the young person in developing their social Guidance and Justice Board, is an alternative to custody for children • skills and changing their behaviours and attitudes good practice and young people whose home life is felt to have contributed significantly to their offending behaviour. • the birth family by offering a range of support, Section 5: including family therapy, counselling and Research parenting skills Background • the foster carer by providing daily contact with a Section 6: Intensive Fostering ensures young people get the supervisor to discuss the young person’s behaviour Glossary support they need within their community to address patterns and ensure that any potential problems are those factors that may have contributed to their identified before they become critical. offending behaviour. The programme, like other community penalties, also aims to hold a young All Intensive Fostering carers are assessed, registered and person to account for their offences. trained by the local authority. Carers are also required

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Section 2: Case studies Æ Click to go to Document map to have in-depth training in the MTFC model as well as Family liaison pilots – Clinical knowledge of offending behaviour, the legal framework assessment tools Introduction and the work of youth offending teams (YOTs). Youth Justice Board Schemes for young people Carers should also receive training on: Snapshot summary Section 1: understanding child/adolescent development High support An outline of • Work has started in six pilot sites to ensure children and schemes for adults the key issues • methods of communicating with young people young people with mental health, learning disabilities dealing with challenging behaviour and other issues such as family conflict, homelessness Staff capacity Section 2: • building and support risk management or drug and alcohol misuse get the help they need as Case Studies • soon as they come into contact with the police. drug misuse. Section 3: • Definitions and The Intensive Fostering scheme is currently being Background weblinks piloted with foster care providers in Hampshire, Staffordshire, London, and Trafford and in 2010 The aim of the six Youth Justice Liaison and Diversion Section 4: schemes is to prevent further offending and avoid future Cambridgeshire and Peterborough. Placements of Guidance and harm to victims by tackling, at the earliest possible young people in homes began in early 2005. The pilot good practice started in 2005 and we are waiting for the evaluation to opportunity, the problems that have led young people be published in summer 2010. to get into trouble. The scheme does not aim to replace Section 5: sanctions for serious crimes. Research Intensive Fostering emerged following the Anti-social Behaviour Act 2003, which makes a provision to include The scheme is supported by the Department of Health, Section 6: foster care as a requirement of a Supervision Order. the Youth Justice Board, the Department for Children, Glossary Schools and Families, the Ministry of Justice and the Contact: [email protected] Sainsbury Centre for Mental Health.

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Section 2: Case studies Æ Click to go to Document map What we do and how we do it High support hostels – Depaul UK Clinical assessment tools Introduction Scheme workers liaise closely with the police and the Crown Prosecution Service in police custody suites to Snapshot summary Schemes for young people identify those young people who need additional help. Depaul UK, in partnership with two local authorities, Section 1: In cases where mental health, learning disabilities or has set up two hostel projects in Rochdale and Oldham High support An outline of drug and alcohol difficulties are suspected, workers will to deal with young people who have multiple and schemes for adults the key issues help these young people and their families get speedy complex needs and to assist the authorities in meeting Staff capacity specialist assessments. They will also work hard to get Section 2: the requirements of the Public Service Agreements building and support young people and their families into the full range of 12 and 16. Case Studies services they need. Section 3: The projects are high-support – with staff present at all Definitions and Contact: [email protected] times – in purpose-built, self-contained flats for eight to nine young people. weblinks Section 4: Each young person has a personal support plan and Guidance and external support from the funding authority, social good practice services, the youth offending team or a worker from Child and Adolescent Mental Health Services (CAMHS). Section 5: Research Background Section 6: In many local authority areas there is likely to be a Glossary cohort of young people aged 16 to 23 with multiple and complex needs. These young people have often been in care, suffered some form of trauma or experienced homelessness.

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Section 2: Case studies Æ Click to go to Document map Their needs may arise from and include: What we do and how we do it Clinical multiple placements assessment tools Introduction • We aim to offer homeless and disadvantaged young • chaotic families people and care leavers the opportunity to fulfil their Schemes for • drug and alcohol abuse potential and move towards an independent and young people Section 1: • offending behaviour positive future through providing safe, secure and High support An outline of emotional problems supported accommodation; and to plan for the schemes for adults the key issues • transition to adult mental health services • mental health issues Staff capacity Section 2: self-harm building and support Case Studies • We aim for our clients to: ADHD; Asperger’s Syndrome and so on. • • develop independent living skills Section 3: Many local authorities find that they cannot place young • address any emotional, mental and/or physical Definitions and people in appropriate accommodation so they have to health issues behavioural/learning difficulties weblinks resort to unsatisfactory options like bed and breakfast or address drug and alcohol issues • Section 4: expensive options like placing them out of the local area. engage in meaningful activity, training, education, • Guidance and employment or voluntary work good practice Mixed funding has come from a range of sources • improve chances of obtaining and maintaining including: accommodation Section 5: • Supporting People • to move on positively Research • The primary care trust • reduce the risk of reoffending Section 6: • Children’s Services • increase confidence and self-esteem Glossary • Drug and Alcohol Action Team • build positive relationships with family and friends • Youth Outreach Services (YOS) and other social networks.

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Section 2: Case studies Æ Click to go to Document map Depaul UK developed a new framework for support • 39% of young people were identified as having a Clinical planning which is aligned with the five Every Child mental health need, and there was a 77% assessment tools Introduction Matters outcomes. A toolkit was developed in-house in success rate in achieving improvement. Schemes for conjunction with staff and young people which helps 54% had a substance misuse need and 22% • young people Section 1: young people to identify their own goals, review their improved in this area. progress and record their achievements. High support An outline of 72% had difficulties with family and friends and 92% • schemes for adults the key issues successfully improved their relationships. The projects run an in-house resettlement programme, Staff capacity Section 2: which helps young people gain points towards their • Out of 93% who had an identified training/education building and support Case Studies future housing tenancies. The young people all have a need, 61% achieved an outcome in participating in training/education. Personal Support Plan, and a series of programmes that Section 3: include techniques such as CBT. Boundaries setting, • Out of 33 young people, all young people moved goal setting, ‘parenting’ and external interventions are on positively except for 4 who moved on to other Definitions and agreed in the plan. temporary accommodation and 2 to bed and weblinks breakfast. Section 4: Many young people come with safeguarding issues, Guidance and and one of the project managers sits on the In managing self-harm, over half of the young people good practice safeguarding panel. improved in this area. 18 per cent of all clients identified a problem with avoiding harm to others. 50 per cent of Section 5: those felt they had achieved a successful outcome. The projects are integrated into the community and Research local services. Where possible, families are involved and family mediation is also provided. The project clearly reduces offending, anti-social Section 6: behaviour, hospitalisation, mental health high-cost Glossary Some outcomes achieved placements, as well as demands on other services. Both projects measure outcomes consistent with the Every Child Matters agenda through a specifically Contact: [email protected] designed Support Planning template.

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Section 2: Case studies Æ Click to go to Document map Kids Company, London Services are extremely fragmented and are Clinical often experienced by our children and young assessment tools Introduction people as being too complex for them to navigate. Schemes for Snapshot summary They require a comprehensive system of care that is young people Section 1: Kids Company is a charity which provides practical, child/young person-centred and that addresses the emotional and educational support to marginalised psychological, emotional and social fragmentation High support An outline of and vulnerable inner-city children and young people. that they struggle with when engaging with current schemes for adults the key issues statutory services. Kids Company currently assists approximately 14,000 Staff capacity Section 2: children with therapeutic and practical interventions building and support Case Studies through street level centre that operate predominantly A sample of the case histories of young people on a self-referral basis, through an educational accessing one of the Kids Company’s street level Section 3: centres shows the type of problems they experience: academy, a therapy house as well as in 38 inner city Definitions and London schools. • 84% – homelessness weblinks • 82% – substance misuse Section 4: Background • 81% – criminal involvement, often to feed and clothe younger siblings Guidance and The children and young people who come to Kids 83% – sustained complex trauma in childhood good practice Company typically present with a lack of basic life skills • and disorganised emotional development. As a result • 87% – emotional difficulties and mental Section 5: they are often unable to organise themselves around health problems Research social or welfare activities that would sustain them; 39% – young carers struggling to cope • Section 6: for example, maintaining financial support through applying for benefits when they are not in paid At the two street level centres, 50-60% of the Glossary employment, or managing their finances to prevent males using the service from age 13 upwards have them from getting into arrears and spiralling into debt. been excluded from school and before engaging Gaps in current statutory service provision do not with Kids Company were not in education accommodate these developmental challenges. or employment.

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Section 2: Case studies Æ Click to go to Document map What we do and how we do it The provision of comprehensive reparative care is Clinical designed to address the underlying developmental assessment tools Introduction In order to meet such complex needs and the myriad of challenges and give our children and young people Schemes for developmental challenges experienced by our children the relationships, care, structure and enrichment young people and young people, the model of care adopted by Kids experiences that all children have a basic right to in Section 1: Company involves a ‘wrap around’ service; a their lives. Kids Company work is based on attachment High support An outline of multifaceted approach which takes into account the theory, and the development of new relations of schemes for adults the key issues neglect and fragmented functioning that results from trust – ‘re-parenting’ – is central. We recognise that Staff capacity Section 2: the experiencing of complex/developmental trauma, this is emotionally challenging work, and all staff are building and support Case Studies particularly during their most formative years of supervised weekly to help recognise, reflect on and development. We therefore employ a widely-skilled manage the emotional issues that are raised. team of professionals working at street level so that all Section 3: Despite being labelled as ‘hard to reach’ by statutory the issues can be addressed by one team in one place. Definitions and systems, approximately 95% of Kids Company’s weblinks This multidisciplinary approach combines health, young people self refer to its services. housing, emotional wellbeing, mental health, arts, Section 4: sports, youth justice, education and employment. Guidance and Our aim is to first stabilise each young person by For more information, contact Safeguarding: good practice meeting their practical needs, before helping them to [email protected] address emotional and behavioural difficulties. These Section 5: interventions are designed to strengthen, supplement Research or substitute the child’s parenting experience. Once the young person has achieved some sense of stability and Section 6: calm, we help them to identify talents and interests and Glossary so develop aspirations for the future.

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Section 2: Case studies Æ Click to go to Document map Clinical The Zone, Plymouth Background assessment tools Introduction The Zone is one of the largest voluntary sector youth Schemes for Snapshot summary agencies in the UK. young people Section 1: The Zone is a multi-function centre in Plymouth for 13-25 year-olds, with a wide range of services The majority of the general advice services are for High support An outline of available for all those who come through its doors, young people aged between 13 and 25 who live, work or schemes for adults the key issues learn in the Plymouth area but some projects work with from information and advice services to counselling Staff capacity Section 2: younger children and some with young people from and activity programmes and other personal building and support Case Studies support services. Tavistock and the South Hams areas. Section 3: This means that young people do not necessarily The Zone offers information on: Definitions and indicate what problems they might have simply by sexual health and sexually acquired infections weblinks • visiting The Zone. They can take the time, in a safe and • pregnancy testing and advice user-friendly atmosphere, to develop the trust to reveal Section 4: • contraception and advice problems that they may have kept hidden. Guidance and • benefit entitlements and how to claim good practice What we do and how we do it The Zone also offers help with: Section 5: The Zone offers support and advocacy with referrals to daily living difficulties Research • other specialist services, such as supported housing • problems in forming or maintaining relationships projects and hostels, available on a drop-in basis; and Section 6: • self-harm or suicidal behaviours or a sense of not cross-referrals within the Zone teams. Glossary belonging. There are outdoor activities, residentials, activity days and more, including support in building on existing skills and learning new ones, advocacy, group work and multi-systemic therapy.

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Section 2: Case studies Æ Click to go to Document map The Zone also houses the Early Interventions in Clinical Psychosis service, and the young people’s preventive assessment tools Introduction personality disorder network – one of the only NIMHE Schemes for personality disorder pilots specifically to focus on PD- young people preventive work with young people. Section 1: High support An outline of Insight, for example, is a small multi-disciplinary schemes for adults the key issues team, made up of workers from youth and community Staff capacity Section 2: work backgrounds, community psychiatric building and support Case Studies nursing, counselling, psychotherapy, social work and occupational therapy. Additionally, the team Section 3: is supported by input from a psychologist and a psychiatrist on a weekly basis. Although situated in the Definitions and voluntary sector, Insight has established links with the weblinks health and social services. Section 4: Guidance and Contact: [email protected] good practice Section 5: Research Section 6: Glossary

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Section 2: Case studies Æ Click to go to Document map High support schemes for adults Clinical assessment tools Introduction Schemes for These case studies offer examples of schemes young people which include a high level of support for clients with What we do and how we do it Section 1: emotional or psychological needs, as part of an overall Many of our service users experience drug and alcohol High support An outline of support package. issues alongside major mental health and behavioural schemes for adults the key issues problems. They often sleep rough for long periods of Staff capacity Section 2: time, outside the system, unable or unwilling to access building and support Case Studies 90 Lancaster Street, benefits or appropriate intervention for their health and Multiple Needs Unit, Birmingham social problems. Section 3: Definitions and Snapshot summary The project comprises 15 self-contained flats with weblinks a communal lounge, training kitchen, laundry and This Birmingham-based project aims to house, and keep communal gardens. There are 24-hour waking staff Section 4: housed, those individuals whose multiplicity of needs (no one works alone) working in the project. We offer Guidance and impact on their ability to maintain accommodation and a high standard of accommodation that reflects the good practice who are excluded from direct access accommodation worth of the individual and acts as a long-term base and community facilities. from which a person can begin to address their needs Section 5: with appropriate support. Research Section 6: Background The support offered is on a one-to-one basis and Glossary The Multiple Needs Unit is the first of its kind in the UK tailored to meet the individual’s changing needs and was set up nine years age to house men between the through a process of mutual negotiation. In reality this ages of 25 to 45 who experience a multiplicity of needs can mean that a support package/plan can sometimes and who have been serially excluded from all direct change daily depending on the person’s issues/wishes. access accommodation within the city of Birmingham.

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Section 2: Case studies Æ Click to go to Document map Responsive and assertive support Outcomes Clinical Support is both responsive and assertive to needs and Over the past nine years we have successfully housed assessment tools Introduction behaviours; behaviour that in other settings might over 89 individuals whose average stay in direct access, Schemes for lead to eviction is challenged and change is sought prior to moving to 90 Lancaster Street, would have young people through consultation and realistic goal-setting with ranged from a few hours to a few weeks. The average Section 1: the individual. stay of our service users is 12 to 18 months although High support An outline of people can stay up to two years if they wish and we still schemes for adults the key issues The project staff work across all disciplines and the house four of our original service users. Others have Staff capacity Section 2: project has built up strong relationships with health, gone on to live successfully in their own homes in the building and support Case Studies social services, probation, drug and alcohol services, community or moved onto more intensively supported education services, learning disabilities, local GPs and accommodation. Section 3: mental health teams within the Birmingham area to ensure there is a multi-agency approach to meeting No matter how long they stay, all our service users Definitions and service users’ needs. Working in this way has enabled are in contact with and using mainstream community weblinks us to address the housing needs of one of the most facilities before they leave 90 Lancaster Street. We Section 4: excluded groups in the city of Birmingham. believe the work at 90 Lancaster makes an outstanding Guidance and contribution to this most excluded client group. good practice Contact: [email protected] Section 5: Research Section 6: Glossary

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Section 2: Case studies Æ Click to go to Document map Home Base – Community Housing • feel worthless Clinical assessment tools and Therapy • find it hard to form relationships. Introduction Schemes for young people Snapshot summary What we do and how we do it Section 1: The Home Base programme consists of four distinct but High support An outline of A planned treatment environment for homeless ex- schemes for adults the key issues service personnel with psychological difficulties overlapping and inter-related treatment interventions. including post-traumatic stress disorder, complex However, the programme is designed as a whole with Staff capacity Section 2: trauma or a diagnosed personality disorder. each element complementing and supporting building and support Case Studies the others. Section 3: Background Emphasis on community membership Definitions and Each year Community Housing and Therapy (CHT) The programme stresses membership of a community weblinks delivers psychological therapies to around 35 homeless and focuses on the interpersonal and social context Section 4: ex-military personnel through its Home Base programme. of psychological disorders and wellbeing, rather than focusing solely on individual psychopathology or Guidance and skills training. good practice Those referred to Home Base will have become homeless partly as a result of the psychological A dispersed housing model allows for members’ Section 5: problems they experience. Many suffer from complex potential for independent living to be tested in a peer- Research trauma, depression or anxiety, or post-traumatic stress supported environment; but the community structure Section 6: disorder (PTSD). A number have a diagnosed personality encourages sharing responsibility and participating in disorder. These problems are frequently exacerbated by community decision making. This enables service users Glossary alcohol or drug abuse, unemployment and inadequate to support one another in the process of recovery, life skills. Nearly all will have: building on members’ experiences of solidarity with • a very limited support network comrades, but then takes this work to develop the skills • suffer from a lack self-esteem needed to live outside the military.

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Section 2: Case studies Æ Click to go to Document map Relationship between symptoms, outlook about the future. CBT interventions to develop Clinical behaviour and unconscious communication skills are particularly effective with assessment tools Introduction Weekly group psychotherapy sessions focus on complex trauma/PTSD sufferers, who otherwise tend to Schemes for discussion of the relationship between symptoms, avoid discussing the traumatic event. young people behaviours and unconscious factors. The aim is to Section 1: enable service users to understand their experiences, Emphasis on training for work High support An outline of particularly those traumatic experiences from their Finally, the programme places a strong emphasis schemes for adults the key issues military service, and to link these with any earlier on training for work. This aspect of the programme Staff capacity Section 2: experiences of trauma, especially those in early is run in partnership with Training for Life, building and support Case Studies childhood. This degree of openness relies and builds on Transitional Spaces and other organisations which the development of a secure attachment with other assess employment skills and deficits, and arrange Section 3: members of the community. courses and placements for homeless people and former members of the armed services. Definitions and weblinks Helping individual gain insight into source of problems In the period April 08–March 09, 52% of clients Section 4: In weekly individual sessions psychological disorders achieved employment and 28% had started Guidance and are treated through psychoanalytic psychotherapy. This training courses. good practice aims at encouraging the person to gain insight into the unconscious, repressed conflicts that are the source Support for staff Section 5: of problems with the goal of diminishing symptoms, Staff have weekly supervision, in individual and group Research developing less destructive patterns of relationships settings, to develop an open, questioning attitude and and changing anti-social behaviour. This in turn leads respect for clients’ experiences, and to understand the Section 6: to improved social and vocational functioning and relationship between events in the community and Glossary personal maturation. the unconscious processes involved in clinical work, particularly transference and projective identification. Cognitive behavioural therapy (CBT) is also used to influence dysfunctional emotions, behaviours and Contact John Gale: [email protected] cognitions aimed at restoring a more optimistic

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Section 2: Case studies Æ Click to go to Document map St George’s Crypt, Leeds needs be, the centre itself has 12 beds of Supporting Clinical People-funded accommodation, plus three respite beds assessment tools Introduction funded independently, and therefore with no eligibility Schemes for Snapshot summary strings, for up to six weeks. young people Section 1: St George’s Crypt offers a range of services during the day and night to homeless and destitute people The Crypt service operates on a principle of ‘elastic High support An outline of in Leeds. tolerance’ that can confront inappropriate behaviour, schemes for adults the key issues but will never reject the individual. So, for example, Staff capacity Section 2: those who act up at the Centre might be barred for building and support Case Studies Background a specific period but will always have the option of St George’s Crypt is not so much a place as a network. returning and negotiating, through, for example, Section 3: Combining direct access with various supported changes to their behaviour, why they should be allowed Definitions and accommodation options and a social enterprise work to try again. weblinks scheme, plus good links with other agencies in the area, the Crypt has developed a network of pathways which Long-stay accommodation for street drinkers Section 4: are carefully attuned to the needs and capacities of the In addition, Regent Terrace, a wet hostel, provides Guidance and service users. long-stay accommodation with 24-hour cover for 10 good practice street drinkers with long-term alcohol dependency and entrenched high-support needs: a ‘wraparound’ Section 5: What we do and how we do it service at the border of palliative care. Care plans here Research are slow-paced and long-term, and can include a detox, At the heart of the Crypt’s service is the Care Centre, Section 6: which by day offers lunch, showers, clean clothes and but the core principles are harm minimisation, with the Glossary advocacy to street homeless and destitute people in opportunity to live with dignity. Leeds. By night, the centre can offer food and shelter, but also a needs and risk assessment; and where Move-on service for detoxed residents possible individuals will be referred on directly to For move-on within the service, the Crypt has now vacancies in other direct access hostels nearby. But if developed Faith Lodge, a 15-bed unit for detoxed residents wishing to manage without drink or drugs.

