Presentation to Y-Foundation Helsinki 20th April 2015

1. Presentation to Y-Foundation • Helsinki 20th April 2015 • Working with rough sleepers with multiple and complex needs • Helen Keats • Rough Sleeping Advisor • helenkeats@gmail.com Helen Keats Associates Limited

2. Working with rough sleepers with multiple and complex needs • Background and context to rough sleeping in England • Tackling the psychosocial impact of trauma in homeless people • The Sussex Police Street Community project • Questions to you Helen Keats Associates Limited

3. Working with rough sleepers with multiple and complex needs Helen Keats - Personal background 15 years in local authority and housing association development and new initiatives 2000-2002 Seconded to Rough Sleepers Unit from Portsmouth City Council 2002-2012 National Youth Homelessness Advisor and National Rough Sleeping Advisor with DCLG 2002 – MBE for work with rough sleepers From 2012 Consultant on rough sleeping Director and Chair of HomelessInsight – advisory website Trustee – Real World Trust –Substance misuse recovery Helen Keats Associates Limited

4. Working with rough sleepers with multiple and complex needs • Rough sleeping in England • 1998 The Social Exclusion Unit set up by Tony Blair commissioned a report called "Coming in from the Cold". At the time a snapshot count found there were 1850 people sleeping on the streets in England. • 1999- The Cabinet Office set up Rough Sleepers Unit headed by Louise Casey, the "Homelessness Tsar" . • The target was to reduce rough sleeping by two thirds from the 1850 figure, by 2002 • By 2002 the number of people on the streets had gone down to 585, meeting the target . Helen Keats Associates Limited

5. Working with rough sleepers with multiple and complex needs • In 2010 the Coalition Government disbanded the National Homelessness Advisor Team. • In 2010 rough sleeping numbers were 1768. • The last snapshot count for 2014 showed the number to be 2744 (55% increase) • There are around 38,500 hostel bed spaces in England, 10,000 of which are direct access. Helen Keats Associates Limited

6. Psychosocial impact of trauma Several projects are being developed in England to address the psychosocial impact of trauma in rough sleepers. • Making Every Adult Matter (MEAM) • Big Lottery Fulfilling Lives • Psychologically Informed Environments. • The Knowledge and Understanding Framework ( KUF) underpins all of these. www.personalitydisorderkuf..org.uk Helen Keats Associates Limited

7. Psychosocial impact of trauma • Making Every Adult Matter (MEAM) is a coalition of four national charities – Clinks, DrugScope, Homeless Link and Mind – formed to influence policy and services for adults facing multiple needs and exclusions. • Together the charities represent over 1600 frontline organisations working in the criminal justice, drug and drug treatment, homelessness and mental health sectors. • They work with clients who have multiple problems , ineffective contact with services and who are living chaotic lives. • http://meam.org.uk/ Helen Keats Associates Limited

8. Psychosocial impact of trauma • Fulfilling Lives is a national, 8 year, £112 million Big Lottery Fund scheme, working in 12 areas of England. It funds schemes working with people experiencing at least 2 of the following problems • Homelessness • Reoffending • Problematic substance misuse • Mental ill health • It is focused on long term system change to improve access to services. • https://www.biglotteryfund.org.uk/ Helen Keats Associates Limited

9. Psychosocial impact of trauma • In 2010 the Royal College of Psychiatrists (www.rcpsych.ac.uk) published a paper as part of their "Enabling Environments" project which coined the phrase "Psychologically Informed Environments" (PIE). • It describes services which recognise and work with emotional and psychological issues arising from continuous exposure to trauma, usually in childhood. • The paper attempted to update the concept of therapeutic communities for the 21st Century, to inform community mental health and public health services. Helen Keats Associates Limited

10. Psychosocial impact of trauma • In 2010 I published guidance on the concept of PIEs for homelessness services followed by operational guidance published in 2012. • It recommended the adoption of a psychological framework, improvement to the physical environment and staff training in reflective practice plus supervision. • www.rjaconsultancy.org.uk Helen Keats Associates Limited

11. Psychosocial impact of trauma • The PIE concept is recognised as an effective housing model both to support staff working with chaotic and challenging rough sleepers, and to encourage behavioural change in clients. • It focuses on managing relationships not sanctioning behaviour (e.g. elastic tolerance rather than eviction as a basic principle). • The approach is evidence based. Any interventions should have a solid empirical base so that services can demonstrate they have resulted in change. Evaluation is central to the process. Helen Keats Associates Limited

