Social Exclusion, Compound Trauma and Recovery

Applying Psychology, Psychotherapy and PIE to Homelessness and Complex Needs

Peter Cockersell

• Publisher: Jessica Kingsley Publishers
• Year: 2018
• Print ISBN: 9781785922848
• eBook ISBN: 9781784505882
• Topic: Psychology
• Subtopic: Post-Traumatic Stress Disorder (PTSD)
• Index: Psychology

Responding to the growing number of psychologically-informed services for people experiencing social exclusion and, in particular, homelessness, this book gives professionals the information and understanding they need to be fully informed in their practice with this client group. It begins with theory, looking at the psychology of social exclusion and the processes that underlie it, and considers the relationship between trauma, complex needs, homelessness and social exclusion. Presenting practical interventions and case studies, the authors then reveal what makes an effective service in practice and a client perspective on social exclusion and recovery is provided.

This is essential reading for all those involved in developing services that meet the needs of socially excluded people with histories of complex trauma or presentations of complex needs, including those who are homeless, refugees and asylum seekers, Traveller and Roma communities and people involved with the criminal justice system.

1

UNDERSTANDING
THE PROBLEM

1

SOCIAL EXCLUSION,
COMPLEX NEEDS AND
HOMELESSNESS

DR PETER COCKERSELL

Introduction

This book is intended to be about the application of psychological principles and understandings to work with socially excluded people with histories of compound trauma and presentations of complex needs. The second half of the book (Parts 3 and 4) is about the application; the first half (Parts 1 and 2) is about the principles and understanding. Of course, all parts contain both theory and application: practice without theory is dangerous, theory without practice is sterile and dangerous.

In Parts 1 and 2 I will try to draw out a few themes of relevant psychological theory, relating it throughout to what really happens in the real world of compound trauma and social exclusion; these themes then find echoes in the practical experience described by the authors of the chapters in Parts 3 and 4 of the book, writing about the work they do, the people they do it with, and the interactions they have with them.

The hope is that the whole book, combining practice-based evidence with a grounding in well-researched but cutting-edge theory, will serve as an evidence-based guide that will inspire and encourage other homelessness service providers, staff, commissioners and clinicians to develop their own psychologically informed services and their own psychotherapy practices with this population of people. They deserve something that really respects where they are coming from.

We will begin with an overview of the association between trauma, complex needs, social exclusion and homelessness and rough sleeping.

Social exclusion and homelessness

Social exclusion is defined by the Oxford Dictionary as ‘Exclusion from the prevailing social system and its rights and privileges, typically as a result of poverty or the fact of belonging to a minority social group’ (Oxford Dictionary, 2017). An excellent report on social exclusion in Britain commissioned by the Social Exclusion Unit, part of the Cabinet Office, summarised a long and thorough look at definitions of social exclusion as follows:

Social exclusion is a complex and multi-dimensional process. It involves the lack or denial of resources, rights, goods and services, and the inability to participate in the normal relationships and activities, available to the majority of people in a society, whether in economic, social, cultural or political arenas. It affects both the quality of life of individuals and the equity and cohesion of society as a whole. (Levitas et al., 2007, p.25)

Homeless people, and particularly rough sleepers – people who sleep out on the streets at night –have long been among the most visibly socially excluded. Homelessness is a powerful indicator of social exclusion because it involves the lack of a very fundamental resource in our society, a home; and that lack or loss leads to other losses, such as warmth, shelter, stability, and makes accessing many other important resources, from social status through to healthcare, education or work, very difficult. It also implies another set of lacks or losses – relationships, family, loved ones: home is more than just shelter or an address; it is the base within and around which our relationships develop and from which we go out to explore and engage with the rest of the world. Rough sleeping is an even more pronounced version of this lack or loss: David Miliband talked of it in terms of ‘deep exclusion’ (Levitas et al., 2007, p.26).

Rough sleepers and homeless people are often described as the most visible form of social exclusion (Guardian, 2016; Crisis, 2017a), but I think it’s useful to think of them as visible yet invisible: one client, who slept rough less than half a mile from the Houses of Parliament, told me, ‘I sit beside the black binliners on the pavement and nobody notices me; the only difference between me and the binliners is that somebody comes to collect them each day’ (personal communication). Or ‘the homeless are what you step over when you come out of the opera’, as Sir George Young, then Housing Minister, infamously remarked (Young, 2017). I will come back to this idea of invisibility as well as visibility later.

Homeless people are, of course, not homogenous: there are as many different histories of becoming homeless as there are homeless people. However, I have suggested elsewhere (Cockersell, 2011, 2017) that there are two broad categories of homeless people:

• those who are chronically homeless, who may have experienced very long-term or repeated episodes of homelessness, often including lengthy periods of rough sleeping, throughout their lives

• those who are homeless following a discrete set of events, whom I have called the transient homeless as they usually pass through the homelessness system relatively speedily, and who may or may not have spent periods of sleeping rough, but not long term.

I have to add two caveats to this. First, many chronically homeless people do move out of homelessness and the homelessness system in the end (though by no means all – sadly many die homeless or in the homelessness system), so could be described as ‘eventually transient’. I once worked with a man who had spent an astonishing 28 years rough sleeping in London, and who managed to ‘come in’: he was eventually offered housing directly into a flat as he had for years refused to go into a homelessness hostel or shelter, and he accepted this. I met him by chance a couple of years after I’d finished my work with him, which was mainly to help with the practical aspects – furniture, managing redecoration, bills, utilities, etc. – of settling him into his new flat, and he was still in his flat, now had a regular job in a street market which he enjoyed, and he described himself as happy. Second, people who are transiently homeless develop some of the characteristics, such as poorer physical and mental health, increased levels of drug and/or alcohol dependency, of those who are chronically homeless if they spend a long time rough sleeping (Homeless Link, 2014). Transient homeless people can become chronically homeless if timely interventions are not available.