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Section 2: Case studies Æ Click to go to Document map Random testing for substances is part of the agreement Social enterprises Clinical – the principle is ‘three strikes and you’re out’ – but There are two mini-social enterprises, Nurture and assessment tools Introduction individuals can also request more specific testing to the Charity Shop. Nurture offers skills training and Schemes for strengthen their resolve to quit. employment opportunities in horticulture. Nurture’s young people profits can help with financial assistance which helps Section 1: On the ground floor, the accommodation is shared with ‘no eligibility criteria’ accommodation. High support An outline of living, with full board. All tenants agree with their key schemes for adults the key issues worker to do three hours proactive work, personal Nurture runs a polytunnel and two allotments, selling Staff capacity Section 2: development or training every day. salad bags and eco-bags. The shop produces greetings building and support Case Studies cards and small items of costume jewellery. On the top floor, there are five fully independent Section 3: bed-sits, with one key worker for all five tenants. Many of the ex-residents stay involved as volunteers Definitions and There are also three move-on houses with shared or as workers in the Care Centre. They get support – weblinks accommodation. In each house a lead tenant or but they are also role models for current residents. mentor makes sure basic tasks are done and alerts the Twenty-two per cent of the staff including support Section 4: resettlement worker if there are problems that need workers, cleaners, and admin staff are former clients. Guidance and intervention. good practice The Crypt is being redeveloped to provide upgraded facilities for service users including 15 self-contained Section 5: accommodation units; a service users' lounge, a dental Research suite, three multi-purpose skills rooms and a new landscaped garden with major input from service users. Section 6: Glossary Contact: [email protected]

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Section 2: Case studies Æ Click to go to Document map Clinical Leeds NFA Health Centre What we do and how we do it assessment tools Introduction The first step in a person’s recovery is engagement. Schemes for Snapshot summary Recognising the difficulty that engagement presents to young people Section 1: The NFA Health Centre (NFAHC), part of NHS Leeds homeless people, the NFAHC has implemented a Community Health Care, provides multi-disciplinary ‘stepped-care’ model of therapeutic interventions High support An outline of primary healthcare to people of no fixed abode in Leeds, tailored to address these challenges. schemes for adults the key issues offering: Staff capacity Section 2: The first point of access to the service is through a daily ‘mental health first-aid’ building and support Case Studies • drop-in mental health clinic that any person, once group work of varying intensities • registered at the practice, can access whenever they wish Section 3: psychological counselling to. (The team also works closely with outreach agencies, • Definitions and to facilitate a way into appropriate interventions for those case management/care coordination weblinks • people experiencing difficulty in accessing the service.) development of robust support networks • Section 4: support in accessing ‘mainstream’ services. • Group work of varied intensities Guidance and The choices available to people wishing to use the good practice Background service include group work of varied intensities: The ‘Drop-In Group’ is an open group that people are Section 5: Approximately 70% of people accessing the NFAHC • able to access as and when they wish. It offers mental service experience complex trauma issues with Research health advice as well as the opportunity to sample attachment and/or relational difficulties that may group work and to begin to develop a therapeutic Section 6: manifest as difficulty in establishing or maintaining alliance with the group facilitators. Glossary relationships with others, and accommodation or employment difficulties. The intention is to provide • The ‘Wellbeing Group’ focuses on supporting people interventions that are timely, accessible, recovery- in developing a recovery tool using the WRAP model focused and relevant to the person’s current experience (Wellbeing and Recovery Action Plan). and immediate circumstances.

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Section 2: Case studies Æ Click to go to Document map • The ‘OK Group’ utilises Transactional Analysis Lifeworks – St Mungo’s Clinical Psychotherapy to facilitate a person’s understanding assessment tools Introduction of how their intra-psychic process impacts on their psychotherapy service Schemes for lives while supporting the person in bringing about young people and maintaining positive change. Snapshot summary Section 1: High support An outline of In addition to theses group activities, the staff offer/use: Lifeworks offer individual psychotherapy (up to 25 schemes for adults the key issues sessions) to chronically excluded adults in a variety of • Cognitive behavioural interventions settings, ranging from a frontline hostel to a medium Staff capacity Section 2: • Transactional Analysis (a humanistic, integrative secure unit in a psychiatric hospital. building and support Case Studies modality) Schema therapy Section 3: • Background • Person-centred counselling. Definitions and There is strong evidence for the link between complex weblinks needs, complex trauma and homelessness. But the staff team also stress that specific techniques Section 4: are not the key to successful engagement. Guidance and Of Lifeworks’ clients: good practice Contact: [email protected] • 52% lost a primary carer in early childhood (often violently, e.g. murder or suicide) Section 5: • over half were abused as children – and most have Research histories of chronic trauma since Section 6: 43% have been in prison • Glossary • 70% – 80% have mental health problems • two-thirds use three or more substances • all have either been in a psychiatric hospital or a hostel.

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Section 2: Case studies Æ Click to go to Document map Attendance by those who take up therapy is 75%, Clinical What we do and how we do it positively comparable to rates for many primary care assessment tools Introduction psychological therapy services working with far less The objective of Lifeworks is to enable the client to Schemes for manage their feelings and think things through better, damaged populations (and above IAPT targets). young people Section 1: and thereby to facilitate their ability to change the destructive patterns that keep them in chronic On the NIHME measure, 76% of clients show an overall High support An outline of exclusion. improvement. On the LHF Outcomes Star, Lifeworks schemes for adults the key issues clients are three times more likely to move from pre- Staff capacity Section 2: contemplation to consolidation (i.e. the whole range There are two key datasets for the outcomes – the building and support Case Studies of the cycle of change) than non-Lifeworks clients, and evidence-based NIHME Wellbeing Impact Assessment more than twice as likely to move from contemplation Measure, and the London Housing Foundation (LHF) Section 3: to consolidation. Outcomes Star, mapped against the stages of the well- Definitions and evidenced ‘cycle of change’. Both datasets cover the One hundred per cent of Lifeworks clients moved from weblinks wide range of psychosocial issues that characterise the ‘inactive’ to ‘active’ compared to 60 per cent of clients chronically excluded. Section 4: not in Lifeworks. Guidance and Lifeworks is also being evaluated through the Adverse good practice Cost-saving and health benefits Childhood Experience (ACE) evaluation, and we are People with complex needs often tend to ‘rattle around’ in the process of collecting data on specific client Section 5: the system, using lots of services but never really outcomes (e.g. around accommodation, voluntary work, Research moving on; many end up in homelessness hostels. substance use reduction, use of secondary care). Section 6: It costs around £500pw to support someone in a Clients are offered an initial assessment, to clarify that Glossary frontline hostel; Lifeworks costs £1,500 per client therapy is what the client wants: 67% take up therapy (assuming they use the full 25 sessions; not all do). (many of the remaining 33% do not come to the first If people are ready to move on just a few weeks earlier, session for various reasons: e.g. death, imprisonment, there is already a cost saving. moving hostel, eviction, abandonment, already in treatment, etc).

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Section 2: Case studies Æ Click to go to Document map Other cost-benefits are through reduced (re) Clinical Positive change in mental well being on the outcomes star hospitalisations, including those discharged from the assessment tools Introduction secure unit, and reduced relapse in clients of substance Schemes for misuse aftercare. Non Lifeworks clients Lifeworks clients young people Section 1: The benefit to our clients is best left to them to High support An outline of articulate: 60% schemes for adults the key issues of Staff capacity

cle Section 2: "I was drinking and using drugs for a Cy building and support Case Studies long time; I …lost it and ended up sleeping 100% rough. I had a lot of family problems and change movement Section 3: for a long time, thought it was all my fault. Definitions and Inactive 20 40 60 80 100 Through my work with Lifeworks I now know to active weblinks % of all clients movement it wasn’t just me, it was all of us… if my Section 4: parents had used this service things may have Guidance and turned out different. I think it could have The above graph compares data from Outcomes Stars for good practice helped them. I now realise that the drink, 58 St Mungo’s accommodation-based clients who had the drugs, [losing] the flat, the family, it’s all participated in Lifeworks with those for 825 St Mungo’s Section 5: accommodation-based clients who had not participated. linked… If it wasn’t for Lifeworks I’d be dead Research by now, no word of a lie." The graph shows the percentage of clients who Section 6: progressed from an ‘inactive’ phase on the stages of Glossary Lifeworks client change – either pre-contemplation or contemplation – to an ‘active’ phase – preparation, action or Contact: [email protected] consolidation. It takes those clients’ first star reading on that scale and compares it to their latest reading at the time of the analysis.

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Section 2: Case studies Æ Click to go to Document map Leicester Homeless Mental There is an additional STR (support worker) post that Clinical is funded by PCTs and managed by the mental health assessment tools Introduction Health Service charity Rethink in partnership with Leicestershire Schemes for Partnership NHS Trust (LPT). young people Snapshot summary Section 1: This collaborative partnership has been sustained High support An outline of The Leicester Homeless Mental Health Service (HMHS) over several years. The Rethink worker works within a schemes for adults the key issues provides assessment, treatment and support to recovery model to support clients with their life choices. Staff capacity Section 2: homeless adults over the age of 16 with mental health This post was developed in order to extend service building and support Case Studies difficulties across the city of Leicester. In addition to provision in Leicestershire and map further gaps in providing direct mental health services, the team also the service. aims to improve access to all mainstream social and Section 3: health care services for single homeless people in the Definitions and locality by advocating with mainstream mental health, What we do and how we do it weblinks social care and primary care providers and We have developed a service which is able to respond to Section 4: commissioners. clients’ needs as they arise and when the client is ready Guidance and to engage. good practice Background We aim to: Section 5: The team consists of: Improve the quality of life for homeless people in Research three full-time Registered Mental Health Nurses Leicester by: • Section 6: one part-time Associate Specialist Psychiatrist providing appropriate, personalised mental health • • Glossary • one full-time psychologist assessment and access to treatment services one half-time admin worker; and • assisting service users to access appropriate • accommodation • sessional input by a Consultant Psychiatrist (supervision). • facilitating access to mainstream mental health and other services

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Section 2: Case studies Æ Click to go to Document map • offering individual and group psychological services The support offered, although based on an access Clinical • promoting positive mental health. criteria of the person being homeless, may also include assessment tools Introduction assisting the transition to new tenancies. Some mental Schemes for We also aim to: health services focus on severe and enduring illness; young people Section 1: Improve other local services currently accessed by others are reluctant to see people with substance-use homeless people by: issues in addition to their mental health problems. We High support An outline of find it possible to assess every homeless person who schemes for adults the key issues sharing models of care with the voluntary and • approaches us (regardless of diagnosis) including people statutory sectors Staff capacity Section 2: with dual diagnosis, and who are still using substances. • disseminating specialist knowledge of mental health building and support Case Studies to people without a mental health background Our goal, when working with people with a history of Section 3: advising other professionals complex trauma, is as simple and as complex as just • Definitions and providing information and training to other staying in touch with them. Many are trapped in a • weblinks professionals cycle of abusive, transient relationships, aggression or liaising between hostel providers and mainstream substance misuse which may lead them to be excluded Section 4: • from hostels and back onto the streets. We try to make mental health services Guidance and our service as accessible as possible by meeting people Informal support and supervision for staff working good practice • wherever it suits them. with people who they often find difficult to engage. Section 5: It is accepted that a good therapeutic relationship is We have developed a service which includes homeless Research crucial to successful therapeutic work, but many of the people or those living in temporary accommodation people we work with have never had a reliable, stable, Section 6: who otherwise might be excluded from traditional consistent and trusting relationship with anyone. Much mental health services, either because they do not meet Glossary of our one-to-one work therefore is focused on the specific diagnostic criteria or their chaotic lifestyles basics, such as establishing a trusting relationship. make it difficult to negotiate and maintain links with these services.

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Section 2: Case studies Æ Click to go to Document map Developing the one-stop shop and day services, and weekly multi-disciplinary/ Clinical The team has developed from a ‘single post service’, to inter-agency meetings, facilitate excellent levels of assessment tools Introduction its current provision, following years of negotiation with communication. This degree of inter-agency Schemes for providers and purchasers. Before the opening of the co-operation is a real strength. young people Dawn Centre (multi-agency homeless accommodation/ Section 1: day centre/ health services) in January 2006, the Raising profile of mental health services and High support An outline of logistics of providing a dispersed service were very homelessness schemes for adults the key issues challenging. The development of the ‘one-stop shop’ Through developing good relationships with other Staff capacity Section 2: concept has facilitated our communication with other services, we can raise the profile of mental health building and support Case Studies agencies as well as the obvious advantages for the issues. By attending regular forums within local mental homeless clients. We continue to offer an outreach health services we also increase raise the profile of Section 3: service to all hostels rather than changing to a clinic homelessness within these services. Definitions and based service located only at the Dawn Centre. Until September 2007, we were unable to access LPT weblinks Often homeless people have become mistrustful of mental health records database at the Dawn Centre Section 4: services. By being accessible and approachable in places initially due to its non-NHS location. Following Guidance and where homeless people present, we have been able negotiations, however, access has now been facilitated good practice to build trust and mutual respect. The challenges of and this has greatly enhanced our working practice. supporting homeless people have altered in accordance Similarly, our close working relationship with the Section 5: with the developments in changing legislation and Homeless Primary Healthcare Service at the Dawn Research the logistics of accessing dispersed services. Homeless Centre has been enhanced by having the facility to people can be very chaotic in their lifestyles and our directly input into their computerised records. Section 6: clinical practice has to adapt accordingly. Glossary Seamless service from multi-disciplinary team Building strong links with frontline workers Our working practice has adapted to accommodate The team has built outstanding links with frontline the developments of the Crisis and Assertive Outreach workers within the wider homeless service including teams within LPT, which have enabled us to provide a primary healthcare, housing outreach, tenancy support more seamless service without duplicating provision.

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Section 2: Case studies Æ Click to go to Document map The team is multi-disciplinary but works cohesively. The Old Theatre, Broadway, London Clinical Over time we have built on mutual trust and respect assessment tools Introduction to facilitate joint collaborative working in the best Schemes for interests of our clients. The nurses have been involved Snapshot summary young people Section 1: in the implementation of the Homeless Nurses Group The Old Theatre is an accommodation-based service UK, which has amalgamated with the Homeless Health that supports serially-excluded ex-rough sleepers with High support An outline of Initiative (The Queen’s Nursing Institute). This is a complex needs. The project, run by Broadway and schemes for adults the key issues networking and peer support group for nurses working commissioned by Hammersmith and Fulham, aims to Staff capacity Section 2: with homeless people. provide clients with a safe place to call home where building and support Case Studies they can be supported to develop skills for The service participated and was highlighted in national independence and move on. Section 3: research that looked at access to mental health services for people who are homeless (DH, CSIP,CLG 1 Jan Definitions and 2007). In April 2008 the team were successful winners Background weblinks of the ‘Mental Health & Wellbeing’ category of the Previous exclusions show that normal hostel systems Section 4: East Midlands Regional – Health & Social Care Awards, have not worked for this client group. The Old Theatre Guidance and and went on to become finalists at the national event takes a more flexible, creative and individual approach. good practice held at Wembley Stadium in July 2008. The service also There is a high staff/client ratio, with 10 workers and highlighted as a good practice example in the recent two managers providing 24-hour support for 12 Section 5: report Down and Out (St Mungo’s December 2009). residents. House rules and visitors’ policies are Research written with clients to meet their individual needs Contact: [email protected] and to address the issues that contributed to Section 6: previous exclusions. Glossary

There is a team approach: each worker has in-depth knowledge of the clients and can provide support when it is needed. But each client also has a lead key worker to co-ordinate support and provide consistency.

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Section 2: Case studies Æ Click to go to Document map Managing relations with local community Clinical What we do and how we do it The Old Theatre service is also highly sensitive to assessment tools Introduction the need to manage relations with the neighbouring There is a focus on health and daily living skills – money Schemes for community, and do not see this as inconsistent management, attending appointments, cleaning and young people food preparation – alongside substance misuse and with providing support and feedback to the project’s Section 1: mental health specialist support. residents. The staff monitor activity outside the High support An outline of project by carrying out regular checks of the local area. schemes for adults the key issues In addition, through the use of cognitive behaviour When residents are seen drinking outside or causing Staff capacity Section 2: therapy (CBT) and motivational interviewing (MI) a nuisance, staff remind clients about the controlled building and support Case Studies techniques, clients are given the opportunity to drinking zone, their responsibilities under the project take responsibility for their actions and change their rules, and offer alternative activities inside the project Section 3: behaviour. One significant difference between the or with external agencies. If the anti-social behaviour Definitions and service and a standard hostel is that many of these continues, project staff contact the police for support weblinks services are provided in-house through agreed to enforce the controlled drinking zone and take further joint working protocols. action as necessary. Section 4: Guidance and Working closely with Street Outreach Response Team Access to local specialist services good practice There are on-site sessions on substance misuse Old Theatre staff also work closely with the Street from local specialist services, Outreach and Druglink, Outreach Response Team (SORT) to ensure any non- Section 5: and project workers will also co-ordinate referrals residents involved in street activity are directed away Research to external agencies for support with drug and from the project and supported to access appropriate alcohol use, mental health and physical health. services, such as housing. Project managers attend Section 6: Clients are supported to take part in activities regular meetings with representatives from the Police, Glossary outside the project such as basic skills classes, Outreach, Community Safety and Anti-Social Behaviour gardening, music, art, job club, training/education, teams to identify individuals causing a particular problem leisure activities and day trips. and agree action around support and enforcement.

Contact David Fisher: david.fi[email protected]

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Section 2: Case studies Æ Click to go to Document map Staff capacity building and support Clinical assessment tools Introduction Schemes for These case studies demonstrate a variety of ways in enabled services to meet their obligations under the young people which staff can be trained, supported and offered new outcomes framework. Section 1: supervision to work with clients experiencing High support An outline of complex trauma. Following on from the success of years one and two schemes for adults the key issues of the Foyer Health Programme, funded by the Big Staff capacity Section 2: Lottery's Well-being Fund, Foyer Managers have been building and support Case Studies Coaching Skills Training Course – keen to embed the coaching skills model within the Foyer Foundation Support Planning process for their staff teams. Section 3: Definitions and Snapshot summary Content weblinks The Foyer Federation has developed a life coaching skills In response to this, the Foyer Federation has now Section 4: programme for Foyer staff to support young people developed a two day Coaching Skills Training Course Guidance and with emotional and mental health problems. which covers the following essential areas of a coaching good practice approach to key work: The two-day course covers the essential areas of a • Principles of coaching Section 5: coaching approach to key work. • The GROW Model Research Communication skills for coaching Section 6: Background • • Reflecting on example coaching sessions Glossary Practitioners within the Foyer Federation staff team Factors effecting health, happiness and motivation identified that when applied to key-working with young • Values and beliefs people, elements of a Life Coaching approach provided • the perfect fit with the Foyer ethos – and, crucially, • Theories of human development • Learning coaching skills practice

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Section 2: Case studies Æ Click to go to Document map After day one, staff will be able to start putting their Westminster Cognitive Behaviour Clinical coaching skills into practice. Day two, which will be assessment tools Introduction delivered approximately four weeks later, is designed Therapy Project Schemes for to support staff to reflect on their practice and to young people offer further development. We are in the process of Snapshot summary Section 1: attempting to gain accreditation for the course. High support An outline of Cognitive Behaviour Therapy (CBT) has been found to Each day starts at 10am and ends at 4pm and as these schemes for adults the key issues be useful in enabling homeless people to address the days are very intensive it is important that staff are able issues underpinning repeat homelessness Staff capacity Section 2: to attend for both full days. building and support Case Studies A CBT staff training and supervision project was Contact Dave Pendle: [email protected] commissioned by Westminster City Council and Section 3: delivered by clinical and counselling psychologists. Definitions and weblinks Background Section 4: Westminster City Council commissioned a project to Guidance and evaluate the impact of a CBT training and supervision good practice package, designed and led by a clinical psychologist. Section 5: Content Research The training package consisted of four days of Section 6: workshops and two follow-up days designed to enable Glossary 30 frontline homelessness staff working across Westminster to use four specific CBT skills.

These were: • engagement in change 68 Mental health Good practice guide

Section 2: Case studies Æ Click to go to Document map formulation and cognitive flexibility Clinical • Results • basic change techniques assessment tools Introduction monitoring of effectiveness. Staff outcomes Schemes for • Data were gathered before the training, after training young people Section 1: One training day was also delivered to the managers of and after six months of supervision. Thirty staff High support An outline of the services in which the staff worked in order so they completed all the questionnaires before the training, schemes for adults the key issues could have an understanding of what was being done 28 completed the measures after the training and 12 people completed the supervision package. The results and to encourage buy-in. Staff capacity Section 2: showed that burnout dropped after the training course building and support Case Studies The supervision was delivered in groups of three, for and further, significantly reduced over the course of the 90 minutes every two weeks for six months by qualified supervision package. Section 3: clinical and counselling psychologists, who were Definitions and Client outcomes themselves supervised by the lead psychologist. weblinks Client outcomes were measured by the staff at up to Evaluation four time points over the six months of supervision. Section 4: Guidance and It was predicted that the training and supervision A number of behavioural measures were used (e.g. good practice package would: the number of incidents of aggression in a given time • reduce staff burnout period) in addition to the CORE (Clinical Outcomes in Section 5: • increase staff members’ perceptions of effective Routine Evaluation) as the main outcome measure of Research working with this complex group general mental health. Section 6: reduce negative beliefs about the population • Both the behavioural and CORE data were highly Glossary variable in terms of number of completed sets. Validated questionnaires were used to measure changes Not enough behavioural data were gathered to provide in these factors. In addition, data on services users’ a useful interpretation, however the CORE data showed general mental health functioning and incidence of improvements between Times One and Three, and asocial behaviours were gathered in order to evaluate then a slight worsening at Time Four, after six months the effect of the package on service user outcomes. 69 Mental health Good practice guide

Section 2: Case studies Æ Click to go to Document map (although the levels did not return to the Time One The Department of Health's Clinical levels, showing an overall improvement). The rise in assessment tools Introduction Time Four scores may have been due to two individuals Knowledge and Understanding Schemes for increasing their scores significantly, possibly due to Framework young people crises or difficult environmental factors. This is of course Section 1: a common occurrence within the population. Snapshot summary High support An outline of schemes for adults the key issues The key goal of the Knowledge and Understanding Conclusion Staff capacity Framework (KUF) is to improve service user Section 2: building and support This project provides further evidence that CBT can be a experience through developing the capabilities, Case Studies useful tool for frontline homelessness workers, and that skills and knowledge of the multi-agency workforces Section 3: the training and supervision package was effective in in health, housing, social care and criminal justice reducing staff burnout and increasing perceptions of who are dealing with the challenges of personality Definitions and effective working with a complex client group, as well disorder (PD). weblinks as reducing negative beliefs about the population. Section 4: There is some evidence that this is associated with Background improvements in mental health, although data Guidance and supporting this needs further work. The project won the We believe that the KUF can contribute to improving good practice the service user experience by: collaboration award at the London Regional NTA Section 5: awards ceremony in 2009. increasing the level of awareness and support offered • Research to staff Contact Dr Nick Maguire: [email protected] • reducing stress, burn-out and unhealthy working Section 6: Nik Ward: [email protected] environments Glossary • making services more efficient and effective.