12. Psychosocial impact of trauma • Traditional homelessness services in England have two key elements- conditionality and compliance. • People have to meet certain requirements before they can access services (conditionality) which effectively filters out the "difficult" ones . • They also have to comply with service expectations in order to "earn" accommodation or services like detox (compliance) with which many people repeatedly fail. Helen Keats Associates Limited

13. Psychosocial impact of trauma • Traditional services generally miss out the crucial bit about helping people to change their behaviour. They tend to focus on professional and organisational priorities rather than those of the client. • Housing First addresses the problem of conditionality by working with the person as they are. • Psychologically Informed Environments tackle the problem of compliance by addressing behavioural issues that lead to failure and exclusion. Helen Keats Associates Limited

14. Psychosocial impact of trauma • Research by Dr Nick Maguire from Southampton University demonstrated that 60% of hostel residents in England have a diagnosable personality disorder (or "complex trauma"). They may typically • self harm • have difficulty managing emotions • appear impulsive/ withdrawn or socially isolated • exhibit antisocial or aggressive behaviour • lack structure or daily routine • have a history of offending behaviour • Maguire found that difficulty in regulating emotions underpinned behaviour that was most likely to result in arrest, eviction, rough sleeping or social exclusion. Helen Keats Associates Limited

15. Psychosocial impact of trauma • Psychologically aware services will aim to risk manage as well as risk assess clients so that vulnerable and chaotic people with challenging behaviour are not excluded (conditionality). • Psychologically informed services work within a therapeutic framework which legitimises and informs the different approaches staff can use, and gives them additional insight into how people may behave. Most good staff will instinctively work in a psychologically aware way but actively committing to be a PIE formalises this. • Supervision and reflective practice are key components of a PIE. PIEs are not a replacement for clinical services. Helen Keats Associates Limited

16. Psychosocial impact of trauma • The Homeless Mentally Ill initiative (1990) worked well at getting people into treatment. • It was followed by the development of Community Mental Health Teams but these tend not to work with street homeless people, especially those with dual diagnosis or who have chaotic lives. • ACT is not widely used in work with street homeless people in the UK, and most mental health services require clients to actively engage. Helen Keats Associates Limited

17. Psychosocial impact of trauma • PIE is similar to the Trauma Informed Care (TIC) approach developed in New York by the Centre for Urban Community Services (CUCS) and is now used in London by Providence Row Housing Association. • TIC brings understanding to the ways in which trauma can change the physiology of the brain and lead to an impairment in cognitive functioning. Helen Keats Associates Limited

18. Psychosocial impact of trauma • TIC trained staff don't diagnose, rather, they attempt to understand how trauma affects people, what can trigger challenging behaviour and how to work with challenging clients and make them feel safe. • There are also interesting links with psychiatric outreach, in particular the Project for Psychiatric Outreach to the Homeless (PPOH) in New York. This offers a humanistic and recovery orientated approach to homeless psychiatry working alongside homeless shelter staff. Helen Keats Associates Limited

19. Psychosocial impact of trauma • There is high turnover and high levels of staff burn out within homelessness services. Staff report clients making what appear to be perverse or destructive decisions and often feel helpless. • In his reflective practice training, Maguire asks hostel staff to consider - • " Is what I'm thinking about what this client is doing, absolutely true?" • " Are they doing it for the reasons I think they are doing it?" • "If what I thought about their behaviour wasn't accurate, could I do something different?" Helen Keats Associates Limited

20. Psychosocial impact of trauma • Maguire has trained 350 staff nationally to address burn out, negative beliefs and confidence in effecting change. • He offered a 2 day training session followed by 6 months training in reflective practice and measured change at 1 month, 3 months and 6 months. • Negative beliefs and confidence in effecting change were improved after the 2 days training. It appears that knowledge and attitudes can be influenced by a short training session. • Burnout is only addressed after people are able to practice their skills through longer term training in reflective practice. • PIE is not a quick fix -it requires a change in organisational culture and practice and a commitment to staff skills development and learning. Helen Keats Associates Limited

