Rebuilding Shattered Lives

Peter CockersellDirector of Health and Recovery

St Mungo’s

• About 2000 beds: hostels to self-contained flats, including registered care

• Specialised drug, alcohol, mental health, dual diagnosis; older, women’s, and sexworkers’ projects

• Street outreach, 2 day centres, employment, training, substance use, health, and psychotherapy

• London, Reading, Oxford, Oxfordshire, Bath, Bristol, Hitchin, Welwyn Garden City…

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Shattered lives

Population

• 1 - 4% schizophrenia

• 5 – 13% personality disorder

• 11% anxiety disorders and depression

• 1.3% have attempted suicide

Homeless People

• 16 – 30% schizophrenia

• 50 – 70% personality disorder

• 50 – 80% anxiety disorders and depression

• 42% have attempted suicide

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Shattered lives: women

• 66% have a mental health problem

• 55% have a substance dependency

• >50% have physical health problems

• >50% have experienced violence or abuse from family/partner

• 41% rough sleepers have been involved in prostitution

• 45% are mothers

Shattered lives: children

• 47% experience of neglect/emotional abuse• 34% early loss of parents through abandonment,

separation or divorce• 31% early loss of parents through death (including

murder and suicide)• 27% sexual abuse• High levels of parental alcoholism, drug use, and

domestic violence

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Behaviours associated with complex trauma

• Self-harm• Uncontrolled drug or

alcohol use• Impulsive, careless

of the consequences• Withdrawn,

reluctant to engage• Anti-social• Isolated

• Aggressive• Lacking daily structure or routine• Inability to sustain work or education• Bullying, or being a victim• Offending• Unstable relationships

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Seeking help

• 70% had sought help: 11%got help

• Majority have histories of compound and complex trauma, not simple diagnoses

• More people have more than onecondition than have only one

• Almost no access to psychotherapy, only drugs

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Client perspective

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

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Psychologically Informed Environments (PIEs)

• Recognition of range of mental health problems encountered by homelessness staff

• Services need a degree of psychological awareness and support

• PIEs focus on the psychological and emotional needs and capacities of clients and use the psychological and emotional resources of staff and clients to create a positive dynamic of change

• PIEs use a therapeutic framework to develop clear and consistent responses to clients

• PIEs are not simply about containing challenging behaviour, but changing it

Places of conscious change

PIEs aim to create: an empowering and calming environment where people can feel emotionally as well as

physically safe, and can gain an understanding of their behaviour and an ability to take

responsibility for themselves

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Rebuilding shattered lives

Dual diagnosis PIE

• Intensive engagement

• 1 – 1’s with specialist substance use worker

• Individual psychotherapy for clients; reflective practice for the staff

• No rehospitalisations; 17 of 18 moves were into less supported accommodation

Lifeworks psychotherapy

• Individual psychodynamic psychotherapy

• 100% improvement on Outcomes Star axes

• 75% improvement on Wellbeing Impact Assessment Measure

• 3x more likely to move from pre-contemplation to active on Cycle of Change

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Key ingredients of St Mungo’s PIEs

•Psychological Framework•Social Spaces•Staff Training and Support•Managing Relationships•Access to psychotherapy

Managing relationships

• Complex trauma arises from abusive relationships• Healing relationships need to be managed, and take

care, and time• Relationships have an impact on both/all parties• Group dynamics affect individual group members’

relationships• Setting up PIEs is also about managing relationships

Staff support and training

• Clinical supervision• Reflective practice• Training:

Attachment, psychological perspectivesMotivational interviewing, psychological techniquesThe Escape Plan, client perspectivesRecovery, enabling management

• Corporate Commitment and Framework• Client access to psychotherapy

Psychodynamic psychotherapy• Based on relational dynamics in the here and now,

while recognising the impact of the past in the present

• Does not require diagnosis or pathologisation of clients, and recognises the reality and validity of their experiences

• Therapy is flexible, client-led and non-directive• Works on linking thinking and emotions, and the

regulation of affect• Evidence of effectiveness

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Client perspective

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

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Client perspective

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

(rough sleeper)

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Further information

• www.groundswell.org.uk/The_Escape_Plan_Report.pdf

• www.homelesshealthcare.org.uk

• www.rebuildingshatteredlives.org

• Peter.cockersell@mungos.org