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Section 2: Case studies Æ Click to go to Document map Content Behaviour Support Service, Clinical assessment tools Introduction The validated multi-level educational package includes Brighton and Hove the following: Schemes for young people • Personality Disorder Virtual Learning Awareness Snapshot summary Section 1: Programme (‘Raising Awareness’) The Behaviour Support Service is a dedicated team set High support An outline of • Validated Undergraduate Degree Programme up to support the work of supported housing providers schemes for adults the key issues (‘Developing Understanding and Effectiveness’) across the city. The long-term aim is to develop Staff capacity Section 2: • Validated Masters Degree Programme mechanisms to ensure that the psychological factors building and support Case Studies (‘Extending Expertise, Enhancing Practice’) that affect people's progress towards more secure housing can be addressed in a coordinated and Section 3: These high-quality educational programmes are comprehensive way. Definitions and delivered by leading practitioners and service user weblinks consultants. The team consists of counsellors and psychologists. The team draws on ideas from: Section 4: The Awareness Programme has a number of packages • cognitive behavioural therapy (CBT) Guidance and available including a Train the Trainers version. • solution-focused therapy good practice The BSc and MSc programmes are available as single motivational interviewing stand-alone modules (suitable as units of learning for • Section 5: Research Continuing Professional Development), or as whole The service remit is to focus on behaviour change programmes with associated qualifications. to break the cycle of eviction/abandonment, street Section 6: homelessness, hostel life/tenancy, and eviction/ Glossary For more information abandonment. There is a lot more detail about the programme aims and specific modules of these courses at the personality disorder website. Visit: www.personalitydisorder.org. uk/training/kuf/index.php

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Section 2: Case studies Æ Click to go to Document map In order to do this effectively the team was set up Clinical Background to deliver: assessment tools Introduction The behaviour support service was set up in response to: • one-to-one client work and staff consultation re Schemes for clients when this is more suitable • an increasing emphasis in the housing sector on young people Section 1: resettlement and proactively trying to help more regular free training courses (modules of eight weekly • High support An outline of people move on towards living more independently 3-4 hour sessions for eight staff) in theories and schemes for adults the key issues • a recognition that the emotional and psychological techniques the team use for working with this client needs of clients have an impact on so many aspects group. These courses support frontline staff to gain Staff capacity Section 2: of providing housing support and on resettlement skills and develop their practice to meet the complex building and support Case Studies outcomes needs of this client group; a dedicated website called • evidence that psychological interventions can be ‘Mortarnet’ www.mortarnet.org.uk Section 3: effective in addressing common issues that block Definitions and effective resettlement (e.g. emotional distress, Dedicated website weblinks behavioural issues) and in reducing Mortarnet also serves as a good practice guide for staff Section 4: repeat homelessness. as it helps enhance understanding of psychological Guidance and theories and knowledge of interventions that can help good practice How the service works hostel staff work with the different roles required of Section 5: We have encouraged support workers to refer: them. For example: Research new clients who have a history of eviction/ • beginning a key working relationship with a • service user abandonment Section 6: goals and support planning and ways of looking at • clients who are accumulating warnings because of • Glossary behaviour that could put their tenancy/licence at risk working with clients who are difficult to engage with • clients who, in their experience, have non-practical • dealing with overwhelming emotions, fear and anxiety, blocks to ‘move-on’ or have had an unsuccessful low mood, guilt and shame, managing our own stress attempt at move on. • positively managing risk and challenging behaviour • ending a key working relationship with a service user. 72 Mental health Good practice guide

Section 2: Case studies Æ Click to go to Document map The website also includes the ‘experience exchange’ Clinical for people to share good practice ideas throughout Mark's story assessment tools Introduction the city. The experience exchange links the bands 2, 3 Mark was referred to our service in September 2008 Schemes for and 4, of the integrated support pathway i.e. supported as his behaviour was putting his tenancy at risk, i.e. young people accommodation across the city to bring together new threatening suicide, self-harm and noise nuisance. Section 1: ideas for working with service users and to access more Alcohol and drug use was often a trigger to these events. High support An outline of schemes for adults the key issues support from Behaviour Support Service. Since leaving care Mark has had nearly three and a half years of living independently over the last Staff capacity Section 2: Below is an example of information shared on 20 years. The rest of the time he has a history of building and support Case Studies experience exchange after understanding and B&B, rough sleeping and staying in hostels. He said enhancing motivation training: he had received a personality disorder diagnosis Section 3: although he is not currently linked in with a mental Definitions and "I think I quite often leap to resolve the health team. He has also described being subjected weblinks situation myself... in these kinds of instances to physical and sexual abuse during his childhood. Section 4: where in some (not all) it might be better to In the previous six months of his referral to our slow things down and assist the client to think Guidance and team he had incurred eight warnings and one good practice of resolutions themselves. Giving the client Notice to Quit (NTQ). the chance to find the solution himself not Section 5: only helped resolve the problem, but seemed In the first six months of our work together he incurred two warnings and was evicted for assault. He Research to have a calming effect on him when initially then moved to B&B and once back with the support Section 6: he’d been quite distressed" pathway we started working with Mark again. During Glossary the last six months of our work together and through Contact: [email protected] joint working with other agencies Mark incurred one warning for noise nuisance and although exhibiting some of the same behaviour patterns, he has maintained his tenancy to date.

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Section 2: Case studies Æ Click to go to Document map Art of Defusing training, Bedford • relationship building between the trainees that has Clinical resulted in ‘added’ benefit to the clients of their assessment tools Introduction respective services. For example, easier sharing of Snapshot summary Schemes for information around the client’s support needs. young people For the past three years this training course has been Section 1: made available to staff working in hostels in Bedford. The feedback highlighted: High support An outline of It has been run by Jo Bunker, a qualified trainer with • how valuable the training was in personally equipping schemes for adults the key issues experience in this field and has equipped more than 50 staff – and in some cases bringing about changes to Staff capacity Section 2: frontline workers to deal effectively with conflict in a policy and procedures for hostels building and support Case Studies residential setting. • that staff related much better and more effectively across agencies than before with sideways referrals Section 3: Background happening, where appropriate, to prevent evictions. Definitions and The course was funded by the council as a result of the weblinks Rough Sleepers Reduction Plan which outlined the need Outcomes from the course Section 4: to reduce evictions from hostels due to anti-social From April 2007-March 2008 43 people were evicted Guidance and behaviour. This plan was produced by a multi-agency for anti-social behaviour (ASB) from Supported Housing good practice task group from the Bedfordshire Supported Housing in Bedford. Forum, following the 2007 Rough Sleepers Count. Section 5: After the first course in November 2007, and two Research Impacts of the course further courses in November 2008, the number of Section 6: evictions for ASB dropped to 25 by April 2009; nearly a The course has had a number of positive impacts since Glossary its introduction including: 50% reduction.

• the opportunity for hostel workers from different The service with the highest number of evictions in agencies to train and network together 2007 invested time training all their staff on this course • enabling good practice to be shared within the and saw a 68% drop in their evictions for ASB, from 22 context of training in 2007 to only 7 by October 2009. 74 Mental health Good practice guide

Section 2: Case studies Æ Click to go to Document map The overall number of evictions has dropped from 180 Novas Scarman psychological Clinical in 2007 to 59 in 2009; a 67% reduction. assessment tools skills training Introduction Schemes for Evictions protocol Snapshot summary young people Section 1: A Task & Finish group has been launched from the High support An outline of The training programme aims to skill up frontline- Bedfordshire Supported Housing Forum to investigate schemes for adults the key issues the benefits of implementing an Evictions Protocol in housing staff to help them work more effectively with Staff capacity Bedford or even across the county. clients with increasingly complex needs – and how to Section 2: avoid burnout themselves. building and support Case Studies This is primarily being driven by a desire to prevent Section 3: more evictions and improve the joint working between Background all agencies involved in delivering support to clients in Definitions and In January 2009 the Novas Scarman group was awarded Supported Housing accommodation. weblinks £42k from the Bristol Primary Care Trust to put together a psychological skills training package for frontline Section 4: Contact Mike Milner: [email protected] housing staff working with hostel residents, of whom or Jo Bunker: [email protected] Guidance and many have experienced repeat homelessness, good practice complex trauma and substance misuse. Section 5: Hostel residents may also have had problems accessing Research psychological therapies being introduced locally through the Improved Access to Psychological Therapies Section 6: (IAPT) initiative in primary care, due to their chaotic Glossary lifestyles, difficulties establishing trust and exclusion criteria because of their drug or alcohol use.

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Section 2: Case studies Æ Click to go to Document map Preventing staff burnout Clinical Content A potential positive effect of this training is on assessment tools Introduction preventing staff burnout, which again can feed into We also wanted to develop some of the applications in Schemes for poor client care. We also aimed to teach some bedrock homelessness services from some of the new young people ‘mindfulness based’ approaches such as: counselling skills including effective listening and Section 1: Mindfulness Based Cognitive Therapy (MBCT) empathy which are sometimes lost in a pressured High support An outline of • environment to secure housing outcomes. schemes for adults the key issues • Acceptance and Commitment Therapy (ACT). Staff capacity Section 2: In February 2009 we held a successful conference in Teaching clients acceptance skills building and support Case Studies Bristol involving health and social care commissioners, Some of these approaches differ slightly from staff and clients that looked at national work, which had Cognitive Behavioural Therapy (CBT) in that they Section 3: utilised psychological approaches when working with emphasise teaching clients acceptance skills rather clients receiving housing support. Definitions and than developing cognitive restructuring or challenging weblinks negative thoughts. By July 2010 we will have trained 80 staff and 20 staff Section 4: in MBCT from organisations that provide housing, However, both approaches place a strong emphasis Guidance and substance misuse and mental heath support; as well as on obtaining a trialled clinical evidence base. ACT also good practice support to women involved in the sex industry. places a strong emphasis on exploring what matters most to clients and helping them structure behaviour Section 5: Next phases: change and enhanced psychological flexibility on the Research basis of uncovering valued directions to live by. • to build in a process of clinical supervision to allow staff to develop skills in this area; and Section 6: Both of these approaches try to support clients in • to look at organisations that can work together to Glossary learning different strategies to deal with difficult do small-scale group work with clients that can be thoughts, feelings and emotions rather than struggling evaluated. to avoid them through substance misuse and self-harm.

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Section 2: Case studies Æ Click to go to Document map Psychological approaches with relevance across Framework Housing Association, Clinical range of problems assessment tools Introduction What has been particularly rewarding is that some Nottingham Schemes for of the trainers have been clinical psychologists young people who are more accustomed to dealing with clients Snapshot summary Section 1: with the psychological aspects arising from chronic High support An outline of Framework works in close partnership with statutory pain management. The possibility of some types of schemes for adults the key issues mental health services as many of our service users face psychological approaches having relevance across serious and challenging mental health difficulties. These Staff capacity Section 2: a whole range of problems and client groups raises links, together with the organisation’s investment in a building and support Case Studies exciting opportunities in health and social care. Lead Practitioner in mental health, have helped create a consistent and considered approach to the training and Section 3: Contact: [email protected] supervision needs of staff in enhanced mental health Definitions and awareness. weblinks

Background Section 4: Guidance and Framework is the largest provider of supported housing good practice and housing-related support to homeless and vulnerable people in Nottinghamshire. Framework’s Section 5: philosophy is that everyone has ‘mental health’ issues; Research but many of our service users face particular challenges in their mental health relating to areas of trauma, Section 6: deprivation, exclusion and the accumulated Glossary disadvantage which many may bear.

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Section 2: Case studies Æ Click to go to Document map Content Accreditation with Leeds University. Training modules Clinical delivered by the Nottinghamshire Healthcare Trust’s assessment tools Introduction Modular approach to training Dual Diagnosis team and the personality disorder Schemes for Framework has devised a modular approach to service are also seen as useful vehicles for establishing young people promoting the mental health awareness and skills of good partnership working. Section 1: their staff. Framework has rolled-out these sessions High support An outline of 20 times or so over the past five years. We continually Supervision and reflective practice schemes for adults the key issues review feedback and make relevant changes in line with In addition to regular line management supervision, Staff capacity Section 2: contemporary research and current best practice. staff have the opportunity to access additional support, building and support Case Studies The basic modules include: mentoring, and supervision from colleagues, peers, • mental health awareness partner agencies, and the Lead Practitioner in mental Section 3: recovery health. For example, the Trust’s Dual Diagnosis Team • runs monthly group supervision sessions for any Definitions and dual diagnosis • Framework staff who face difficult issues or challenges weblinks personality disorder • in supporting someone with a dual diagnosis. This Section 4: self-harm allows us to deliver an effective service to people who • Guidance and might otherwise bounce from pillar to post in search of • statutory mental health services good practice help and support. the Mental Capacity Act 2005 • Section 5: ‘advanced’ mental health and self-harm • Service user involvement plays an important part in Research our work and in the training and development of staff. The modules are delivered either by external partners or Without doubt the most inspiring contributions in the Section 6: internal ‘champions’, including input from service users. in-house ‘Recovery’ training we deliver are those from Glossary Framework has adopted an organisation-wide approach service users. Personal testimonies and representations to training which aims to bring all staff up to NVQ of recovery from service users, together with the staff’s Level 3 in Advice and Guidance or the equivalent. own skilled interventions and interactions inspire staff to work from a perspective of strength and with Framework’s Mental Health and Longer-Term Services creativity and hope. have also gained Level 2 Practice Development Unit 78 Mental health Good practice guide

Section 2: Case studies Æ Click to go to Document map Making partnership working a reality Young People in Focus: Clinical Partnership working is a term that is used a great deal, health and wellbeing scheme assessment tools Introduction but turning it into reality takes openness, commitment, Schemes for creativity and persistence and the supervision framework young people helps this happen. There are no magic wands when Snapshot summary Section 1: it comes to developing an informed, aware, skilled, An accredited staff training programme High support An outline of emotionally literate and recovery-focused workforce. Young people in focus has developed an accredited schemes for adults the key issues training programme on promoting young people's Staff capacity Section 2: This training and supervision programme has helped health and wellbeing for supported housing workers. building and support Case Studies create a culture which is built on openness, continuous For more information please see learning, bottom-up thinking, reflective practice and www.youngpeopleinfocus.org.uk/courses/open_ Section 3: the embracing of evidence-based practice. For example, courses/supportedhousing.html staff and service users have run reflective practice Definitions and groups on issues as diverse as dealing with complaints, weblinks positive endings, hoarding, self-harm, and working with Section 4: service users who have pets. Guidance and good practice Staff in the third sector are often well placed, by virtue of the close contact they have with service users, to Section 5: offer real, tangible, solution-focused support to people Research with mental health problems. Once these building blocks are in place, it takes continuing learning, support, Section 6: supervision, reflective-practice and practice development Glossary to create a culture in which we can deliver the best service and opportunities for recovery, to the most disadvantaged and excluded members of our society.

Contact: [email protected]

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Section 3: Definitions and weblinks Æ Click to go to Document map Psychological disorders which can predict homelessness – Complex trauma Introduction some key definitions Personality disorder Post traumatic stress disorder Section 1: This section offers some key definitions of psychological Links are made between complex trauma and the An outline of Conduct disorder disorders, together with some useful weblinks on psychiatric diagnosis of ‘borderline personality disorder’ the key issues psychological techniques and approaches. (BPD), particularly when interpersonal problems and Oppositional disorder self-harm are evident. Indeed, some authors argue that Section 2: Persistent, pervasive the two terms describe the same phenomena. Similar Case studies Complex trauma problems links are made between complex trauma in childhood Complex trauma (or Complex PTSD, Type II Trauma) Section 3: and attachment disorders. Co-morbidity refers to the psychological problems and linked patterns Definitions of thoughts, feelings and behaviours which tend to result Attachment Personality disorder and weblinks from prolonged exposure to traumatic experience. It is Emotion regulation associated with repeated situations in which the individual There are many different theoretical and diagnostic Section 4: Useful weblinks loses control or is disempowered and from which there is approaches to the definition of personality disorder Guidance and no apparent escape. Extreme examples of such experiences (PD), but generally it is the diagnosis applied to patterns good practice may be hostage situations or torture, or more commonly of thoughts, emotions and difficulties in interpersonal childhood abuse of any form and domestic violence. functioning and impulse control, which often result Section 5: from difficult experiences in childhood and concomitant Research When such ongoing traumatic experience occurs within attachment problems. the context of a care relationship, e.g. parents or care- Section 6: givers being the primary abusers, attachment processes The American Psychiatric Association (APA) defines Glossary can be fundamentally disrupted. This may then cause PD as ‘an enduring pattern of inner experience and problems in forming relationships later in life, as well behaviour that deviates markedly from the expectations as difficulties with regulating emotions and attempts of the culture of the individual who exhibits it’. The to avoid unpleasant emotional or cognitive experiences World Health Organisation (WHO) also states that PD (experiential avoidance). is a set of ‘deeply ingrained and enduring behaviour

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Section 3: Definitions and weblinks Æ Click to go to Document map patterns, manifesting themselves as inflexible responses PD reported in some surveys of non-clinical staff, Complex trauma to a broad range of personal and social situations’. such as in homelessness services. Personality disorder Introduction http://psychcentral.com/personality/ Recognising that PD and other formal illnesses can www.rcpsych.ac.uk/campaigns/changingminds/ Post traumatic co-exist, the APA uses a number of ‘axes’ to describe mentaldisorders/personalitydisorder.aspx stress disorder Section 1: An outline of different forms of mental health problem or incapacity. Conduct disorder PD is classed as an ‘Axis II’ disorder (as opposed to Post traumatic stress disorder the key issues depression, anxiety and psychosis which are ‘Axis I’ Oppositional disorder Post traumatic stress disorder (PTSD, Type I Trauma) Section 2: disorders). A number of different sub-types of PD can be Persistent, pervasive is an anxiety disorder usually caused by exposure to Case studies discriminated, but the number and descriptions of these a highly traumatic event in which personal safety problems subtypes differ according to which diagnostic system or integrity is seriously threatened. Symptoms can Section 3: is used, i.e. the APA system (DSM-IV) or the WHO Co-morbidity include re-experiencing the original trauma in the form Definitions system (ICD-10). Explicit links are currently being made Attachment of flashbacks or nightmares; avoidance of situations and weblinks between one particular subtype (borderline personality associated with the trauma; increased arousal and anger Emotion regulation disorder) and complex trauma (see above). outbursts, sleep difficulties and hyper vigilance for Section 4: Useful weblinks threat. There are a number of very useful neurological Guidance and This term is not used for children and young people and psychological models accounting for these good practice under 18 as their personality has not been fully symptoms in terms of causes and maintenance. formed. There are, however, strong traits which can Section 5: become apparent from early childhood and which Conduct disorder Research are compounded by trauma and lack of attachment to carers. These are often described as attachment Conduct disorder is a diagnosis used for children under Section 6: difficulties or disorders. 18 with a pervasive pattern of behaviour which violates Glossary social norms or the rights of others. Such behaviour The stigma and ‘therapeutic nihilism’ previously may include verbal and physical aggression; cruel associated with a diagnosis of personality disorder may behaviour towards people and animals; destructive account in part for the often low or erratic prevalence of behaviour; lying; truancy; vandalism; and stealing.

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Section 3: Definitions and weblinks Æ Click to go to Document map A number of factors are thought to underpin documented and investigated. Theories describing the Complex trauma these behaviours, including genetic predisposition, generation of symptoms of complex trauma still require Personality disorder Introduction environmental factors and inconsistent or absent empirical evaluation. parenting styles. There is some neurological evidence Post traumatic implicating a lack of empathy and concern in the cause However, clinical observations and anecdotal evidence, stress disorder Section 1: An outline of of such behaviours. Note that if these behaviours persist supplemented by recent findings in neuroscience, Conduct disorder into adulthood (18+ years) a diagnosis of antisocial strongly suggest that the same processes underpin the key issues personality disorder may be given (ASPD). complex trauma and PD, further suggesting that the Oppositional disorder Section 2: two are linked or are the same. Equally, the behaviours Persistent, pervasive Case studies Oppositional disorder demonstrated by people with PTSD and complex problems Young people who demonstrate a number of persisting trauma are similar. The behaviours observed in people Section 3: with PD can be described as ways of coping with the Co-morbidity behaviours for at least six months, including loss of Definitions traumatic experience of difficult childhoods. Attachment temper, being angry and resentful, being argumentative, and weblinks shifting blame to others, demonstrating spiteful or Emotion regulation vindictive behaviour, and defying rules can be described The literature review www.personal.soton.ac.uk/nm10/ Section 4: Complex_Trauma.doc on prevalence and homelessness Useful weblinks as having oppositional disorder. Guidance and suggests a particularly strong and close overlap good practice Persistent, pervasive problems between these different presentations; and it may be that among people who are homeless or in insecure Section 5: A number of key factors distinguish complex trauma in accommodation, and more generally among those with Research principle from PTSD. Whereas PTSD is a psychological chaotic lifestyles, the distinction between these clinical reaction to a single event or set of discrete events, syndromes may be less clear-cut than it is for the rest of Section 6: complex trauma is a reaction to ongoing traumatic the population. Glossary experience from which the individual cannot escape. It may therefore be more useful to think of PD as Theories accounting for the symptoms of PTSD (e.g. long-standing or ‘chronic’ complex trauma, that is a flashbacks, nightmares and mood disturbance) are well reaction to ongoing and sustained traumatic experience.