21. Sussex Police Street Community Project Helen Keats Associates Limited

22. Sussex Police Street Community Project • Sussex Police employs nearly 5,500 staff and has an annual budget of £237 million. • It serves a population of 1.6 milliion. • Budget cuts mean the Force has to save £56m by 2020, meaning the loss of up to 1,000 jobs including 500 police officers. • There are 12 District Councils, 2 County Councils and 1 Unitary Authority within the Force area. • District Councils are responsible for housing and County Councils commission support and Public Health Services. 7 Clinical Commissioning Groups are responsible for health services. Helen Keats Associates Limited

23. Sussex Police Street Community Project • I have worked with Sussex Police since September 2013, developing a multi agency and collaborative approach to tackling street community issues through pop up hubs. • Sussex Police gets a phone call every 30 minutes complaining about begging, street drinking, anti social behaviour and shop lifting. All officers can do is move people on or arrest them. • Each arrest costs £1668. 18 members of the street community in Bognor have a total of £1.3m in arrest costs. • There are approximately 800 members of the street community across the force area, about half of whom rough sleep. Helen Keats Associates Limited

24. Sussex Police Street Community Project • The last snapshot count in 2014 found 159 rough sleepers across the force area. • Street community members are both victims and perpetrators of crime and are a vulnerable group-12 murders since 2005- £1.5m to investigate each one. • Many have had traumatic childhoods which has led to psychological problems that influence their challenging/offending behaviour. Helen Keats Associates Limited

25. Sussex Police Street Community Project • Pop up hubs – Bognor, Eastbourne and Hastings • Catalyst for improved multiagency interventions to tackle vulnerability and offending behaviour. • 114 clients assessed by outreach, primary care, mental health professionals, social workers, local housing authority and benefit advice service. • More than just accommodation. Issues around domestic violence, looked after children, dual diagnosis, public health and undiagnosed physical and mental health issues. Helen Keats Associates Limited

26. Sussex Police Street Community Project • Hubs promote a collaborative model of work at a local level, focused on named individuals known to the police. • All the key services (drugs, alcohol, housing, GP and mental health) are asked to work from a community based location for 3 days, where clients can be jointly assessed and action plans developed. • The evaluation of the first two hubs is available at • http://shorehomeless.wordpress.com/pop-up-hubs/ Helen Keats Associates Limited

27. Sussex Police Street Community Project • Health Inequalities in Bognor hub • (38%) had drug problem • (83%) had alcohol problem • (66%) experiencing mental health problems • (56%) had physical health issues • (39%) registered with GP Helen Keats Associates Limited

28. Sussex Police Street Community Project • Health Inequalities in Eastbourne hub • 71% had drug or alcohol problem • 32% had both drug and alcohol problem • 82% experiencing mental health problems • 27% had 5 or more mental health issues • 50% had physical health issues • 59% registered with GP Helen Keats Associates Limited

29. The problem! • Hub clients are chronically homeless, socially excluded and have significant multi morbidity. • They have drug, alcohol, mental and physical health problems plus cognitive impairments such as personality disorder or traumatic brain injury. • Despite this, most are invisible to mainstream services. Helen Keats Associates Limited

30. The problem! • All health and housing services in East and West Sussex require behaviour change before access. • There are no unconditional or low threshold services for people with challenging behaviour who are self medicating with drugs and alcohol. • There is no appropriate clinical psychological service for this group and the dual diagnosis service will only work with people psychosis and substance misuse. • People are expected to fail. Helen Keats Associates Limited

31. The answers! • A street medicine service with an assertive mental health service ( ACT) which recognises the emotional and psychological issues the street community has. • Housing First ( with a PIE approach ) and other low threshold accommodation services • Wet clinics • Shared housing for drinkers such as The Lodge • http://www.mungosbroadway.org.uk/documents/3046/3046.pdf Helen Keats Associates Limited

32. Questions for You • Research shows that Housing First develops differently from country to country. We are looking at starting a scheme in East and West Sussex and have following questions for you. • Do men and women have similar outcomes with Housing First ( we are looking at one scheme for women)? • Does your Housing First model address the psychosocial impact of trauma and if not, would it enhance the scheme if PIE principles were adopted? Helen Keats Associates Limited

33. Questions for You • What is your pre-treatment approach with clients, either while they are on the streets or first in accommodation? • Would you advise psychiatric outreach linked to Housing First ? • What does "good" look like, and what would you do differently if you were starting from the beginning again? Helen Keats Associates Limited

34. Street Community Project • Thanks for your time! My contact details are • Helenkeats@gmail.com • Helen Keats Associated Limited • 07805 273458 • Twitter @HelenKeats Helen Keats Associates Limited