Complex Trauma and Rough Sleeping: New Insights and Approaches 14th July, 2010

1. Complex Trauma and Rough Sleeping: New Insights and Approaches14th July, 2010 Helen Keats Specialist Advisor Communities and Local Government Dr Nick Maguire Programme Director University of Southampton

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

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

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

6. Complex Trauma in Homelessness Observe many CT issues (�symptoms�) Impulse control Negative self-perceptions Interpersonal problems Physical problems Emotion dysregulation Behaviours Drug and alcohol abuse Promiscuity Self-harm Violence Argued that some are coping strategies

7. Diagnosis Sometimes problems diagnosed as �personality disorder� Borderline Personality Disorder (BPD) Antisocial Personality Disorder (APD) Weak concepts in terms of validity and reliability Some argue that BPD should be recast as complex trauma

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

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

10. Psychological, emotional and behavioural pathway to repeat homelessness

11. Psychological, emotional and behavioural pathway to repeat homelessness

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

13. Results: Links between complex trauma and homelessness Strong and consistent evidence supporting an association between homelessness and complex trauma Research investigating the temporal relationship inconsistent But, complex relationship between traumatic experience, mental health issues, behavioural factors and homeless status Few empirical studies and very few longitudinal studies Evidence with young people supports this complex picture Young people more likely to have experienced earlier trauma, abuse or neglect and been accommodated in care Also more likely to experience similar traumas in later life

14. Mental health and homelessness Mixed evidence of higher rates of Axis I and Axis II disorders than non-clinical populations; rates are comparable with psychiatric populations Trauma associated with other diagnoses Mixed evidence in terms of health services use Higher rates of hospitalization Psychological illnesses tend to remain untreated Interpretation � services used only when problems become severe

15. Interventions Evidence of effective interventions is very poor in terms of breadth, sophistication and definition of issues. Evidence from the trauma and PD literatures suggests that a number of intervention and settings for delivery of interventions have been found to be useful No overwhelming evidence for one form of therapy or setting over another

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

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

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