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Section 3: Definitions and weblinks Æ Click to go to Document map Co-morbidity One of the most powerful motivations for continuing Complex trauma to take narcotics is to prevent the difficult physical A number of theories describe the way in which drug Personality disorder Introduction and alcohol use functions as a maladaptive coping symptoms associated with non-use. These may Post traumatic strategy for individuals with underlying mental health exacerbate the negative emotions prevalent in people stress disorder Section 1: difficulties of all kinds. There are a number of factors, with psychological difficulties. Finally, there is some An outline of physiological, emotional and psychological, which are evidence that people believe that using narcotics helps Conduct disorder the key issues believed to be related to drug use. them to maintain relationships with others, either through loss of inhibition or through a peer group based Oppositional disorder Section 2: around acquisition and use of a particular substance. Persistent, pervasive Dialectical behaviour therapy (DBT) particularly Case studies emphasises the role of substance and alcohol use as problems Attachment an emotion regulation strategy. For those who do not Co-morbidity Section 3: have the skills to regulate their own strong emotions Neglect and abuse in childhood has many effects, not Definitions Attachment (see emotion regulation), taking drugs or alcohol is least on the process of attachment in early childhood and weblinks the fastest way to change their internal state, both and separation in adolescence. Emotion regulation cognitive and emotional. Emotions may be dulled Section 4: Useful weblinks or eradicated through the use of narcotics, a process Infants become attached to adults who respond Guidance and sometimes referred to as ‘experiential avoidance’. appropriately to their needs for example with food, good practice contact, attention etc. If the infant does not receive Other theories suggest that drug and alcohol use is this kind of care, or it is unpredictable or inconsistent, Section 5: related to how people manage the distress caused attachment may be disrupted. Research by constantly thinking about difficult experiences. Ruminations about experiences which make someone Disrupted attachment is often described on two Section 6: feel afraid, shameful or guilty may be dulled by drugs or dimensions, avoidance and anxiety. Avoidant infants Glossary alcohol. Anecdotal clinical evidence suggests that some may grow up believing that others will never meet people use alcohol to help them sleep (although alcohol their needs, or even that they are not worthy of care, will interfere with the quality of sleep), which again may resulting in mistrust of others and avoidance of close be partly related to rumination. relationships even though proximity may be craved.

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Section 3: Definitions and weblinks Æ Click to go to Document map Anxiously attached infants may grow up hyper vigilant the infant becomes aware that their distress is valid and Complex trauma for signs of neglect, and make behavioural attempts to others are available to soothe. Later, when language Personality disorder Introduction prevent others from leaving them (which paradoxically is developed, children may learn to describe their may increase the likelihood of this happening). emotional state with the help of information from Post traumatic care-givers, through labels applied to specific emotions stress disorder Section 1: An outline of Neglect, physical, emotional or sexual abuse (e.g. jealousy, anger). Again, attention to these Conduct disorder in childhood have all been found to disrupt the emotions validates them, and the child is taught the key issues attachment process. Such effects are reversible as strategies to manage them. Throughout childhood and Oppositional disorder Section 2: children can develop multiple attachments with adolescence a great deal is learnt about acceptable and Persistent, pervasive Case studies carers, and this is a positive message for interventions unacceptable presentation of emotional states because problems and services. They can however also lead to more boundaries are made explicit. Section 3: entrenched relationships and emotional difficulties in Co-morbidity Definitions later life if the cycle is not broken by a secure and stable If the environment in which the child grows up does Attachment environment and by developing positive experiences of not serve these functions, the individual may grow and weblinks Emotion regulation themselves and the adult world. up unable to self-soothe, and may seek other ways of Section 4: avoiding unpleasant emotions (for example drug or, Useful weblinks Guidance and alcohol use or self-harm) and may be prone to periods Emotion regulation good practice Emotion regulation refers to the process whereby of unregulated emotions (e.g. anger, anxiety) associated we attempt to regulate strong, usually unpleasant, with antisocial or self-destructive behaviours. Section 5: emotions either before they occur or afterwards. Research These skills are learnt incrementally over the lifespan, but much formative experience in emotion regulation Section 6: occurs in childhood and adolescence. Glossary

Infants who do not suffer abuse or neglect may learn that having signalled distress, consequent attention from care-givers reduces those unpleasant emotions. In this way, emotional experience is made ‘valid’, i.e.

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Section 3: Definitions and weblinks Æ Click to go to Document map Psychological techniques and approaches – useful weblinks Complex trauma Personality disorder Introduction The evidence of feedback from frontline services Social problem-solving therapy (‘Stop and think’) Post traumatic suggests that there is a wide range of specific www.britannica.com/bps/additionalcontent/ stress disorder Section 1: An outline of psychological techniques and approaches 18/32682944/Problem-Solving-Therapy-for-People- Conduct disorder which may be suitable, including: with-Personality-Disorders-An-Overview the key issues Oppositional disorder Section 2: Cognitive behavioural therapy Acceptance and commitment therapy Persistent, pervasive Case studies www.nhs.uk/conditions/cognitive-behavioural-therapy/ www.contextualpsychology.org/act problems Pages/Introduction.aspx Section 3: Mindfulness-based cognitive therapy Co-morbidity Definitions Dialectical behavioural therapy mbct.co.uk/ Attachment and weblinks http://behavioraltech.org/resources/whatisdbt.cfm Emotion regulation Systemic / family therapy Section 4: Useful weblinks Psychodynamic psychotherapy www.aft.org.uk/home/familytherapy.asp Guidance and http://easyweb.easynet.co.uk/simplepsych/204.html good practice section 3.6 Many of these specific techniques will require specialist training and supervision, and can only be, or are best, Section 5: Cognitive analytical therapy delivered by specialist staff, working in collaboration with Research www.acat.me.uk/catintroduction.php housing and resettlement staff. However, in many cases, a broad awareness and recognition of the psychological Section 6: Rational emotive behavioural therapy dimension to dysfunctional behaviour can be shared Glossary www.rebtinstitute.org/public/ amongst all staff who are dealing with such difficulties.

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Section 3: Definitions and weblinks Æ Click to go to Document map Training can significantly enhance the capacity of Complex trauma frontline services in all sectors to manage such Personality disorder Introduction difficulties. Moreover, there is also increasing evidence that it may not necessarily be the particular techniques Post traumatic that are used that most count, but rather the strength stress disorder Section 1: An outline of of the relationship with the staff member or peer Conduct disorder mentor, and in particular the setting or context in which the key issues engagement takes place. Oppositional disorder Section 2: Persistent, pervasive Case studies Effective engagement should contain the following problems three elements: Co-morbidity Section 3: • Client involvement and responsibility, particularly in Definitions Attachment the process of change; and weblinks • Supportive, interested and well-trained staff; and Emotion regulation Section 4: • Input from specialist mental health workers. Useful weblinks Guidance and good practice Section 5: Research Section 6: Glossary

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Section 4: Guidance and good practice Click to go to Æ Document map The psychologically informed environment (PIE) The psychologically informed environment Introduction (PIE) Below is an excerpt from: Social Psychiatry and Social persons hostels, women’s refuges and foyers for Reflective practice Policy in the 21st Century; new concepts for new needs, homeless youth, is currently being actively explored. Section 1: Robin Johnson and Rex Haigh, 2010. Similarly, in the context of the prison service, the Personalisation pilots An outline of concept of a psychologically informed environment and invest to save the key issues may also in many situations be more useful than the Wherever an agency has effective control over most Working with people Section 2: aspects of the day-to-day lives of the individuals earlier notion of a Therapeutic Community (or TC), at with complex needs least as narrowly defined. Case studies living there, as for example in a hospital or a prison, CBT project we have in effect a highly managed environment. When Section 3: There certainly are and have been many valuable in addition the primary task or ethos of the service is The use of medication Definitions and initiatives to create specialist TC units within the the treatment, rehabilitation or other management of Childhood experiences weblinks problematic behaviour, we have an environment that is, prison system; but they remain at the margins, going or can be, consciously planned for the purpose – against the tide. And yet equally clearly there are other Collaboration models Section 4: despite whatever inevitable constraints there may successful and constructive prison and youth offender for complex trauma and Guidance and be. The concept of a “psychologically informed institutions, which are not modelled on TCs, and yet severe social exclusion good practice environment”, or PIE, then describes the outcome of any which in some perhaps less clearly articulated way do attempt to identify, adapt and consciously use those manage to create and use positive relationships very Section 5: features of the managed environment which would effectively. Here, we may now need to find another Research allow the resources and functioning of the service to vocabulary, to describe what is most effective in the Section 6: be focused on addressing the psychological needs and most constructive prison regimes; it is likely that such emotional issues thrown up by the residents. factors are ‘highly distilled’ in formal TCs, but could also Glossary be developed in another fashion, as PIEs. As we have seen with the Places for Change programme, the possibility of a more carefully planned One thing, however, that we can say with confidence and also “psychologically informed” environment in is that, whether in a prison, a night shelter, or even an residential resettlement settings, such as in homeless acute ward, or wherever safety and management of risk

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Section 4: Guidance and good practice Click to go to Æ Document map is a key concern, a genuinely constructive environment NLP to existential humanism. It is perhaps arguable The psychologically always aims to do more than simple containment that a meditation space or retreat founded on the more informed environment Introduction of challenging behaviour. A PIE will aim to use the psychologically oriented faiths, such as Buddhism, (PIE) potential for change that resides in all human beings might qualify. Certainly the York Retreat, the original Reflective practice in the pursuit of some wider or future goal, whether it template for compassionate care, has a good claim to Section 1: be the reduction of re-offending, a positive attitude to the name. Personalisation pilots An outline of learning, or engagement with treatment and therapy. and invest to save the key issues But wherever that psychological thinking can then be Working with people Section 2: As to how it may approach the task, however, the translated meaningfully into a carefully considered with complex needs field is entirely open. For the moment, at least, the approach to designing and managing the social Case studies CBT project definitive marker of a PIE is simply that, if asked why environment, then we have a PIE. Although training Section 3: the unit is run in such-and-such a way, the staff would may well help, the key to psychological thinking The use of medication Definitions and give an answer couched in terms of the emotional and here is not received wisdom, or even acquiring new weblinks psychological needs of the service users, rather than skills, but reflective practice – and this also requires a Childhood experiences giving some more logistical or practical rationale, such management of the service which is prepared to allow Collaboration models Section 4: as convenience, costs, contracts or regulations. the time and this scope for frontline staff to think, for complex trauma and Guidance and discuss and argue over how things could perhaps be severe social exclusion good practice Variety done differently, and make whatever changes they can. Other than that, there is no particular school of thought Section 5: or of human understanding that necessarily underpins It is the changes in day-to-day running, derived from Research or informs the thinking in a PIE. There is no one set reflective practice and discussion, that mark the of beliefs that the staff of a PIE need to sign up to, no development of the PIE. In homelessness resettlement, Section 6: overall view of the nature of human nature, or even such changes may come about gradually and Glossary of the underlying problems of the “membership”. incrementally. In a more controlled environment such It might be any form of psychological theory that as a prison, where all changes in the daily routine must informs the work of the staff, from psychodynamics to be thoroughly managed in detail, introduction of a behaviourism, from Gestalt to evolutionary psychology, PIE may need to be more tightly programmed. But Transactional Analysis, Dialectical Behavioural Therapy, the common thread is that these changes come about

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Section 4: Guidance and good practice Click to go to Æ Document map through the conscious application of careful thinking The psychologically about the emotional and psychological needs and informed environment Introduction potential of the resident ‘clientele’. (PIE)

Reflective practice Finally, while it is important to stress the role of the Section 1: staff team in thinking afresh over the needs of the Personalisation pilots An outline of client group, we should not overlook the impact of and invest to save the key issues the built environment itself. A number of studies Working with people Section 2: have demonstrated for example that a pleasant with complex needs view of greenery in a central courtyard can delay the Case studies CBT project deterioration of mental functioning of those inflicted Section 3: with dementia. Even the positioning of a reception area The use of medication and security lights in a hostel can completely change Definitions and the institutional atmosphere, from something alienating Childhood experiences weblinks to something welcoming. A planned environment can Collaboration models Section 4: be planned on many levels. for complex trauma and Guidance and severe social exclusion good practice Section 5: Research Section 6: Glossary

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Section 4: Guidance and good practice Click to go to Æ Document map Reflective practice The psychologically informed environment Introduction (PIE) Reflective practice is an essential component of that negative beliefs about people experiencing Reflective practice effective, safe work with people who suffer complex complex trauma reduced and perceptions of effective Section 1: trauma. This is just as applicable when working working increased. Personalisation pilots An outline of psychologically in an informal way as when working • Thirdly, it enables shared learning cycles to be set and invest to save the key issues formally as a psychologist or psychotherapist. up which enhance the acquisition of skills. Staff Working with people Section 2: Reflective practice is typically organised in small attending such groups have the opportunity to with complex needs Case studies groups, and may be facilitated by a person trained discuss the models and techniques employed to CBT project in a psychotherapeutic model (e.g. CBT/DBT, facilitate change in detail, and corrective feedback Section 3: psychodynamic therapy, person-centred therapy). may be offered. The use of medication Definitions and Childhood experiences weblinks In the non-specialist area of work (e.g. with frontline There are obvious time and cost commitments hostel workers) reflective practice is advantageous in involved in enabling frontline staff to attend regular Collaboration models Section 4: three distinct ways: supervision, typically for an hour and a half every two for complex trauma and Guidance and • Firstly, by aiming to recognise and understand weeks. It is vital, therefore, that managers buy in to severe social exclusion good practice people’s difficulties, it helps to generate amongst the concept and are able to perceive the benefits in clients a sense of being understood and heard. order that a long-term commitment can be made. Section 5: It enables key workers to identify and to defuse Costs can be reduced by running groups rather than Research potential conflicts, and so to ensure safe practice. individual reflective practice sessions, but it must be Section 6: • Secondly, it enables staff to get some perspective borne in mind that all members should have adequate on the emotional challenges of their work, thereby opportunity to discuss their practice. Glossary enabling some distance from it and the possibility of working out the emotional content of the work being done. In this way anxieties may be reduced and burnout may also go down. Recent evidence shows

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Section 4: Guidance and good practice Click to go to Æ Document map The psychologically Personalisation pilots and invest to save informed environment Introduction (PIE)

Reflective practice Section 1: Preventing and tackling rough sleeping: Personalisation pilots An outline of Impacts and outcomes – for individuals and communities and invest to save the key issues Working with people Section 2: with complex needs Preventing and tackling rough sleeping has We have set this out in the Case studies CBT project positive impacts for individuals, communities following sections: Section 3: and the public purse. In this paper we present The use of medication Definitions and case studies from around the country that 1 Case studies from around England Childhood experiences weblinks show that while initial investment is required 2 The case for investment in preventing Collaboration models Section 4: to develop and sustain pathways from the and tackling rough sleeping for complex trauma and Guidance and streets, overall cost savings can be evidenced severe social exclusion good practice together with improved quality of life for 3 Longitudinal studies and impacts individuals. Section 5: Research Section 6: Glossary

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Section 4: Guidance and good practice Click to go to Æ Document map 1. Case studies from around England The psychologically informed environment Introduction (PIE)

Frank’s story Reflective practice Section 1: Camden In 2008 ‘Frank’ came to the attention of the Housing Personalisation pilots An outline of For the year 2008/09 Camden had 15 Options Service via probation. and invest to save the key issues former rough sleepers move on and sustain accommodation and five failed to move on Working with people Section 2: Frank was first verified by the (then) Contact and in a planned way, giving a success rate of with complex needs Assessment Team (street outreach) in 2001 aged just Case studies about 67%. 21. Over the next six years CHAIN (the London data CBT project Section 3: base used by all street outreach services and funded The use of medication For the year 2009/10 (to end December) Definitions and by CLG) indicates he continued to be street active 16 former rough sleepers have moved on with Childhood experiences weblinks and was booked in and out of a number of one unplanned move giving a success rate of emergency hostels. Collaboration models Section 4: 94%. However, five of these new tenancies are for complex trauma and of less than three months duration, so it is still Guidance and During this time Frank was committing a string of severe social exclusion early days. good practice offences (23 in total) ranging from theft to public disorder. He was also drinking up to 15 cans of Section 5: Each sustained tenancy represents an improved strong lager a day and this seemed to trigger his quality of life for the individual, and a reduced Research offending behaviour. Frank admitted he had abused presence on the streets which contributes to alcohol from the age of 12 when he witnessed his Section 6: improved community safety. father’s death. Glossary The following individual case studies reflect Housing Options were able to accommodate the outcomes achieved for individuals (and Frank in Parker House hostel in an assessment their communities) by assertive and consistent bed (part of the Hostel Pathways Model). He support and enforcement action. was soon referred to Cambria House which was a

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Section 4: Guidance and good practice Click to go to Æ Document map move-through bed space. This prepared Frank for his health deteriorated to such a degree that he made The psychologically independent living and he was assisted in updating contact with Spectrum day centre that brought Tyrone informed environment Introduction his CV and encouraged to look for work. to Housing Options. (PIE) Reflective practice The Pathways and Move-On Team (PMOT) identified Tyrone was placed in Endell Street hostel in an Section 1: a suitable flat for Frank and within a month he had assessment bed. After only six months it was clear Personalisation pilots An outline of moved in. The PMOT also referred him to Camden Tyrone could manage to live independently, he and invest to save the key issues Floating Support for resettlement support which budgeted well, had no issues around substance misuse Working with people Section 2: was particularly important for Frank as he had a and was now linked in with a GP. with complex needs long chaotic past starting from a young age. Case studies CBT project Tyrone was referred to the PMOT and a one bedroom Section 3: The key worker continues to see Frank and confirmed flat was identified as being suitable. A referral to The use of medication that he has not touched alcohol while he has been floating support was made the next day. Definitions and living in his own flat. Frank identified isolation as being Childhood experiences weblinks a potential problem so he was assisted in buying a dog His support worker has ensured he is now with a local Collaboration models Section 4: and now feels much more stable and secure and has a GP and visits regularly. Tyrone himself has said he for complex trauma and Guidance and dog to keep him company. cannot believe he finally has a place. He likes to stay in severe social exclusion good practice as much as possible as it allows the reality to sink in. Tyrone’s story Section 5: Ian’s story Research ‘Tyrone’ first approached Housing Options in 2007. He had been living in hostels for the past 16 years and had ‘Ian’ was a verified rough sleeper and in 2008 Camden Section 6: been evicted from the last hostel for fighting with another Safer Streets Team placed Ian into an assessment bed in Glossary resident. This was a year ago and Tyrone had spent the the Pathway. past year sleeping in a car a friend had given him. Ian had been working in the past but had a breakdown After 16 years of living in hostels Tyrone was unsure when his mother passed away. He began drinking, lost how or who to approach for assistance. It wasn’t until his job and lost his flat as a result of rent arrears.

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Section 4: Guidance and good practice Click to go to Æ Document map From an assessment bed he was moved into a move- stopped using and is now on a reduced methadone script. The psychologically through bed space where he stopped drinking and She has not reoffended while living at the project. informed environment Introduction attended the in-house training the project offered to (PIE) prepare someone for independent living. Lindsay became pregnant and as she engaged well with Reflective practice staff at the project and also her social worker she was Section 1: Within a week of being referred to the PMOT he was referred for move-on. Personalisation pilots An outline of offered a one-bedroom flat in an area he specifically and invest to save the key issues had asked for. As Ian was slightly older, it was important The PMOT were able to find Lindsay a two bedroom Working with people Section 2: to him to be around old friends and support networks. flat before she was due to give birth and covered the with complex needs shortfall in Housing Benefit (Lindsay was only entitled Case studies CBT project The PMOT referred Ian to Camden Floating Support to a one-bed rate prior to giving birth) by a combination Section 3: however after the assessment Ian felt he did not require of Discretionary Housing Payment and our Homeless The use of medication support and could manage on his own. This was almost Prevention Fund. Definitions and two years ago and Ian says he feels much more settled Childhood experiences weblinks and is hoping to become involved in voluntary work in The baby is now six weeks old and Lindsay is very happy Collaboration models Section 4: the near future. in her new home which is in an area she wanted and is for complex trauma and Guidance and the appropriate size for her family. She has an 11 year severe social exclusion good practice Lindsay’s story old son who is now able to visit. She is linked in to social services and continues to receive support from Section 5: ‘Lindsay’ was a verified rough sleeper who was street them in relation to her child and past substance Research active and was using substances. CHAIN records her as misuse problems. going in and out of various hostels and she had Section 6: numerous shoplifting offences between 2005 and 2007. John’s story Glossary In 2007 Lindsay moved into a Single Homeless Project ‘John’ had been rough sleeping for many years and was (voluntary sector supported housing organisation) in deteriorating health as he drank on the street. Under service which specialised in those who were continuing threat of an ASBO he finally accepted an offer of a to use substances. She engaged with staff and gradually hostel place, ending six years of living on the street.

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Section 4: Guidance and good practice Click to go to Æ Document map The psychologically Julie’s story Barnet informed environment Introduction ‘Julie’ was a crack-using prostitute under the control of a Barnet benefits from the service provided by (PIE) violent pimp. Her health was very poor and she had lost the London Street Rescue service, delivered Reflective practice Section 1: care of her daughter. Following an ASBO and repeated by Thames Reach and funded directly by CLG, jailing she accepted help, returned home to her parents, because it covers all outer London boroughs Personalisation pilots An outline of regained access to her child and began training for a job. without a dedicated street outreach team of and invest to save the key issues their own. Working with people Section 2: All the above cases resulted in the person with complex needs Case studies reflecting that enforcement had saved them. CBT project And yet when asked at the time they all said Sally’s story Section 3: The use of medication they wanted to stay on the street. ‘Sally’ spent many years on the street supported by Definitions and soup runs. As her health deteriorated she was visited by Childhood experiences weblinks a number of local services, but maintained her right to Collaboration models Section 4: remain on the street. for complex trauma and Guidance and severe social exclusion good practice A GP was asked to visit her on the streets and met with Sally every week over a 10-week period. This assessment Section 5: identified underlying mental health problems and Sally Research was sectioned and forcibly removed from the street under powers in the mental health act. She has since Section 6: made good progress and is now living in residential Glossary accommodation and getting involved in a range of activities. She now says she doesn’t want to go back to the streets, although she told charity workers for years she wanted to be out there.