Transient homeless people may become homeless for many reasons, but they become homeless because of a single event, or a limited number of discrete events – typically either economic or relational. Transient homelessness is sometimes called economic homelessness because it rises at times of ‘austerity’ and when there are increases in poverty and social deprivation: rough sleeping in England has doubled in the years between 2010, when the Coalition Government began their austerity drive, and 2016, and statutory homelessness applications have risen by 11 per cent in the same period (Crisis, 2017b). But transient homelessness is not just economic: another main reason is relationship breakdown. Many people become homeless as a result of leaving their families or partners, for example because of divorce or bereavement, or fleeing domestic abuse (adults) or escaping from abusive home situations (young people), or because they have no resources to access housing, for example on discharge from prison or other institutions, such as hospital, or because of their status, as (increasingly) with some classes of refugee or immigrant.

When I began working in homelessness in London in the 1990s, I volunteered with and then became an employee of St Mungo’s, a large London-based homelessness agency. The year I started, its annual review was headlined ‘Homelessness is not a housing issue.’ In fact, for the transient homeless, homelessness often is principally a housing issue. It is very difficult to rebuild your life without somewhere to live, regardless of whether you became homeless because of relationship breakdown, because of financial pressures, because of adverse domestic situations, or because of leaving an institution. This is the logic behind the North American ‘housing first’ movement, which is now gaining considerable support and traction in Western Europe (see Feantsa, 2016). It can equally be argued that for the chronically homeless housing is also a necessary and primary step: for the man I mentioned earlier who had spent 28 years living on the streets, housing was a significant step in his recovery, and, without it, it is very unlikely that he would have been in the (literally) happy position he was when I re-met him years later.

However, this does not mean that the author of the 1993 St Mungo’s review was completely wrong: it would have been more accurate, though, to have used the headline ‘Homelessness is not just a housing issue’. For many homeless people, and almost by definition for the chronically homeless, housing is not the only – or even necessarily the most important – issue. In their peer-researched report on how ex-homeless people had made the journey out of homelessness and the homeless system, Groundswell found that housing was hardly mentioned (Groundswell, 2010). From my own experience, I worked with a man who had been rehoused 88 times in his life; he kept a record of how many times he had been housed, and how many times he had lost or left his accommodation. For him, homelessness was not primarily a housing issue: it was a product of his sense of relatedness and stability, or rather his sense of unrelatedness and instability, a sense that arose from specific experiences and relationships in his childhood compounded by later experiences and relationships as he grew up. He had what has been neatly termed an ‘unhoused mind’ (Adlam and Scanlon, 2006).

Homelessness and trauma

There is a large body of evidence now of the association between trauma and homelessness, and particularly of the association between ‘compound trauma’, often referred to as ‘complex trauma’ (see Chapter 2 for the argument as to why compound trauma is a better name), and homelessness. As mentioned in the Preface, when I asked about what having a home would mean to him, a young man I was working with replied that ‘Home is my mother’s blood spraying across the wall’ (personal communication). ‘Home’ is not always a happy concept: home can be the place where you are not safe, where you are attacked, where the horror is; home can be and feel unbearable. Home can be the site of, and, for a very long time or even forever, associated with trauma.

Compound trauma describes a situation in which a person experiences a sequence of traumatic events usually beginning in infancy or childhood with what are known as ‘adverse childhood events’. Indeed, trauma sometimes predates even infancy: for example, I worked with a homeless man whose father had tried to murder his mother while he was still in her womb (the man was convicted of attempted murder, but returned to see the woman and child he had tried to kill when my client was about ten years old, even though she was in another – also abusive, but less life-threatening – relationship by then).

The prevalence of compound trauma in the histories of long-term, chronically homeless people has been highlighted in many studies. A very good study on trauma and homelessness in Glasgow, both its prevalence and some of the effective responses, was published by the Glasgow Homeless Network (GHN, 2003). However, perhaps the most influential study published in England demonstrating the link between compound trauma and homelessness was Dr Nick Maguire’s literature review, which detailed a large amount of academic and clinical evidence from across the developed world illustrating the wide prevalence of compound trauma in the histories of chronically homeless people (Maguire et al., 2009). Meeting the Psychological and Emotional Needs of People Who Are Homeless (Maguire et al., 2010), published online by the now-disbanded National Mental Health Development Unit (NMHDU), which was part of the Department of Health, built on this and laid down some ideas on potential ways to work with this understanding of the trauma-related underpinnings of chronic homelessness; unfortunately, the 2009 publication is no longer available. I think it is worth quoting at length some of its key findings here: interested readers can refer to the original source for further information.

Links between complex trauma and homelessness:

1. It is clear from the vast majority of the literature that there is strong and consistent evidence supporting an association between homelessness and complex trauma. Some papers investigated homelessness as a risk factor for trauma (e.g. Goodman et al., 1991), whereas others noted that trauma precedes homelessness (e.g. Taylor and Sharpe, 2008). Other studies quantified this relationship (e.g. North and Smith (1992) found that for almost three quarters of cases, PTSD preceded the onset of homelessness.

2. There is a complex relationship between traumatic experience, mental health issues, behavioural factors and homeless status. Althoug...

Table of contents

• Cover
• Title Page
• Contents
• Preface
• 1 Understanding the Problem
• 2 Solutions: Principles of Practice
• 3 Solutions: Practice and Experience
• 4 Conclusion: Contextualising the Problem in the Culture and System of Care
• Authors’ Biographies
• Subject Index
• Author Index
• Join Our Mailing List
• Copyright
• Of Related Interest