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Section 4: Guidance and good practice Click to go to Æ Document map The psychologically Sammy’s story Kirklees informed environment Introduction Kirklees undertook a review of rough sleeping in ‘Sammy’ has sniffed butane since a teenager, after (PIE) 2008 and sought funding from CLG for a small being introduced to the practice by his father. He has Reflective practice grant to pay for a dedicated housing options acquired brain damage/ impaired cognitive functioning Section 1: worker. The worker started in post in late as a result. He also has some undiagnosed mental Personalisation pilots An outline of August 2009. He has worked closely with local health problems – but the Community Mental Health and invest to save the key issues voluntary sector providers and faith-based day Team requires cessation of his substance misuse before Working with people Section 2: centres to make contact with people known to engaging with him. with complex needs sleep rough. Case studies CBT project He is currently in custody (again) for the (repeated) Section 3: Since the beginning of the initiative there breach of (another) ASBO and was due for release in The use of medication Definitions and have been 10 former rough sleepers who late February. weblinks have been taken off the streets and provided Childhood experiences with accommodation. Nine have been Kirklees are planning to hold safeguarding meeting Collaboration models Section 4: accommodated in the Councils own temporary (for vulnerable adults) to plan for his release. Sammy for complex trauma and Guidance and accommodation using the powers under needs supervision in his accommodation because of severe social exclusion good practice section 192(3) of the Housing Act 1996. the risks he poses to himself (and others) – so self- contained accommodation is not appropriate and B&B Section 5: One former rough sleeper has been helped providers may be unwilling to accommodate him as Research to find settled housing in the private rented he has been evicted from most in Huddersfield in the sector. All of these placements have been past. Kirklees are planning to speak with local supported Section 6: sustained to date, despite some challenges. housing providers to develop a personalised package. Glossary

Kirklees have identified three particularly Stabilising Sammy’s accommodation will make a entrenched rough sleepers for whom tailored significant contribution to levels of anti-social behaviour options will be needed. in the town centre, and deliver savings against the criminal justice budget by reducing his level of offending.

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Section 4: Guidance and good practice Click to go to Æ Document map The psychologically Mick’s story David’s story informed environment Introduction ‘Mick’ is 60 years old and has slept rough in Huddersfield David is a vulnerable adult, and some learning (PIE) (squatting occasionally) for about 20 years. Has begun disabilities are suspected. He was harassed and bullied Reflective practice to engage with the dedicated worker and was placed in in his local authority tenancy on a large estate and left Section 1: Kirklees’ temporary accommodation, provided by the his flat without seeking help. Personalisation pilots An outline of LSVT. However, things have not gone completely and invest to save the key issues smoothly. Mick “trashed” his temporary flat by He has been sleeping rough for several years, but began Working with people Section 2: disconnecting the gas fire, preferring to burn furniture in to engage with Ian the worker at the local day centre. with complex needs the place it used to be to recreate an open fire that he is He has now been placed in temporary accommodation Case studies CBT project used to (although there is no chimney). He also didn’t and Ian, the worker, is navigating the choice-based Section 3: use the toilet; preferring a bucket (most of the time). lettings (CBL) system to secure a sensitive letting in a The use of medication Definitions and quiet and safe location. Childhood experiences weblinks However, Mick has not been aggressive towards staff and continues to engage and say he will accept help. Collaboration models Section 4: Kirklees have now re-housed him in a local B&B while for complex trauma and Guidance and they consider longer-term accommodation options with severe social exclusion good practice him. It is likely he will need a tailored package of support – including some cleaning. Kirklees have committed to Section 5: continuing to engage with him and will not give up. Research Section 6: Glossary

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Section 4: Guidance and good practice Click to go to Æ Document map developing monitoring systems The psychologically Thames Reach GROW • Identifying and overcoming organisational and informed environment Introduction Thames Reach established the Giving Real regional barriers (PIE) Opportunities for Work (GROW) Project, • Getting staff on board and addressing resistance Reflective practice Section 1: which aimed to employ 10% of its workforce Changing HR policies to enable direct recruitment from people who have direct experience of • Personalisation pilots An outline of into current vacancies; homelessness by 2007. This figure now stands and invest to save the key issues Effectively managing potential conflicts of interest, at 20%. • Working with people sickness rates, relapse, dual roles Section 2: with complex needs Case studies The aim of the National GROW Programme is Developing routes into employment including: • CBT project to disseminate the learning and good practice service user volunteering schemes and traineeships Section 3: developed through GROW and change the • Addressing financial and resource issues. The use of medication Definitions and culture of the homelessness sector in England Childhood experiences weblinks so that it fully embraces employing service A service user who is employed in the homelessness users. Thames Reach is being funded by CLG, sector is transformed from someone who is most often Collaboration models Section 4: and supported by Homeless Link to deliver a thought of as dependent, needy and incapable, into for complex trauma and Guidance and bespoke consultancy service to homelessness someone who is enthusiastic, responsible, economically severe social exclusion good practice organisations and consortia across the country. independent, tax-paying, and making a significant contribution to the lives and wellbeing of others. As Section 5: they transform themselves, so the organisation they Research From October 2008 through September 2010, the work for goes through a parallel transformation – from National GROW Programme is offering a range of being an out of touch business with low expectations Section 6: support to organisations, including: and an overdeveloped sense of ‘us and them’ to a Glossary • Preparing an organisation for change; principles service user-focused entity with high aspirations, greater behind service users employment flexibility and responsiveness and more effective service • Benefits and challenges of employing service users delivery. This process of change, in which service users Benchmarking service user employment and can become leaders, is tremendously exciting and models • all that this sector can be. Employing service users:

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Section 4: Guidance and good practice Click to go to Æ Document map • Provides role models for other service users and staff Kay started with Thames Reach as a GROW trainee in The psychologically • Develops a set of talented and knowledgeable 2008 and is both a full-time project worker in Lambeth, informed environment Introduction new staff and an ambassador for the scheme. She is a great (PIE) advocate for the different that being employed has Increases the diversity of staff teams to better reflect Reflective practice • made to her and her family. For example, she reports Section 1: the communities they serve being able to travel to home at Christmas to see her Personalisation pilots An outline of • Demonstrates to service users, staff and strategic family in a set of new clothes rather than in old torn and invest to save the key issues partners that their organisation is sincere and ones and the impact this has on her self-esteem. successful in its mission. Working with people Section 2: with complex needs Case studies CBT project Kay’s story Section 3: ‘Kay’ has a long history of homelessness and offending, The use of medication Definitions and related to drug use. After release from custody, and on Childhood experiences weblinks moving into a hostel, she came to appoint at which she Collaboration models wanted to start sorting out her life. Section 4: for complex trauma and Guidance and severe social exclusion She saw the GROW trainee programme on a website, good practice and called to see if she might apply. Kay is well spoken and articulate, and was originally told the programme Section 5: would not be available as it was for people who had Research been homeless. She explained she had slept rough Section 6: and was currently in a hostel. As she divulged more about her offending background, she was concerned Glossary she would be told she would not be eligible, and was delighted when the GROW programme was fully explained – with its emphasis on rehabilitation and providing an opportunity for people to “give back”.

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Section 4: Guidance and good practice Click to go to Æ Document map 2. The case for investment The psychologically informed environment Introduction (PIE) Reflective practice Community and budget benefits – Reduced costs to health and Section 1: Kirklees criminal justice system budgets – Personalisation pilots An outline of and invest to save the key issues It is just six months since Kirklees appointed Cambridge their dedicated worker and adopted a flexible Cambridge’s Rough Sleeping Manager has Working with people Section 2: with complex needs approach to tackling their rough sleeping established a multi-agency partnership to look Case studies population. In this time: at ways of addressing the needs of the most CBT project The police have reported a reduction in entrenched rough sleepers in the city. Section 3: • The use of medication complaints about street drinking and a Definitions and fall in levels of street begging since the They have adopted the New Directions Index Childhood experiences weblinks 10 regular rough sleepers have been which has been developed by one of the CLG- Collaboration models Section 4: accommodated; funded Adults Facing Chronic Exclusion (ACE) for complex trauma and Guidance and The local town centre health centre has projects in south London. • severe social exclusion good practice also reported fewer presentations by people The New Directions Index considers an sleeping rough Section 5: individuals presenting multiple needs and Research Kirklees will do further work to evaluate the weights these according to the level of savings achieved across these different by engagement the client has with services. Section 6: This recognises the fact that chaotic lifestyles tackling rough sleeping over the next Glossary six months. and an inability to work with and use support services contributes to the difficulty in helping someone and needs tailored solutions.

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Section 4: Guidance and good practice Click to go to Æ Document map Jon’s story prison sentences. He has poor physical health and The psychologically suffered a minor heart attack in 2007. informed environment Introduction ‘Jon’ was one of the highest scoring individuals when (PIE) first assessed using the New Directions Index. His case He was referred to the Safeguarding Vulnerable Adults Reflective practice study has been compiled by Cambridge County Council Team by the council’s Rough Sleeping Coordinator after Section 1: and shows how despite resource intensive interventions, an exercise in which he was identified as one of Personalisation pilots An outline of when a “whole public purse” perspective is taken, the the most difficult to engage people sleeping rough – and invest to save the key issues costs of individuals to their wider community can be in February 2009 Working with people mitigated and reduce. Section 2: with complex needs A homeless application was made and temporary Case studies CBT project Jon is 45 years old. He was taken into care as a baby accommodation (TA) and support arranged in June Section 3: following a head injury and was diagnosed with a 2009. However, before he was able to move into the TA The use of medication Definitions and specific learning disability in 1997. He experienced sexual he was sent back to prison. When he came out of prison Childhood experiences weblinks abuse as a young person and has self-harmed since he his expectation was to go straight into the TA, but early was nine years old (cutting and burning). From the age discharge meant this was not available on the day. Collaboration models Section 4: of 13, Jon has misused alcohol and solvents; currently he for complex trauma and Guidance and For 12 days in June 2009 he slept rough and was only uses alcohol. He became homeless at 16. severe social exclusion good practice arrested eight times. Jon told the Street Outreach Team Jon is a risk to others – becoming aggressive when drinking worker that: “This always happens – people always Section 5: and has committed offences of assault, affray and promise help but there’s always a reason they don’t”. Research criminal damage. He has been subject to several ASBOs. Jon indicated he finally wanted to work with support services, and find a way out of his current situation. Jon Section 6: Jon is equally at risk from others and has been was sent back to prison for the offences in June. Glossary financially and physically abused, requiring the use of A&E after assaults on the streets During his time in custody, a Safeguarding Vulnerable Adults case conference was arranged. This time on his Since 1996 Jon has committed around 400 offences, release, Jon was housed in temporary accommodation appeared in court 260 times and served 120 short term with a raft of support in place from the learning

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Section 4: Guidance and good practice Click to go to Æ Document map disabilities team, the mental health team, the street The psychologically outreach team, Mind, and the council’s homelessness Savings to criminal justice system informed environment Introduction prevention team. budgets – Leeds (PIE) Leeds City Council funds CRI (Crime Reduction Reflective practice Two weeks later however he was admitted into Section 1: Initiative – a voluntary organisation that specialises psychiatric hospital following alleged threats to throw Personalisation pilots An outline of in street outreach, drug and alcohol services) to acid over him and cut his feet off. and invest to save the key issues provide an assertive outreach service and has an effective supported housing pathway from the Working with people On discharge, he was able to return to his Section 2: streets, with specialist provision. They also have with complex needs accommodation which had been kept available for him. Case studies a private rented access scheme for non-statutory He continued to drink heavily, but began to take steps CBT project households which they have recently reviewed Section 3: to avoid his old peer group and drinking school and and developed with input from the Crisis project The use of medication engaged with his support package. Definitions and funded by CLG. Crisis is supporting the council Childhood experiences weblinks He recently went into hospital for a physical health to promote this prevention offer actively to raise Collaboration models Section 4: problem and a detox was arranged while he was an in- awareness and improve use of the private rented sector scheme by voluntary sector agencies. for complex trauma and Guidance and patient. Jon has now reduced his drinking and moved back severe social exclusion to his flat which, again, had been kept available for him. good practice However, Leeds is seeing an increased number Section 5: The council plans to convert the TA property into an of rough sleepers from the A8 and A2 countries, introductory tenancy so Jon will not need to move, now who have no recourse the public funds and Research cannot access these services. he is more stable and likes the area. Support is ongoing Section 6: and Jon is still there – the most stable he has been since Glossary he was a child. CRI have therefore developed a supported reconnections offer which is funded through Jon has not offended since June (almost six months) Leeds’ Homelessness Prevention Fund. The which is a major achievement for him and his health has following case study has been developed to improved, leading to significant savings to community show the savings achieved by this service. safety, police and health budgets. 102 Mental health Good practice guide

Section 4: Guidance and good practice Click to go to Æ Document map Estimated cost to services from the time that VK The psychologically VK’s story lost his accommodation: informed environment Introduction VK is a Lithuanian national who first came to the UK two • Arrest leading to court proceedings on (PIE) years ago. He worked for just under a year before losing 3 occasions £30,000+ Reflective practice Section 1: his job and accommodation. He was arrested shortly Assessment for mental health issues £362 after this for criminal damage and served a six-month • Personalisation pilots An outline of prison sentence. • 46 weeks in prison £43,700 and invest to save the key issues Total estimated cost is £74,062 • Working with people Section 2: He was released back to the street and was again with complex needs arrested for robbery and served a further three-month The average cost of repatriation incurred by CRI in Leeds Case studies is £155 CBT project prison sentence. Section 3: The use of medication Definitions and He was again released to the street and was re arrested Childhood experiences weblinks for shoplifting £17 worth of food. Police contacted the local Outreach Team who assessed VK. Collaboration models Section 4: for complex trauma and Guidance and VK drinks alcohol to excess two to three days per week. severe social exclusion good practice He has evident mental health issues but no diagnosis. He self-harms and has presented at A&E with suicidal Section 5: ideation. Research

VK has stated that he had planned to continue to Section 6: re-offend until he was sent home or received a very Glossary long prison sentence. He has received a further 8 week sentence for the shoplifting offence. The Outreach Team plan to meet VK on his release date and take him to the airport for his flight to return home.

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Section 4: Guidance and good practice Click to go to Æ Document map – assuming 8 hours used to assess and establish a The psychologically Invest to save – generic examples bond within agreed scheme. The hourly rate may informed environment Introduction The following examples are based on “typical” be higher in London, but £16.50 is equivalent to (PIE) rough sleepers and show how the costs of c. £24,000 salary plus NI plus 10 per cent on costs/ Reflective practice Section 1: interventions to support and tackle rough management overheads) sleeping can be offset by savings made £540 (rent in advance for one calendar month) Personalisation pilots An outline of • and invest to save the key issues elsewhere to the public purse. • £162 (assuming a 30% claim rate against a bond of 1 calendar month) Working with people Section 2: Our advice to local authorities is to work with complex needs £858 (for floating support at average of 2 hours per Case studies through the Local Strategic Partnership (LSP) • week at £16.50 per hour for six months) CBT project to ensure that savings to other budgets are Section 3: The use of medication recognise and appreciated – to minimise the This assumes the person is able to make their own Definitions and impact of “budget parochialism”. arrangements for up to one week as they are assured of Childhood experiences weblinks assistance with moving to a PRS property. Their support Collaboration models needs are assessed as being housing and budgeting Section 4: “Prevention first” – private rented sector for complex trauma and Guidance and related, and can be addressed through floating support, severe social exclusion access schemes (Low needs) in the PRS. good practice Section 5: The client: A 29 year-old man; sofa surfing; The alternative would be in the region of £4,730, working part time; is asked to leave by a friend following a week sleeping rough and then being referred Research following argument. into supported housing projects for a period of 19 Section 6: months, based on the following costings: The costs of providing comprehensive housing options Glossary advice and assistance to access the private rented • £132 (at £16.50 per hour for street outreach contact sector (PRS) using a bond scheme is approximately and assessment service – assuming 8 hours of street/ £1,700, including six months of floating support, based day centre office time required to establish needs and on the following costings: refer into services) • £132 ( at £16.50 per hour for housing options advice • £1,000 (for direct access hostel for four weeks assuming 104 Mental health Good practice guide

Section 4: Guidance and good practice Click to go to Æ Document map £250 per week for SP grant – double cover 24/7 at £15 The psychologically “Housing first” – personalised support per hour for block grant service for 20 people) informed environment Introduction packages (high needs) • £2,730 (for 52 weeks in a second stage supported (PIE) house – assuming £52.50 SP grant – 1 FTE staff The client: Entrenched rough sleeper. Male, aged 40. Reflective practice Section 1: member at £15 per hour covering two shared houses Has alcohol dependency, linked to chaotic use of Personalisation pilots An outline of and key working 10 people) A&E and contact with criminal justice system. and invest to save the key issues • £858 (for floating support for six months when moving out) Housing first approach c. £18,000 Working with people Section 2: with complex needs • £2,080 cleaning (two hours twice per week at £10 Case studies This assumes that a failure to intervene and prevent per hour) CBT project Section 3: homelessness meant the individual was unable to remain £520 laundry (£10 per week) with the friend. They slept rough for three nights, and • The use of medication Definitions and £1,000 per annum for replacing furniture/ carpets went to a local church group that referred them to a direct • Childhood experiences weblinks hostel in a neighbouring town. They slept rough there for • £10,400 (support worker with alcohol specialism a further two nights, awaiting a vacancy, and had their visiting two hours per day Monday – Friday, at £20 Collaboration models Section 4: belongings stolen/damaged by rain. As they were out of per hour – outside London) for complex trauma and Guidance and their local support network, and had found the experience • £5,460 (generic support worker visiting for 1 hour severe social exclusion good practice traumatising, they were unable to maintain their part- each day, 7 days a week, at £15 per hour – may be time job and needed help to start benefit claims, including more in London) Section 5: a crisis loan, and to rebuild their confidence. • £520 (community alarm at £10 per week) Research Section 6: This does not assume any contact with the criminal However, the costs of the status quo (i.e. continued Glossary justice system or a deterioration in physical or mental rough sleeping and chaotic lifestyle) are in the region of health/ assault requiring use of A&E during the period £25,500, based on the following assumptions: sleeping rough. • £15,000 per annum for policing (for moving individual on when street drinking; arresting for Minimum saving per person achieved by timely aggressive begging; court proceedings and short prevention option: £3,300.

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Section 4: Guidance and good practice Click to go to Æ Document map sentence in magistrates’ court at £4,950 a time; leads to him being evicted. He uses A&E for primary The psychologically Harries 1999 – CRI estimate this is now nearer care and has had presentations with two overnight informed environment Introduction £10,000 per court appearance) admissions and one requiring a three-night stay. (PIE) • £4,800 to issue ASBO (Home Office report, 2002) Reflective practice These costs will be recurring, and do not reflect on Section 1: £3,000+ for use of A&E (DH estimate, 2009, for • wider impacts such as loss of trade and impacts on Personalisation pilots An outline of average homeless person; likely to be higher – for feelings of community safety. and invest to save the key issues example, admission through A&E costs c. £400 per time – for flu/COPD related causes – NHS network Working with people Section 2: The saving achieved by a personalised care package in March 2006) with complex needs own property c. £7,500 per annum. These savings are Case studies £2,000 (eight weeks in the night shelter) CBT project • likely to increase over time as the individual stabilises Section 3: • £480 (costs of DAAT worker seeking to engage – and the very intensive high level support can The use of medication assuming three hours each time client uses be reduced. Definitions and night shelter) Childhood experiences weblinks • £300 (costs of additional street cleansing around Collaboration models Section 4: sleeping site/ drinking sites) for complex trauma and Guidance and severe social exclusion good practice While sleeping rough, the individual drinks c.2 to 3 litres of cider over a 24-hour period, on the streets in Section 5: the town centre. The individual does not claim benefits Research consistently due to involvement with criminal justice system, and chaotic lifestyle and so begs, sometimes Section 6: aggressively. He has been the victim of assaults as well Glossary as occasionally being the perpetrator of threatening behaviour and shoplifting, resulting in three arrests and one short sentence. He has been in the direct access hostel eight times over the last 12 months – stays usually last for about a week before a confrontation

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Section 4: Guidance and good practice Click to go to Æ Document map 3. Longitudinal studies and evidence The psychologically informed environment Introduction (PIE) There is an emerging body of evidence on the long-term current levels of investment in temporary Reflective practice outcomes and impacts secured through investment accommodation services for single homeless people Section 1: in preventing and tackling rough sleeping. However, (and thereby preventing rough sleeping) delivers the net Personalisation pilots An outline of studies on outcomes to date have tended to be financial benefit of £97.0m per annum. This includes a and invest to save the key issues qualitative. Evaluation of the long-term impacts and saving of £3,560 for each single homeless person who Working with people Section 2: effectiveness of different interventions is still a work in might otherwise sleep rough, plus the avoidance of with complex needs progress for rough sleepers. additional costs associated with offending, increased Case studies CBT project use of health services and being assaulted while Section 3: sleeping rough. Economic and Social Research The use of medication Definitions and Council studies Childhood experiences weblinks The outcomes data for Supporting People also indicates CLG is jointly commissioning a series of longitudinal that 37,500 people were supported through the Collaboration models Section 4: studies on the impacts of tackling rough sleeping. programme to retain their tenancies during 2008/09, for complex trauma and Guidance and This is being delivered through the Economic and Social avoiding the costs of homelessness and rough sleeping. severe social exclusion good practice Research Council and will provide a body of evidence that is both qualitative and quantitative when the Conclusion Section 5: studies report in 2010/11 and beyond. Within CLG, Research Keith Kirby is overseeing the projects. Work to date indicates that tackling and preventing rough sleeping makes economic sense as well as Section 6: Supporting People – improving the life outcomes for individuals, and Glossary improving the safety and wellbeing of wider Cap Gemini evaluation communities. Supporting People colleagues commissioned a benefits realisation tool from Cap Gemini to support continued Contact Rebecca Pritchard: investment in the programme. This has shown that [email protected]

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Section 4: Guidance and good practice Click to go to Æ Document map Working with people with complex needs The psychologically informed environment Introduction (PIE) To be effective, competent and confident when working a suitably experienced mental health worker from an with people with mental health problems or complex external organisation. Reflective practice Section 1: needs, housing staff need to have good access to advice. Personalisation pilots An outline of Housing providers need to be able to establish good and invest to save the key issues They need support from their own managers and working relationships with key health and social care employers as well as regular supervision. Supervision partners, such as the Primary Health Care Team, Working with people Section 2: with complex needs can be provided either from within their service or from Primary Care Trust (PCT) and Mental Health Trust. Case studies CBT project Section 3: Key messages in managing clinical risks and benefits The use of medication Definitions and • 80-90% of the work in supporting a person with clear agreed protocols for information sharing. Childhood experiences weblinks Mental Health problems or complex needs is Stigma and discrimination badly affect people who Collaboration models Section 4: establishing a trusting relationship with them. • are homeless or in insecure accommodation and for complex trauma and Guidance and • Be positive – services will need to agree plans especially those with mental health problems. A non- severe social exclusion good practice together with the person being supported, which are judgmental, open attitude from the people around both hopeful and realistic. them will go a long way toward supporting them. Section 5: • Communication within your team and between Research services is critical – do not try to work on your own with For further information: an individual without support from within the team. www.dh.gov.uk/en/Publicationsandstatistics/ Section 6: Publications/PublicationsPolicyAndGuidance/ Respect confidentiality – but be clear about your Glossary • DH_083650 boundaries; do not agree to withhold information www.dh.gov.uk/en/Publicationsandstatistics/ disclosed to you from colleagues in your team. Publications/PublicationsPolicyAndGuidance/ • Equally important is good communication with DH_076511 other agencies. Ensure that you have simple and

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Section 4: Guidance and good practice Click to go to Æ Document map • All frontline homelessness services need to be aware • Special provision (such as walk-in services) is needed, The psychologically that many clients are likely to have a range of mental but ensuring local access through GPs and hostels is informed environment Introduction health problems. the most important. (PIE) All frontline staff in homelessness services need Mental health treatment on its own cannot solve an • • Reflective practice Section 1: training in basic mental health awareness and a individual’s problems. People who are homeless or thorough understanding of what to do if they believe in insecure accommodation also need good support Personalisation pilots An outline of a client may be in need of referral for assessment and form the people around them (hostel staff, friends, and invest to save the key issues treatment. family etc) in order to get better. What really works is Working with people Section 2: a combination of approaches. with complex needs • All services involved with people who are homeless Case studies or in insecure accommodation need to be aware that, • Medication has its place, but ‘talking’ therapies are CBT project even if their clients do not have a formal diagnosis of very much in demand and are not so widely available. Section 3: The use of medication mental ill health, they are likely to be experiencing • Holistic approaches are the only way to tackle the Definitions and poor emotional well being that affects their chance multiple needs of this client group. The people Childhood experiences weblinks of making a better life. we spoke to wanted to be seen as people first and Collaboration models • A typical client, who has experience of, or is foremost and their problems tackled as a whole. Their Section 4: for complex trauma and Guidance and vulnerable to, sleeping rough, will likely have highly entire history needs to be taken into account. severe social exclusion complex needs involving poor emotional wellbeing, • Personal safety and the quality and condition of good practice possible mental illness, likely personality disorder and buildings may seem comparatively unimportant Section 5: poly-substance use. ‘All-in-one’ approaches are the but in fact have a huge impact on this client group’s Research only way to deal with these issues. emotional wellbeing and their motivation to make • People sleeping rough on the streets have mental their lives better. Section 6: health and substance use needs over and above those Glossary of the general homeless population. Urgent action and effective, prolonged engagement is needed to target people whose mental ill health is keeping them on the streets.

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Section 4: Guidance and good practice Click to go to Æ Document map Good information, training and support of human beings and our emotional lives, there are four The psychologically A lot of help is available including free information key dynamics or relationships: informed environment Introduction and affordable training. Websites such as NHS Choices • between one person and another (interpersonal); (PIE) www.nhs.uk describe mental health conditions and • between a person and their environment (social); Reflective practice Section 1: how they can be treated, using short pod casts. The between a person’s own physiological, emotional, Personalisation pilots An outline of electronic mental health library NHS Evidence provides • and rational/cognitive selves (intrapersonal); and and invest to save the key issues more detailed information, aimed at professional carers. between any one person’s past, present and future www.evidence.nhs.uk • Working with people (biographical) . Section 2: with complex needs Case studies We particularly recommend practical awareness training For example, one of the most important relationships CBT project which is available though ‘Mental Health First Aid’ Section 3: is that between the baby/child and his/her mother/ www.mhfaengland.org.uk The use of medication primary care giver. The experience we have as a Definitions and baby/child affects how we see and respond to all Childhood experiences weblinks Where needs may be more complex, the Department other relationships. Not only does it affect how we of Health’s ‘Knowledge and Understanding Framework’ Collaboration models Section 4: think about things; there is now growing evidence has an online training programme which can support for complex trauma and that experience shapes the very physiology of the Guidance and staff and volunteers to establish helping relationships severe social exclusion developing brain. These early experiences continue with good practice www.personalitydisorder.org.uk/training/kuf/ us throughout our lives, and play a significant part in awareness-level Section 5: shaping who and how we are. Research Psychodynamic therapies However, psychodynamic therapists believe that these Section 6: Robin Johnson and Peter Cockersell 2010 processes continue to be dynamic – that is, responsive Glossary All psychodynamic therapy is based on the idea that to change – throughout our lives. This is essentially a how and who we are is shaped by dynamic processes. hopeful approach, based both on the idea that what we ‘Dynamic process’ here means that in any system there think, feel and do makes sense (or, often, once made are relationships between the parts, and that changes in sense in a particular context), and also that we can and one part of any system will affect the others. In the case do change how we think, feel and behave. However

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Section 4: Guidance and good practice Click to go to Æ Document map we sometimes need specialist help to change deeply Reflective practice is crucial to this understanding and The psychologically entrenched, often unconscious patterns of thinking and its impact. Even when such awareness is simply implicit informed environment Introduction behaviour, or even to realise what those patterns are – as it seems to be in many of the successful practice (PIE) and how they affect us. examples included with this paper – it may nevertheless Reflective practice still be strongly influential, and many services have Section 1: In psychotherapy, change is effected primarily developed appropriate responses in a purely intuitive Personalisation pilots An outline of through talking and feeling in a safe and holding (or way. This is because psychodynamic processes happen and invest to save the key issues “containing”) environment, and especially through regardless of whether the participants in any social Working with people Section 2: the therapeutic relationship. Psychodynamic situation are overtly conscious of them or not: they are with complex needs psychotherapy uses what the client brings and the the natural processes of human ‘being’. Case studies CBT project relationship between therapist and client to make links Section 3: between, and understand, the client’s past and present, For homelessness resettlement, achieving an initial The use of medication Definitions and internal and external, experience. Thinking about and engagement with the homeless person, and building weblinks understanding this experience enables the client to and sustaining a relationship of trust, is central to the Childhood experiences work through it, and to manage and (re)mediate its work. Psychodynamic approaches – which place great Collaboration models Section 4: effects on their lives. emphasis on the quality of relationships – have gone for complex trauma and Guidance and furthest in developing the tools to understand these severe social exclusion good practice However, psychodynamic thinking is not confined solely complex interactions. However, one of the main reasons to one-to-one therapeutic work between therapist and why the psychodynamic approach is popular with the Section 5: client. The same perspective and values can also be clients themselves (apart from that it works) is that Research expressed in group work, in peer-to-peer support, and it is a person-centred approach which listens to and even embedded in an organisational culture, in a way respects the reasons why individuals have made the life Section 6: of working which pervades the service model. When choices they have, recognises the impact others and the Glossary the impact of such psychodynamic thinking in the environment have had on them, and works with them running of a particular service is conscious and explicit, to create a better future without denying the awfulness we can talk of a “psychologically informed planned or impact of the past. environment”.

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Section 4: Guidance and good practice Click to go to Æ Document map CBT project, Derby Road, Southampton The psychologically informed environment Introduction (PIE) Hants Partnership NHS Trust, with input from the Reflective practice Summary Southampton Street Homeless Prevention Team (SHPT) Section 1: • 23 people were referred to the project between to address the needs of entrenched rough sleepers Personalisation pilots An outline of September 2001 and April 2004 to be treated using who had been excluded from all the hostels in the and invest to save the key issues City. It was funded by the Rough Sleepers’ Unit and CBT and DBT Working with people Section 2: Southampton City Council. with complex needs • All 23 had some form of alcohol and/or substance Case studies abuse problem – nine of these were associated CBT project with the use of a Class A substance, and 19 of the As well as the usual housing-related support delivered Section 3: by the project workers, the scheme offered residents individuals had experienced childhood neglect The use of medication Definitions and access to cognitive behaviour therapy (CBT) and and/or abuse Childhood experiences weblinks dialectical behaviour therapy (DBT) formulation Nine people were evicted • and intervention techniques, delivered by a clinical Collaboration models Section 4: 14 were in accommodation at the end of the project • psychologist. Residents attended individual and for complex trauma and Guidance and At six month follow-up, only two were back on • group therapy on a weekly basis to help them address severe social exclusion good practice the street. problems that underpinned their antisocial behaviours and repeated tenancy loss. Section 5: Background Research In addition to this, the project aimed to ensure The Derby Road CBT project operated from a small, consistency of approach and collaboration by providing Section 6: four-bed shared house in Southampton between CBT supervision for the project workers. It also enabled Glossary September 2001 and April 2004 when it closed down due the residents to take an active role in managing aspects to the end of the contract with the housing association. of the running of the house, through house meetings. The project was carefully evaluated to investigate The project was initially set up by the Society of effectiveness of this novel approach. St James in conjunction with Swaythling Housing and

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Section 4: Guidance and good practice Click to go to Æ Document map It is important to note that for many residents, the reductions were noted for all clients for nights spent The psychologically Derby Road CBT project was just one aspect of the sleeping rough, violent incidents and criminal incidents. informed environment Introduction multi-agency approach adopted to address their (PIE) complex needs. Specifically, close liaison with the SHPT In total, between September 2001 and April 2004, Reflective practice was found to be particularly important to follow up 23 people were resident in the project. They included; Section 1: evicted residents. 14 street homeless Personalisation pilots An outline of • and invest to save the key issues Two straight from prison A psychological measure, the Clinical Outcomes • Two street homeless via a detox unit Working with people Section 2: in Routine Evaluation (CORE) was used to gather • with complex needs information at four time points: • Five from direct access hostels Case studies CBT project before entry into the project Section 3: • Nine residents were evicted over this period, on entry to the project The use of medication • for a number of reasons. These were: Definitions and 10 weeks after entry; and Childhood experiences weblinks • • Four threats to kill one year follow-up. • Two dealing class A drugs Collaboration models Section 4: • for complex trauma and Two extreme chaos associated with alcohol Guidance and The CORE measures social functioning, problems and • severe social exclusion symptoms, wellbeing and risk. • One physical assault on another resident good practice Section 5: Two of the residents showed distinct improvements In terms of length of stay at the project, seven people Research on the functioning, problems and symptoms and risk were resident less than 10 weeks (three were evicted, subscales after entry into the project. In addition, three left of their own accord and one moved on to Section 6: supported accommodation). The average number of one improved in terms of his wellbeing and risk, and Glossary the fourth improved in terms of functioning and weeks that the remainder of the people were resident risk. Importantly, all residents improved in terms of in the project was 21 weeks (the average of all residents risk to themselves and others. This was one of the was 17.5 weeks). The shortest stay was two weeks primary outcomes for the project – reducing antisocial (evicted), the longest 62 weeks. behaviours that lead to tenancy breakdown. In addition,

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Section 4: Guidance and good practice Click to go to Æ Document map All residents had some form of alcohol and / or Background The psychologically substance abuse problem: informed environment Introduction Seven alcohol alone According to these figures, around 44% of people were (PIE) • successfully moved on to supportive housing (including Seven alcohol, cannabis and / or amphetamines • one of the individuals who was killed), while around 9% Reflective practice Section 1: Nine heroin, crack and / or amphetamines • were left on the streets, the remainder achieving an Personalisation pilots An outline of outcome somewhere in between. It is therefore possible and invest to save the key issues This level of drug and alcohol abuse represents a to speculate that a successful move-on rate of around significant challenge to agencies and therapeutic 45% is realistic for this complex client group. These Working with people Section 2: with complex needs approaches. Importantly, nineteen of the residents figures also highlight the need to specify what form of Case studies suffered some form of neglect (83%). This has important accommodation represents a successful outcome. CBT project implications in terms of possible factors implicated in Section 3: The use of medication many of the behaviours which lead to tenancy breakdown. A number of important factors were found to be Definitions and implicated in the success or failure of the project in Childhood experiences weblinks Other agencies were contacted to establish where addressing the needs of this challenging population. Collaboration models residents were living six months after leaving the project. Therapeutic engagement skills were crucial in enabling Section 4: for complex trauma and Nine were in accommodation in the city individuals to consider change, and many individuals Guidance and • severe social exclusion • Three were living out of area reported being unused to discussing personal issues. good practice • Two were in direct access hostels Section 5: One lost contact The type of tenancy has to be considered when • engaging a risky population in a hostel environment, Research • Three were in prison as well as the effect of such an environment on the Section 6: • Two had been killed, one while in supportive housing immediate surroundings (i.e. neighbours). • Two were rough sleeping Glossary Lastly, the type and hours of support services were found It appears that there was a very positive outcome for 14 to be important in terms of the practicalities of working of the 23 people, which is a significant number, given with a risky population, in particular, cover at weekends. the complexity and challenging nature of the client group and their long history of eviction. Contact Dr Nick Maguire: [email protected]

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Section 4: Guidance and good practice Click to go to Æ Document map The use of medication Childhood experiences The psychologically informed environment Introduction Some people with Mental Health problems will require Margaret E. Blaustein, Director of Training and (PIE) day-to-day support in order to manage their prescribed Education, at The Trauma centre JRI, Brookline, MA, Reflective practice Section 1: medications. This could involve: identifies adverse childhood experiences and Personalisation pilots An outline of outcomes and the resulting behavioural adaptations. • advice or reminders from housing staff and invest to save the key issues Her presentation (see weblink) defines complex use of ‘booster packs’; or • trauma and outlines appropriate interventions. Working with people Section 2: • help with monitoring and understanding potential www.degpt.de/daten/2007%20-%20Blaustein.pdf with complex needs side effects. Case studies CBT project Section 3: MIND produces a series of simple information leaflets The use of medication Definitions and about mental health treatments and locations at weblinks www.mind.org.uk. Childhood experiences Collaboration models Section 4: The importance of managing medication is described in for complex trauma and Guidance and the NMHDU booklet, ‘Getting the medicines right’. severe social exclusion good practice www.nmhdu.org.uk/silo/files/getting-the-medicines- right--jul-2009.pdf Section 5: Research Very many people who are, or have been, homeless may have a problem with alcohol or street drugs which Section 6: can be a cause or consequence of a mental health Glossary problem. Mental Health Services describe this as a dual diagnosis. For further information on this: www. dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_062649

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Section 4: Guidance and good practice Click to go to Æ Document map Collaboration models for complex trauma and The psychologically informed environment Introduction severe social exclusion (PIE) Reflective practice Section 1: These papers offer some top-level research to help Needs and the available resources or services will vary Personalisation pilots An outline of commissioners explore a wide range of issues widely across the country, and it is not possible or even and invest to save the key issues surrounding complex trauma. appropriate to specify or promote any particular model. Working with people It is perhaps most important that developments are Section 2: with complex needs Meeting these more complex psychological and well attuned to local circumstances and opportunities. Case studies emotional needs cannot be achieved by any one agency CBT project Section 3: or sector working in isolation, however sophisticated Various possible models of inter-agency and The use of medication their work. Co-operation and collaboration between inter-service collaboration, and the implications for Definitions and agencies will typically be necessary, both to ensure funding, local commissioning and accountability, are Childhood experiences weblinks effective pathways into and between services at various outlined below. These range from awareness and skills Collaboration models Section 4: stages of engagement, and to enhance the capacity of training and sessional input by health professionals, for complex trauma and Guidance and each agency to work with sensitivity and awareness, to fully-integrated services, managed networks and severe social exclusion and with the resilience and range of specialist skills that psychologically informed planned environments. good practice may be brought to bear. Section 5: Research Section 6: Glossary

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Model Description Resources Notes The psychologically Resettlement Awareness and skills development Resources for additional in-put Needs to be accessible for all informed environment Introduction A services with for frontline staff, intended can be provided by any funding levels of staffing, including (PIE) additional to enable workers to become source; the skills in-put may be ancillary staff and volunteers, peer clinical in-put suitably sensitive to relevant delivered by statutory or third support etc. Training that includes Reflective practice psychological issues. sector services. former service users as trainers Section 1: 1: Awareness is believed to be particularly Personalisation pilots An outline of and skills Skills development would enable Outcome measures would effective. training workers to become adept at using normally be based on the and invest to save the key issues specific relevant skills themselves, enhanced effectiveness of Awareness training will aid and more confident in referring resettlement efforts. development of a ‘psychologically Working with people Section 2: to specialist services where informed environments (PIE)and with complex needs appropriate. Established training programmes meeting ‘enabling environment’ Case studies exist which could be suitably standards (see E). CBT project See for example the DH “KUF” adapted. Section 3: (Knowledge and Understanding www.babcp.com Training enhances access to and/ Framework) programme for staff or provision of individual therapy The use of medication KUF programme consists of six Definitions and from all agencies, for responding in sessional in-put for selected weblinks more effectively to complex needs online modules supported by service users. Childhood experiences virtual learning environment and and longstanding emotional Collaboration models problems (with particular three seminars. Section 4: reference to personality disorder). www.personalitydisorder.org.uk/ for complex trauma and training/kuf/awareness-level Guidance and NB: some reciprocal training from www.personalitydisorder.org.uk/ severe social exclusion good practice housing and resettlement staff to assets/resources/169.pdf enable MH workers to understand Section 5: housing issues would also be helpful. Research Section 6: Glossary

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Model Description Resources Notes The psychologically Resettlement Specific on-site counselling, group Resources for specialist clinical in- Clinical in-put needs to involve informed environment Introduction B services with work or comparable in-put, for put would normally to be provided techniques from established (PIE) additional hostel/foyer/refuge service users, from health and social care funding, evidence-based therapies. clinical in-put provided by specialist MH staff or commissioned locally, monitored Reflective practice counsellors. and regulated according to clinical NB: Can include group work, Section 1: 2: “In-reach” outcome measures. psychodrama, creative arts, or other sessional in-put Suitable skills might include Art skills development for service users, Personalisation pilots An outline of Therapy; Cognitive Analytic (CAT); Resources for arts or other skills and can include or complement and invest to save the key issues Cognitive Behavioural (CBT); training may be provided by a range more generic primary care health Dialectical Behaviour (DBT); of funding sources. in-put. Working with people Section 2: Interpersonal (IPT); Integrated with complex needs Arts; Mentalisation Based (MBT); NB: Individual-focused work may Case studies Psycho-Analysis; Psychodynamic; not address ‘whole system’ factors CBT project Transactional Analysis (TA) or team dynamics. Section 3: Counselling has similarities see: The use of medication www.bacp.co.uk Definitions and Childhood experiences weblinks C Multi-agency Co-location of services from different Resources for specific services Co-location reduces the visibility environment agencies, for a more holistic approach would normally be funded and and possible stigma of using any Collaboration models Section 4: and greater sensitivity and ease of commissioned by the specific particular service, and would for complex trauma and access to services for service users relevant funding body, and facilitate access to therapeutic in- Guidance and accountable separately. put for reticent or reluctant service severe social exclusion good practice The distinction between sessional users. in-put and a full multi-agency Sharing premises, publicity and environment may not be clear-cut. reception functions can provide Co-location of services encourages Section 5: But co-location implies a more some savings; streamlining of cross-referral and co-working concentrated presence on site of referral and co-working may be between agencies, and can mean Research each of the component parts, and particularly cost effective for more that full disclosure of underlying a location which is not primarily complex needs and preventive problems is under the control of the Section 6: identified with any one agency work. individual service user. Glossary

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Model Description Resources Notes The psychologically Multi-source Sophisticated joint funding Resources may be block purchased Multi-source funding for a single informed environment Introduction D funding for a arrangements to allow a single or delivered via personal budgets, ’core‘ agency does not preclude the (PIE) single agency agency to deliver services flexibly or tiered with any combination of possibility of additional specialist environment across a range of health, social care the two. in-put from another service, Reflective practice and housing support activities and as in A, B or C. Section 1: commissioned outcomes Personalisation pilots An outline of and invest to save the key issues E Psychologically A managed environment, such as A PIE will typically be managed Reflective practice, supported by Informed a hostel, refuge, foyer or day care by a single staff team, though this training (see A), can specifically Working with people Section 2: Environment service, where procedures etc have team may be multi-disciplinary address the whole psychosocial with complex needs been carefully modified to meet the and/or include staff from various environment, in the name of ‘PIE’ Case studies needs of the particular client group. agencies. Each agency’s funding maximum engagement and CBT project and commissioning then needs to flexibility to meet complex needs. Service design and delivery in Section 3: reflect the ambition to create a The use of medication a PIE would typically be under single, coherent service. NB: Can also be tailored to work Definitions and constant review by the staff team, for a managed clinical network through reflective practice. Service DH’s KUF awareness training is (F, below) for support and Childhood experiences weblinks design thinking should include the suitable for promoting reflective treatment pathways from specialist appropriate staff mix, roles for practice (see 1) services Collaboration models Section 4: service users, layout of the building, www.personalitydisorder.org.uk/ for complex trauma and timetables, etc training/kuf/awareness-level The Royal College of Psychiatry’s Guidance and ‘Enabling Environment’ award is severe social exclusion good practice NB: for these purposes, a currently in pilot stage. therapeutic community (“TC”) can www.enablingenvironments.com be regarded as a particular example Section 5: of a PIPE. Both are examples of an Research “enabling environment” Section 6: Glossary

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Model Description Resources Notes The psychologically Managed Explicit co-ordination of services to Although particular individual A managed network concentrates informed environment Introduction F clinical network ensure coherent and streamlined components of a managed on pathways and communications (PIE) support and care pathways, with clinical network may be funded between services measures to identify and cover and commissioned separately, Reflective practice gaps, bottlenecks or shortfalls. monitoring and performance “Nidotherapy” might be seen as an Section 1: management measures need to be individual-focused managed clinical Personalisation pilots An outline of more sophisticated, as outcomes network. are particularly inter-dependent. and invest to save the key issues Working with people Section 2: Individual Work directly with families and Family and systemic interventions Training is available for individual with complex needs G family/systemic significant others. are normally funded and staff. Case studies interventions commissioned as specialist services CBT project Examples are Intensive Fostering; via health and social care. May also address ‘whole system’ Section 3: Family Group Conferences; Family factors. The use of medication Therapy. Housing and resettlement staff Definitions and may be involved as facilitators or, in Childhood experiences weblinks the case of ASBO plus schemes, as stakeholders. Collaboration models Section 4: for complex trauma and Guidance and severe social exclusion good practice Section 5: Research Section 6: Glossary

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Section 5: Research Click to go to Æ Document map Cognitive and behavioural therapeutic interventions to Cognitive and behavioural therapeutic Introduction tackle homelessness – research synopsis interventions to tackle homelessness – Nick Maguire, Helen Keats & Suzanne Sambrook – December 2006 research synopsis Section 1: An outline of How psychological the key issues Introduction This discussion paper attempts to highlight the links factors related to Homelessness is a social problem that has a major between mental health problems and homelessness, traumatic experience Section 2: impact, both on society as a whole and the individuals and describes a pattern of cognitive, emotional and and personality disorder Case studies concerned. While a common perception of a homeless behavioural difficulties which leads to repeated tenancy are associated with person is of someone sleeping rough, there are a number breakdown and homelessness. It offers some solutions chronic homelessness Section 3: to tackling homelessness, which can be incorporated of other situations in which people can be described as Definitions and into work on homelessness resolution and prevention. Research synopsis insecurely housed and/or at risk of homelessness, such as weblinks It attempts to offer suggestions for pathways out of living in a hostel, ‘sofa surfing’ and staying with friends or homelessness, detailing the implicated cognitive, Section 4: family, usually for short periods of time. emotional and behavioural factors and ties this to Guidance and individual developmental experience. As such it is good practice presented within frameworks associated with cognitive Although the Government and its stakeholders behavioural therapy (CBT) and dialectical behavioural Section 5: achieved the target to reduce rough sleeping therapy (DBT), with reference to attachment processes. Research by two thirds by April 2002, there remains an insecurely housed population, many of whom have Two categories of serious and enduring mental health Section 6: drug, alcohol or mental health problems and who problems will be discussed in detail. First, the psychotic Glossary are at risk of rough sleeping. There is also evidence disorders (i.e. those associated with the diagnosis of of some people having difficulty maintaining schizophrenia), and second, the personality disorders (PD) tenancies because of anti social behaviour, which will be considered. For the purposes of this discussion, PD is being tackled through the Government’s Respect will be considered as a mental health problem, despite Task Force. the ‘treatability clause’ associated with the 1983 Mental Health Act (this is discussed in more detail below). 121 Mental health Good practice guide

Section 5: Research Click to go to Æ Document map Current policy Mental health and homelessness Cognitive and Current Government policy focuses on tackling and A significant factor contributing to someone becoming behavioural therapeutic Introduction preventing homelessness as early as possible, through a homeless is mental health problems, many of which interventions to tackle homelessness – combination of housing advice, tools such as mediation remain undiagnosed. The prevalence of psychotic Section 1: or rent deposits and housing related support funded disorders in the homeless population (i.e. those research synopsis An outline of through the Supporting People (SP) programme. associated with diagnoses such as schizophrenia) How psychological the key issues However SP excludes financial support for therapeutic varies between 4% and 40%, depending on factors related to services, such as psychotherapeutic input. assessment methods and populations investigated. traumatic experience Section 2: and personality disorder Case studies The £90m Hostels Capital Improvement Programme There is no published literature describing the are associated with (HCIP) currently in place aims to make hostels places of prevalence of personality disorders, although an chronic homelessness Section 3: change rather than containment. unpublished doctoral thesis found that 59% of a Research synopsis Definitions and It focuses on ensuring that homeless people are given hostel population reached diagnostic levels. weblinks the opportunity to change their expectations and their lives, through access to a range of services, which The lack of research data may be partly due to the Section 4: could include psychotherapeutic interventions where difficulties in diagnosis and treatment, but may also Guidance and available and appropriate. be due to the ‘treatability’ clause still in operation good practice due to the 1983 Mental Heath Act. This states that Section 5: There is evidence that unless the underlying causes any patients to be ‘sectioned’ under the Act must be Research of homelessness, such as drug or alcohol misuse, ‘treatable’, meaning that individuals diagnosed with a PD could not be sectioned as an inpatient solely anti social or violent behaviour or mental health Section 6: problems are tackled, some people will continue due to their diagnosis as PD was not deemed Glossary to be at risk of rough sleeping or of repeatedly treatable when the Act was published. It is useful losing their accommodation. There is also evidence to consider PD as a serious and enduring of a link between mental health problems and mental health problem, which can have long- substance misuse, with some people using drugs term negative effects on the way in which a and alcohol to “self-medicate”. person interacts with their environment.

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Section 5: Research Click to go to Æ Document map 8 Inappropriate or uncontrollable anger Cognitive and Other mental health problems that may be 9 Transient stress-related paranoid ideation or severe behavioural therapeutic Introduction implicated are post traumatic stress disorder dissociative symptoms (i.e. paranoia induced by interventions to (PTSD), anxiety and depression, in addition to drug stress, and ‘dissociation’ – a process of ‘removing’ tackle homelessness – Section 1: and alcohol problems. PD is characterised by a oneself from reality typically learned during research synopsis number of emotional, cognitive and behavioural An outline of episodes of early abuse) How psychological factors which can be seen to contribute to the key issues factors related to repeated tenancy breakdown. Observations indicate that a proportion of homeless traumatic experience Section 2: people, particularly rough sleepers or those living in and personality disorder Case studies hostels or night shelters, exhibit behaviours which are associated with The diagnostic criteria for borderline personality frequently result in eviction. Typically, this is behaviour chronic homelessness Section 3: disorder (BPD) are particularly useful when considering which contravenes the rules of the establishment, Research synopsis Definitions and such factors. The following are the diagnostic criteria e.g. consuming alcohol on the premises or returning weblinks associated with BPD set out by the North American obviously intoxicated, owning, obtaining, or consuming Diagnostic and Statistical Manual (DSM): illegal substances and violent or aggressive behaviours. Section 4: These latter behaviours can be functionally related to Guidance and 1 A pattern of intense and unstable interpersonal forms of substance abuse, e.g. to obtain substances or good practice relationships as a result of injesting them. Section 5: 2 Frantic efforts to avoid real or imagined These behaviours can be seen to be similar to a number Research abandonment of behavioural factors associated with personality 3 Identity disturbance or problems with sense of self disorders. It is argued that most of these can be traced Section 6: 4 Impulsive behaviour that is potentially to abusive experiences in critical developmental stages, Glossary self-damaging i.e. childhood and adolescence. There is evidence of an 5 Recurrent suicidal or parasuicidal behaviours association between having been brought up in care and 6 Affective (emotional) instability later homelessness. Additionally clinical observations indicate a high prevalence of early neglect and abuse in 7 Chronic feelings of emptiness the homeless population.

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Section 5: Research Click to go to Æ Document map Possible pathway to homelessness Cognitive and behavioural therapeutic Introduction Abusive interventions to Negative childhood tackle homelessness – Section 1: view of self, Survival, research synopsis coping An outline of world and How psychological strategies the key issues others factors related to traumatic experience Section 2: Negative and personality disorder Case studies ruminations are associated with chronic homelessness Section 3: Research synopsis Definitions and weblinks

Difficult Section 4: emotions Guidance and good practice Section 5: Substance Research misuse Antisocial Section 6: behaviours Glossary Repeated tenancy breakdown

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Section 5: Research Click to go to Æ Document map It is being proposed here that repeated tenancy (NICE) recommends that CBT should be a treatment Cognitive and breakdown and eviction can be formulated, taking into option for those with suffering schizophrenia along behavioural therapeutic Introduction account a number of individual historical, cognitive, with medication. interventions to emotional and behavioural factors. These are described tackle homelessness – in the diagram below. The research literature examining models and research synopsis Section 1: treatment of personality disorders has not been so An outline of How psychological Early abusive experiences can result in difficult thought fruitful. The evidence so far is mixed in terms of its the key issues factors related to processes and rumination and concomitant intolerable findings regarding personality disorders generally. traumatic experience Section 2: emotions. The easiest method of altering these in the Methodological, design, population and research setting and personality disorder short-term at least is to take some form of substance, problems mean that definitive conclusions can not yet Case studies are associated with i.e. drugs or alcohol. This is more likely to happen be made. There is however some evidence that a variant chronic homelessness Section 3: when skills in regulating emotion have not been learnt of behavioural therapy, dialectical behavioural therapy in childhood. These, in combination with aggressive (DBT) is effective in reducing self-harming behaviours Research synopsis Definitions and behaviours learnt in childhood and adolescence, of those suffering borderline personality disorder (NICE weblinks result in antisocial behaviours and repeated tenancy now recommends DBT as a psychological treatment for Section 4: breakdown. Where more adaptive interpersonal skills borderline personality disorder). Guidance and have not been learnt, more destructive ones which good practice have previously been successful to some extent Supervision (e.g. aggression) are used. The problems that people within the homelessness Section 5: population suffer are complex and often of an Research Therapeutic interventions interpersonal nature. This means that interpersonal In the last twenty years a great deal of progress has interactions can be difficult due to inherent ambiguities Section 6: been made in terms of the treatment of severe mental in human communication and sensitivities of clients Glossary health problems, particularly those associated with associated with childhood neglect and abuse. Some cognitive behaviour therapy (CBT) and its variants. The may interpret others’ attitudes as rejecting and research examining cognitive models and treatment neglectful easily, and become depressive or angry, of psychosis in particular have progressed to such an behaving accordingly. extent that the National Institute of Clinical Excellence

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Section 5: Research Click to go to Æ Document map Frontline workers are expected to deal first hand The Southampton experience Cognitive and with such difficult interactions, without the aid of behavioural therapeutic Introduction taught psychological skills and frameworks to work Single men’s homelessness CBT project interventions to with. Frameworks and methods of working with In Southampton between 2001 and 2004 a project tackle homelessness – interpersonal difficulties are best learnt through case to deal with clients who had proved most difficult research synopsis Section 1: discussion in a group format. There should be ongoing to maintain in tenancies was commissioned, funded An outline of How psychological clinical supervision, provided regularly (e.g. once every through the then Homelessness Directorate. This the key issues factors related to fortnight) and facilitated by a qualified practitioner. was a four-bed house (leased from a local housing association) with dedicated support workers provided traumatic experience Section 2: by a local homelessness charity (Society of St James), and personality disorder Case studies are associated with In addition, supervision within a cognitive and psychologist time bought from the local NHS trust. chronic homelessness Section 3: behavioural framework focuses on facilitating In addition to the Society of St James and NHS Trust, workers to enable cognitive, emotional and Southampton City Council and Rough Sleepers Initiative Research synopsis Definitions and behavioural change, and deal with the difficult (now Southampton Street Homeless Prevention Team) weblinks were involved in the collaboration. The arrangement of interactions which are inevitably experienced. Section 4: These are described in terms of the beliefs about tenancies meant that clients with greater difficulties Guidance and the interactions, and associated emotions. For could be taken on, and typical referrals were people good practice example many staff have thoughts about not who had been evicted from all or most other projects in the city, had poly-drug and alcohol abuse issues, some being effective when clients relapse in terms of Section 5: having prison records. a particular behaviour that has been worked on. Research These beliefs are made explicit and alternative thoughts about what is happening developed. The psychologist provided CBT input for two and a Section 6: half days a week, comprising individual sessions with Glossary residents and group supervision with support workers. One possible outcome of regularly attending to Attempts were also made to engage clients in the staff clinical practice and emotions is fewer staff running of the house through house meetings. experiencing burnout and less staff turnover. This may save money in the long term.

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Section 5: Research Click to go to Æ Document map Between September 2001 and April 2004, 23 people DBT and Domestic Violence Project Cognitive and were resident in the project. Fourteen of these had behavioural therapeutic Introduction previously been street homeless, two came straight A joint project between Hampshire Partnership interventions to from prison, two were street homeless and referred via NHS Trust and Women’s Aid was funded by the tackle homelessness – the local detox unit, and five came from direct access Homelessness Directorate to find ways of preventing research synopsis Section 1: hostels, having been evicted. repeat homelessness in women who have experienced An outline of How psychological domestic violence. the key issues factors related to The average stay for all clients was 17.5 weeks (range 2 – traumatic experience Section 2: 62 weeks). In terms of move-on, nine went to their own The project tested the idea that if the women involved and personality disorder residence, three went to residences out of area, two could feel more in control of their lives they would be Case studies are associated with were referred back to direct access hostels, three went more able to solve day to day problems and hence be chronic homelessness Section 3: back to prison, two moved away and lost contact, and more able to maintain their tenancies. The project used Definitions and two returned to street homelessness. Two clients were a short-term group based on DBT. DBT is a therapeutic Research synopsis weblinks murdered, one after having left the project and one intervention which focuses on teaching skills such as shortly after having moved in. managing emotions, problem solving, distress tolerance Section 4: and assertiveness. Guidance and The project and psychological therapy was effective in good practice terms of enabling 14 out of the 23 clients to find and The project comprised a 12-week group for the women sustain accommodation, despite their previous history and training for the staff at Women’s Aid so that they Section 5: of repeat homelessness. The rest were either difficult to could continue to support the women both between Research engage and / or their continued antisocial behaviours sessions and after the group had finished. resulted in eviction. Section 6: Results from the group showed improvements in Glossary self-esteem, mood and feelings of control. Comments from the women themselves suggested that the group was well received, and that they found they could deal with problems and negotiate with professionals and systems more effectively. Almost half of the group

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Section 5: Research Click to go to Æ Document map members moved out from the hostel during the course • Thought must be given to the type of property and Cognitive and of the group and were able to establish themselves tenancy agreement made available to clients of the behavioural therapeutic Introduction independently. There was no evidence that any of the service. interventions to women went back into their abusive situations. Because of the chaotic nature of many of the tackle homelessness – • Section 1: clients, services should be provided within the research synopsis Developing ways in which such groups could become An outline of accommodation rather than through traditional out How psychological more readily available is the challenge of the future. the key issues patient services. factors related to Training the staff of the hostel to provide the Levels of engagement can vary considerably and traumatic experience Section 2: intervention is one way forward, but requires time and • services must be flexible enough to manage this. and personality disorder ongoing supervision if it is to be successful. However, Case studies are associated with such therapeutic approaches have wide ranging benefits • Hostel staff must be offered training in the CBT/DBT chronic homelessness Section 3: for those who go through them and could in the long approach (as opposed to delivery of the therapy) so term be very cost effective in preventing the cycles of that they have an understanding of the models and Research synopsis Definitions and behaviour which keep people stuck and dependent can reinforce key messages consistently. This may be weblinks on services. difficult to sustain, given the traditionally high staff turn-over rates in the sector. Section 4: Guidance and Implications • This is a challenging client group to work with, and staff can feel frustrated and demoralised on good practice Both CBT and DBT have been successfully used occasions. Support must be made available to ensure alongside Supporting People and other services within Section 5: that staff avoid ‘burn out’ and maintain motivation. some hostels to enable highly chaotic people to find Research and keep accommodation. This has led to greater access • Additional funding has to be identified for to other services such as detox and has also led to psychotherapeutic services, and this can be difficult. Section 6: reduced numbers of people rough sleeping. It is particularly important as access to local mental Glossary health provision (e.g. community mental health However the schemes have identified a number of key teams) is extremely limited, partly due to limited issues which need to be addressed by agencies wishing access to primary care and therefore referral but also to commission similar services: because of a shortage of therapists. Even those who do access secondary and tertiary care are unlikely

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Section 5: Research Click to go to Æ Document map to be offered psychological therapies if they are Useful reference Cognitive and currently using substances or alcohol. It could be that NICE Guidelines, Mental Health: behavioural therapeutic Introduction this would be a fruitful area for investment in primary www.nice.org.uk interventions to care psychology for primary care trusts to consider. tackle homelessness – Section 1: Identifying shared outcomes such as a reduction in research synopsis • An outline of the use of A&E and mental health crisis services / How psychological the key issues admissions, reduced re-offending, reduction in anti factors related to social behaviour, reduction in evictions, reduced traumatic experience Section 2: numbers rough sleeping, harm minimisation etc can and personality disorder Case studies be an effective way of encouraging multi agency are associated with buy-in. chronic homelessness Section 3: Research synopsis Definitions and Conclusions weblinks Undiagnosed and / or untreated severe and enduring mental health problems can contribute to repeated Section 4: tenancy breakdown and therefore homelessness. Guidance and Psychological therapies have proved an effective good practice intervention for chaotic and challenging clients and Section 5: have reduced time spent homeless. Research

Psychological therapies should be specifically funded and Section 6: delivered within accommodation rather than through out patient services, to maximise take up and engagement. Glossary

Schemes need to have multi agency involvement, to have clear outcome measures and to be properly evaluated.

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Section 5: Research Click to go to Æ Document map How psychological factors related to traumatic experience and Cognitive and behavioural therapeutic Introduction personality disorder are associated with chronic homelessness interventions to tackle homelessness – Nick Maguire University of Southampton research synopsis Section 1: Robin Johnson RJA consultancy An outline of How psychological Panos Vostanis University of Leicester the key issues factors related to Helen Keats Department for Communities and Local Government traumatic experience Bob Remington University of Southampton Section 2: and personality disorder Case studies are associated with Summary Introduction chronic homelessness Section 3: Definitions and Homelessness is a complex problem which, for many Research synopsis This paper outlines how psychological factors related weblinks to traumatic experience and personality disorder are people, results from an interaction between associated with chronic homelessness. It reports a environmental and mental health factors. For many Section 4: systematic review of the literature which supports years, social policy and funding sources in the UK have Guidance and the conclusion that psychological disorders strongly focused on factors such as poverty, housing provision, good practice predict homelessness and provides indicative evidence and the practical aspects of being homeless (e.g., that psychological interventions can improve the Supporting People, ODPM, 2003). More recently, Section 5: life chances of homeless people. It concludes that however, research has highlighted the individual factors Research additional research is required both to establish the that may underpin homelessness. Although the most effective psychological interventions for chronic homeless population is heterogeneous and there are Section 6: homelessness in the UK cultural context, and to many disparate circumstances underpinning the reasons Glossary evaluate the effective transfer of research knowledge why people find themselves without a home, many from research to service delivery settings. aspects of chronic homelessness, including rough sleeping, eviction and repeated tenancy breakdown are thought to result from severe and enduring mental health problems. There is strong evidence that those

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Section 5: Research Click to go to Æ Document map who experience repeat homelessness experience such There is a reasonable literature on the prevalence of Cognitive and problems. For example, US research indicates that personality disorders (PD) in the homeless population,8 behavioural therapeutic Introduction approximately 91% of a homeless sample had received but the extent to which PDs may be implicated in the interventions to some form of primary psychiatric diagnoses, with about aetiology and/or maintenance of homelessness is not tackle homelessness – 40% suffering psychoses and 29% chronically misusing yet certain. Although few studies have systematically research synopsis Section 1: alcohol.5 In the UK, schizophrenia is present in an diagnosed personality disorders, unstructured clinical An outline of How psychological estimated 31% of the homeless population;6 Axis I assessments suggest rates up to 70% (although rates the key issues factors related to disorder (e.g., depression, anxiety) in an estimated are highly varied;9) with schizoid, borderline, dependent, traumatic experience Section 2: 50-75%,7 and Axis II problems (personality disorder; PD) and antisocial features often identified.10 Antisocial and personality disorder present in up to 70% (PD is considered in more detail personality disorder has received some attention, Case studies are associated with shortly). Many of these different problems are with estimated rates of 10-40% in the homeless chronic homelessness Section 3: commonly co-morbid in homeless people. population.11 Recent evidence investigating the prevalence of PD in a UK population of street homeless Research synopsis Definitions and Thus, homelessness may be more than simply not having and hostel dwelling adults found that 58% reached weblinks somewhere to live owing to unforeseen circumstances. diagnostic levels (Maguire, Munwar, Levell, McClean & Section 4: The experience of agencies working with homeless people Matthews, in preparation12). Guidance and is that unless and until the underlying psychological good practice issues behind the presenting problem are identified and addressed, homelessness is likely to be repeated. This Section 5: means that the problem of homelessness cannot be Research solved by the provision of accommodation alone. Section 6:

8 e.g. Fazel, Khosia, Doll & Geddes, 2008 Glossary 9 Fazel et al, 2008 10 Tolomiczenko, Sota & Goering, 2000 11 Caton, Hasin, Shrout, Opler, Hirschfield et al. 2000 5 Bassuk, Rubin & Lauriat, 1984 12 For a comprehensive systematic review and meta-analysis of the 6 Timms & Fry, 1989 mental health literature, the reader is referred to Fazel, Khosla, 7 Drake, Osher, & Wallach, 1991 Doll & Geddes (2008); Rees (2009).

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Section 5: Research Click to go to Æ Document map Research shows that PDs are often the product of meta-engine EBSCO Host, which searches CINAHL, Cognitive and traumatic childhood and adolescent experiences. The MEDLINE, PsycARTICLES and PsycINFO, was also behavioural therapeutic Introduction experience of sustained exposure to traumatic events employed. Search terms included combinations of the interventions to has recently been termed complex trauma13. This following, where an asterisk (*) denotes any subsequent tackle homelessness – sustained exposure to toxic experience distinguishes string of characters (e.g. homeless* would include research synopsis Section 1: complex trauma (or Type II Trauma) in principle from homeless and homelessness): homeless*, aetiology, An outline of How psychological post-traumatic stress disorder (PTSD, or Type I Trauma), complex trauma, personality disorder, antisocial, the key issues factors related to which describes cognitive, emotional and behavioural borderline, child* neglect, child* abuse, childhood, traumatic experience Section 2: reactions to a single event. Although circumstantially psychology*, impulsivity. In addition, experts in the and personality disorder complex trauma makes clinical sense in terms of a field were consulted to contribute papers that were not Case studies are associated with high prevalence of childhood abuse and neglect in the identified in the first search. Similarly, the reference chronic homelessness Section 3: entrenched homeless population, very little research lists of recent reviews were trawled for papers not has been conducted on how the resulting personality initially identified. Research synopsis Definitions and disorders lead to entrenched or repeat homelessness. weblinks These search strategies yielded 154 papers for inclusion. Section 4: The inclusion criteria were that 1) the papers had been Literature search strategy Guidance and published in peer-review journals; and 2) the papers The aim of the literature review was to identify all good practice relevant published work emanating from the scientific were empirical in content, i.e. including quantitative and mainstream communities on personality and and/or qualitative data. Purely theoretical papers were Section 5: psychological factors (including complex trauma) excluded, as were books and book chapters which Research thought to be implicated in repeat homelessness. To summarized original research. Because this is the first maximise transparency, a formal search strategy was attempt to identify all empirical papers investigating Section 6: adopted. Two major search engines were used (Web of the link between complex trauma and the aetiology and Glossary Science and Google Scholar), in addition to which the maintenance of entrenched / repeat homelessness, all identified papers have been included in the final table.

13 Herman, 1992

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Section 5: Research Click to go to Æ Document map • There is a complex relationship between traumatic Cognitive and Results experience, mental health issues, behavioural factors behavioural therapeutic Introduction The results are broken down into five main areas: and homeless status. Although a number of models interventions to have been proposed, few have been empirically tackle homelessness – 1 Links between complex trauma and evaluated.17 research synopsis Section 1: homelessness Evidence from research with young homeless people An outline of 2 Trauma in relation to other factors in • How psychological supports the complexity of the relationship between the key issues homelessness factors related to multiple traumas, homelessness, and mental health traumatic experience Section 2: 3 Mental health and homelessness outcomes. Young people are more likely than adults and personality disorder Case studies 4 Interventions to have experienced earlier trauma, abuse, or neglect are associated with 5 Limitations of reported studies and been accommodated in care; but are also more chronic homelessness Section 3: likely to experience similar traumas in later life.18 Research synopsis Definitions and weblinks 1 Links between complex trauma and 2 Trauma in relation to other factors in homelessness homelessness Section 4: • It is clear from the vast majority of the literature that • Early traumatic experiences are associated with such Guidance and there is strong and consistent evidence supporting factors as low levels of social support, low levels of good practice an association between homelessness and complex family support, and ‘deviant’ peer associations. Section 5: trauma. Some papers investigated homelessness There is an association between traumatic experience 14 • Research as a risk factor for trauma, whereas others noted and maladaptive behaviours such as: drug and that trauma precedes homelessness.15 Other studies alcohol abuse; conduct disorders; sexual risk Section 6: quantified this relationship16 found that for almost taking (and other sex-related behaviours). Other Glossary three-quarters of cases, PTSD preceded the onset of behavioural factors include sexual victimization, homelessness). increased use of health and social services, and reduced participation in the labour force. 14 e.g. Goodman et al., 1991 15 e.g. Taylor & Sharpe, 2008 17 e.g. Martijn & Sharpe, 2006 16 e.g., North & Smith, 1992 18 Taylor et al., 2006

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Section 5: Research Click to go to Æ Document map 3 Mental health and homelessness 4 Interventions Cognitive and • There are higher rates of mental health problems, • A number of forms of intervention have been behavioural therapeutic Introduction both Axis I (anxiety disorders, depression, dementia found to be useful in treating homeless youths and interventions to and psychosis disorders) and Axis II (personality adults. These include family therapy, therapeutic tackle homelessness – Section 1: disorders) than non-clinical populations. Evidence communities, behavioural contingency programmes, research synopsis An outline of indicates that rates are comparable with psychiatric cognitive-behaviour therapy, psychodynamic How psychological the key issues populations. However these data were mixed, with psychotherapy, 12-step programmes, and generic factors related to some studies finding no significant differences for counselling in the context of supported housing. traumatic experience Section 2: schizophrenia between homeless and non-homeless There is as yet no evidence to support the suggestion and personality disorder Case studies groups.19 Young homeless people are more likely of a single treatment of choice. are associated with than adults to present with emotional disorders • Although a number of forms of intervention are chronic homelessness Section 3: (anxiety and depression), substance abuse, self-harm highlighted as useful, the research in this field is Research synopsis Definitions and and attachment disorders (from which full-blown generally poor in terms of design. There are few weblinks personality disorders may emerge). controlled trials and no randomised control trials • Some evidence indicates that psychiatric (RCTs). Section 4: hospitalisations are higher than other clinical • The literature often does not clearly define the Guidance and populations for homeless adults, but psychological intervention models used or the settings in which good practice disorders in this population also tend to remain interventions are practised. These two factors 20 Section 5: untreated suggesting that hospitalisation measures are often conflated. Many studies do not specify Research underestimate prevalence. Young homeless people outcomes in detail or discuss the reliability or validity find it particularly difficult to access services, because of their measures, and very few (if any) attempt to Section 6: they usually fall between the remit of adolescent and establish the process underlying observed change. adult mental health services. Glossary

19 e.g. North et al, 1997 20 Bassuk et al, 1984

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Section 5: Research Click to go to Æ Document map 5 Limitations of reported studies diagnoses identifiable from mainstream medical and Cognitive and • The term ‘trauma’ is generally poorly defined in the psychological research. This may reflect the different behavioural therapeutic Introduction literature. A number of terms are used in addition approaches of the respective funding bodies. interventions to to trauma, e.g. ‘psychological trauma’, ‘PTSD’, The majority of published research in this area tackle homelessness – • Section 1: ‘traumatic experiences’, ‘traumatic events’. Some originates from the USA. Around three quarters of research synopsis An outline of of these terms are used as outcome variables and papers identified were from the USA, the remainder How psychological the key issues some are confounded with historical variables, e.g. from the rest of the world. Around 10% of papers factors related to ‘victimization’, ‘abuse histories’, ‘childhood abuse’. identified were published in the UK. Although the traumatic experience Section 2: No papers discriminate between Type I and Type II North American research is strongly suggestive of a and personality disorder Case studies trauma, or PTSD and complex trauma. These terms link between trauma and homelessness, the extent are associated with and constructs need to be defined and validated. to which results obtained overseas are completely chronic homelessness Section 3: Figures for the prevalence of specific disorders and generalisable to UK populations remains to be • Research synopsis Definitions and other constructs are greatly dependent on the type of determined. weblinks assessment used (e.g., Fazel et al, 2008, the reported prevalence of personality disorders is highly variable, Section 4: possibly owing to a reliance on clinical diagnosis). Guidance and This suggests that the type of assessment used good practice should be carefully considered in terms of validity and reliability. Section 5: Research • Literature in the area of mental health is generally sophisticated, using such methodological techniques Section 6: as meta-analysis,21 factor analysis22 and path Glossary analysis23. Homelessness research has not to date been framed within the tightly defined constructs and

21 e.g. Fazel et al, 2008 22 e.g. Yoder et al, 2008 23 e.g. Whitbeck et al. 1997

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Section 5: Research Click to go to Æ Document map Recommendations 4 Any intervention or management projects, whether Cognitive and existing or newly commissioned, should be carefully behavioural therapeutic Introduction 1 Further research is necessary to map the causal evaluated, with clear outcomes and controlled interventions to relationships between complex trauma and designs. tackle homelessness – Section 1: homelessness. Psychological research methods, 5 The settings in which such services are delivered research synopsis An outline of including longitudinal designs, path analysis, and should receive careful consideration in terms of How psychological the key issues structural equation modelling can all be used to gain practical and therapeutic variables, in addition to factors related to a better understanding of the processes involved. service-user defined outcomes. traumatic experience Section 2: 1 The extent to which ‘complex trauma’ acts as both 6 Services for young homeless people need to pay and personality disorder Case studies a causative and maintaining factor for homelessness particular attention to the transition between are associated with should be addressed and a common understanding children/young people and adult agencies, and chronic homelessness Section 3: generated. to provide interventions tailored to the clients’ Research synopsis Definitions and 2 The measures used to assess complex trauma developmental needs. weblinks should be specified and their reliability and validity 7 In order to facilitate robust research programmes established. addressing aetiology, maintenance and treatment Section 4: 3 There is a clear case for promoting models of issues, research funding from a number sources Guidance and intervention and clinical management which are should be sought, e.g. government departments, good practice research councils, health and social care designed to address the problems associated Section 5: organisations. with complex trauma and PD (e.g. attachment, Research emotional regulation, interpersonal skills, social 8 Given the conclusions of the review, it will problem solving). These therapeutic frameworks be important to consider the emotional and Section 6: are particularly important for young people, in psychological needs of frontline homelessness Glossary preventing more entrenched behaviours and staff, which should be recognised, quantified, and emotional dysregulation. addressed.

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Section 5: Research Click to go to Æ Document map Research synopsis Cognitive and behavioural therapeutic Introduction interventions to Biopsychosocial influences in ‘complex trauma’ and We therefore suggest that, taken together, these tackle homelessness – repeat homelessness: the evidence base, and the complex presentations are most usefully conceptualised research synopsis Section 1: An outline of implications for future research and practice. as indicative of a single broad syndrome of “complex How psychological the key issues trauma” (CT) which we will take as the unifying factors related to framework, rather than current perhaps prematurely What does the evidence of prevalence traumatic experience Section 2: narrow medico-diagnostic formulations. It is this tell us? and personality disorder Case studies There is now good evidence for a high prevalence broader concept, and its links with the narrower are associated with of personality disorder (PD) among those who are diagnostic formulations of personality disorder, which chronic homelessness Section 3: the following chapters then explore. homelessness – although much PD may go un- Definitions and Research synopsis diagnosed, and some interpretation is sometimes weblinks needed, in context, of data sources such as surveys What can we learn from medico-diagnostic that initially may indicate lower incidence. It may be approaches? Section 4: the case, for example, that the stigma and “therapeutic One key feature that personality disorders typically Guidance and nihilism” previously attached to a diagnosis of PD, share with conduct disorders is the phenomenon good practice and the exclusion criteria of some services, has known technically as ‘ego-syntonicity’. That is, the Section 5: meant that resettlement staff have been reluctant to problematic behaviour patterns which are characteristic Research record personality problems in the absence of a clear of individuals with PD reflect persistent emotions authenticated diagnosis. and beliefs which appear natural and normal to the Section 6: individual concerned; they are not experienced as But there is also growing evidence of many inter-linked external, alien or distinct from ordinary experience Glossary difficulties – what in medical terms is called ‘co-morbid – which indeed, for this individual, they are not. This symptomatology’ – such as dual diagnosis (PD plus feature distinguishes PD and CT from other, more other and/or overlapping complications), or associated evidently psychiatric phenomena such as panic states, and clinically comparable problems, such as substance flashbacks, mood swings or hallucinations. abuse and suicide, frequent A&E presentations, PTSD.

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Section 5: Research Click to go to Æ Document map For this reason, it has been suggested, services working least, markedly less responsive or amenable to change Cognitive and with and supporting individual’s with the more deeply via later influences and experiences. However, this is behavioural therapeutic Introduction entrenched forms of complex trauma – whether as then counter-balanced and possibly contradicted by interventions to children or as adults – need to pay particular attention other strands in contemporary neuroscience that by tackle homelessness – to consistency, coherence and clarity in their work. contrast stress neural regeneration, plasticity, on-going research synopsis Section 1: Approaches such as the therapeutic community, neurological self-organisation, and so allow more scope An outline of How psychological Nidotherapy, re-parenting, and other “wrap-around” for later adaptive (or maladaptive) learning. the key issues factors related to environments may be a reflection of this need. traumatic experience Section 2: The explanatory frameworks that neuroscience currently and personality disorder offers do not however appear to fit or confirm the Case studies What can the evidence of recent are associated with formal diagnostic categories of personality disorder with neuroscience tell us? chronic homelessness Section 3: any great precision. If these clinical patterns are in fact There is a rapidly growing body of neuroscience valid, there would appear to be some other, or further, Research synopsis Definitions and providing evidence for stress and trauma at critical processes of shaping or selection of the presentations weblinks developmental stages producing high levels of chemical and behaviours that medical services have identified. triggers leading to anomalous brain development in Section 4: the infant, features which are associated with later Guidance and behavioural problems. Although dysfunctional for the What can the evidence of other disciplines good practice individuals concerned, this appears to be a natural tell us? developmental process, which may even have its Psychology focuses primarily on learning and function Section 5: origins in evolutionary survival advantage in adaptation rather than diagnosis of pathology; and models of Research to adverse conditions (significantly, some studies distress and dysfunction in psychology seem to reflect Section 6: on the impact of stressful neighbourhoods indicate the neuroscience findings of underlying process more an independent and additional impact from wider closely than the medico-diagnostic formulations Glossary environmental influences). of pathology. There are also many studies from social psychology that stress the role of repetitive The neuroscience of childhood trauma tends to re-enactment and cyclical re-enforcement of early suggest that the developmental “damage” of stress traumas and schemas – cycles which can in principle be and trauma in childhood may be irreversible; or at interrupted if managed with care.

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Section 5: Research Click to go to Æ Document map These approaches echo earlier studies from sociology Finally there is some evidence of what works both Cognitive and exploring the role of social processes in the management in treatment environments and in homelessness behavioural therapeutic Introduction of deviance, including the attitudes and beliefs of staff, resettlement. In either context, the keys to success interventions to as itself impacting significantly upon the course and seem to involve engagement, safe containment, tackle homelessness – outcome of dysfunctional behaviour. Micro-social practical and emotional skills learning. These are research synopsis Section 1: processes, societal reaction, stereotyping and exclusion, precisely the areas where the neuroscience findings An outline of How psychological the institutional “processing” of discordant behaviour, have suggested that early childhood trauma may the key issues factors related to and the wider shifts in the economy which impact upon have the greatest problematic impact; but they also traumatic experience Section 2: social norms and acceptability, all shed further light on suggest that constructive and remedial engagement and personality disorder the frameworks of society’s response, and the services in later life, though difficult, can be achieved. Case studies are associated with which are available, to “remedy” the problems. chronic homelessness Section 3: Research synopsis Definitions and What does the evidence of practitioners What does the evidence taken as a whole weblinks tell us? tell us? Meanwhile, the experience of clinicians, resettlement These studies, both the neuro-biological and the Section 4: staff and others of “what works”, and what remains psycho-social, converge in indicating strong associations Guidance and problematic, offers further evidence of a different with attachment difficulties, emotional disregulation, good practice kind of the possibility of behavioural adaptation in poorer social problem-solving as the underlying later life, given the right conditions or environment; behavioural issues – all of which are implicated and Section 5: but also of the difficulty of “getting it right”. The readily identified with a diagnosis of PD, but they also Research evidence from healthcare on specific interventions seem to point towards a more malleable and potentially Section 6: for specific personality disorders is notably equivocal treatable underlying condition; and all indicating – but it is still incompatible with the “therapeutic the possible necessary focus of remedial work. Glossary nihilism” of the past. This is at least consistent with the messages from relatively successful Both the “hard” and “softer” evidence now suggest psycho-educational treatment modalities such that emotional and behavioural change is possible; as “Stop and Think” with ex-offenders, and peer but that it may be significantly harder for individuals support, including via therapeutic communities. traumatised in early years. This may be in part due

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Section 5: Research Click to go to Æ Document map to such individuals’ greater reliance on a limited and range of influences and interventions in support of Cognitive and inflexible repertoire of stress-scenario responses; in part the therapeutic or remedial task than more standard behavioural therapeutic Introduction due to the close inter-connected-ness of beliefs and approaches such as medication, counselling or interventions to feelings underlying such behavioural repertoires. But it behavioural therapy alone. The social context in tackle homelessness – may also be due in part due to the powerful dynamism particular, and the worker/client relationship, may be research synopsis Section 1: of re-enactment of such early traumatic schemas, critical for effective interventions; and for those most at An outline of How psychological which tends to evoke punitive or rejecting responses risk, the whole environment may need to be working in the key issues factors related to in others, so perpetuating rather than breaking the re- tune with the therapeutic aims. traumatic experience Section 2: enforcement cycle. and personality disorder This has considerable implications for the way that, Case studies are associated with Two key principles or features of success are for example, homelessness resettlement services chronic homelessness Section 3: recognising: need to be able to work. From this we can therefore Definitions and • the slow pace of the change process for some, and claim to have derived an indication of the potential Research synopsis value of novel interventions in resettlement services. weblinks the need for personal and organisational resilience • There remains some uncertainty over how far the within the service. That is to say, resilience is needed Section 4: maladaptive behaviour characteristic of PD, CD, CT both in the resources and skills of the workforce, Guidance and etc is embedded in the personality through early and in the way that the service as a whole operates good practice trauma in critical development periods, how far they – the formal structure of roles, rules and times, the remain malleable through constructive, containing and informal social structures of meeting places and Section 5: enabling experiences later in life, and how far the failure friendship groups, and in the nature and design of Research to develop reflects unintentional mismanagement by buildings, etc. welfare and correction agencies. Section 6: Glossary Implications and approaches These are not options and hypotheses that are easily In short – what evidence there is suggests that tested in laboratory conditions. We suggest therefore personal change work is a harder task with PD and that practice in homelessness resettlement and in “complex” trauma: but change is possible, though it community mental health alike needs to be informed may be necessary to enlist a wider and more creative by new developments in research and theory; but that

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Section 5: Research Click to go to Æ Document map research and theory development also has much to References Cognitive and learn from studies of (emerging) practice. APA. (2000). Diagnostic and Statistical Manual of Mental Disorders: behavioural therapeutic Introduction Fourth Edition, Text Revision (4th ed.). Washington DC: American interventions to The case studies on this site give an indication of the Psychiatric Association. tackle homelessness – kind of ground-breaking work being done in some areas CLG. (2008). No one left out: Communities ending rough sleeping. research synopsis Section 1: London: Communities and Local Government. to respond to these needs in innovative ways. The An outline of Hayes, S. Strosahl, K.D. & Wilson, K. (2004) Acceptance and How psychological hostel and “managed network” services described in the key issues Commitment Therapy: An Experiential Approach to Behaviour factors related to the practice section provide ample scope for studies to Change. New York: Guildford. traumatic experience Section 2: enhance our understanding of the maintaining factors Hyler, S.E. (1994) Personality Diagnostic Questionnaire – 4+. and personality disorder of PD/CT in later life. A more collaborative and inter- New York: New York State Psychiatric Institute. Case studies Millon, T., Davis, R., Millon, C. & Grossman, S. (1994) Millon Clinical are associated with disciplinary approach to research is likely to be most Multiaxial Inventory III. Pearson Assessments: San Antonio. chronic homelessness Section 3: productive of new insights; and the homelessness sector Segal, Z.V., Williams, J.M. & Teasdale, J.D. (2002) Mindfulness-based Definitions and would appear to be a particularly useful testing ground Cognitive Therapy for Depression: A New Approach to Preventing Research synopsis weblinks for more rounded frameworks of understanding. Relapse. New York: Guildford. WHO (1994) International Classification of Diseases – 10. World Health Organisation. Section 4: Guidance and good practice Section 5: Research

Section 6: Glossary

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Section 6: Glossary

Document map

Glossary of acronyms Introduction

A D Section 1: ACE Adverse Childhood Experience/Adults Facing DAAT Drug and Alcohol Action Team An outline of Chronic Exclusion DBT Dialectical Behaviour Therapy the key issues ADHD Attention Deficit Hyperactivity Disorder DH Department of Health Section 2: ACT Acceptance and Commitment Therapy DSM Diagnostic and Statistical Manual Case studies APA American Psychiatric Association ASB Anti-Social Behaviour H Section 3: ASBO Anti-Social Behaviour Order HCA Homes and Communities Agency Definitions and B HMP Her Majesty’s Prison weblinks Section 4: BPD Borderline Personality Disorder I Guidance and C IAPT Improved Access to Psychological Therapies good practice IPT Interpersonal Therapy CAHMS Child and Adolescent Mental Health Services Section 5: J CAT Cognitive Analytic Therapy Research CBT Cognitive Behavioural Therapy JSNA Joint Strategic Needs Assessment CJS Criminal Justice System Section 6: CPN Community Psychiatric Nurse K Glossary CHT Community Housing and Therapy CORE Clinical Outcomes in Routine Evaluation KUF Knowledge and Understanding Framework CPD Continuing Professional Development

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Section 6: Glossary

Document map L S Introduction LAA Local Area Agreement SP Supporting People LHF London Housing Foundation LSP Local Strategic Partnership T Section 1: An outline of M TA Temporary Accommodation TC Therapeutic Community the key issues MBCT Mindfulness-Based Cognitive Therapy Section 2: MI Motivational Interviewing W Case studies MTFC Multi-dimensional Treatment Foster Care WHO World Health Organisation Section 3: N Y Definitions and weblinks NDT New Directions Team YOS Youth Outreach Services NICE National Institute for Clinical Excellence YOT Youth Offending Team Section 4: NIMHE National Institute of Mental Health in England NLP Neuro-Linguistic Programming Guidance and NTQ Notice to Quit good practice P Section 5: Research PCT Primary Care Trust PD Personality Disorder Section 6: PDQ Personality Diagnostic Questionnaire Glossary PIE Psychologically Informed Environment PSA Public Service Agreement

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