CLCH NHS TRUST HOMELESS HEALTH COUNSELLING SERVICE A THREE STEPPED APROACH John Conolly October 20151

John Conolly October 2015 1

CLCH NHS TRUST HOMELESS HEALTH COUNSELLING SERVICE

A THREE STEPPED APROACH

John Conolly October 2015

The Challenges Of Homelessness

• Time Horizon – Day to Day, • Tri-morbidity: Physical, Mental Health and

Addiction Needs• Competing Priorities – Welfare appointments,

Multiple healthcare appointments• Impact On Healthcare

• Inconsistent Attendance Rate• Inconsistent Treatment – crisis only

2


Homelessness and Personality Disorder

• It is estimated that up to:

70% of single homeless people may have undiagnosed

personality disorder (Maguire et al, 2009).

• The American Psychiatric Association defines Personality Disorders as:

‘relatively stable, enduring, and pervasively maladaptive patterns

of coping, thinking, feeling, regulating impulses, and

relating to others’. (Bleiberg, Rossouw and Fonagy, 2012).

3


Complex Causes of PD

PD has complex causes: ‘ multiple biological, psychological and cultural factors contribute to its development’ (Livesely, 2003).

‘ A history of childhood abuse, deprivation, neglect, appears to be associated with the diagnosis of PD (Alwin,2006).

4


DSM V ICD-10Cluster A Paranoid

Distrust and suspiciousnessParanoid

Distrust and sensitivity

Schizoid Socially and emotionally

detached

Schizoid Emotionally cold and detached

Schizotypal No equivalent

Cluster B AntisocialViolation of the rights of others

DissocialCallous disregard of others, irresponsibility

and irritability

BorderlineInstability of relationship, self-

image and mood

Emotionally UnstableA) Borderline type: unclear self-image and

intense unstable relationshipsB) Impulsive type: inability to control anger,

quarrelsome and unpredictable

HistrionicExcessive emotionality and

attention-seeking

HistrionicDramatic, egocentric and manipulative

NarcissisticGrandiose, lack of empathy,

need for admiration

No equivalent

Cluster C AvoidantSocially inhibited, feelings of inadequacy, hypersensitivity

AvoidantTense, self-conscious and hypersensitive

DependentClinging and submissive

DependentSubordinates, personal need, seeking

constant reassurance

Obsessive compulsivePerfectionist and inflexible

AnankasticIndecisive, pedantic and rigid

The PD Challenge - Shocking Figures

– 77% of suicides have PD ( DOH, 2009)

– 73% prison population ( Ministry of Justice 2007)(Mi70% of single homeless (Maguire et al, 2009)

– 67% Mental Hospital population(NIMHE, 2003)

– 4% general population (Coid et Al, 2006) oid et al, 2006).


JC Draft 1JC Draft 1 6


Complex Problems

• People with personality disorders have increased risks of suffering additional mental health problems, such as:

• Anxiety, • Depression • Addictions• Recurrent deliberate self harm, suicide• Brief Psychotic episodes• Eating Disorders.

7

Treatment Assumptions violated by PD patients

1. Treatment compliance.

2. Access to own thoughts & feelings, and ability to report them back.

3. Responsive to logic & experimentation.

4. Can engage in a collaborative relationship.

5. problems are readily identifiable as targets of treatment.

6. People seek validation and empathy for their suffering rather than learn how to deal with it.

(Young at al, 2003)



HOMELESSNESS & TRAUMA 1.• Most people become homeless after a series of cumulative

trauma• Homelessness itself being a further secondary trauma. • Trauma reactions involve:

– disorientation, – memory loss,– poor focus, attention span, retention and processing of information; – panic, the oscillation between intense, overwhelming emotions

with a sense of numbness and not feeling anything. • Many will turn to deliberate self-harm and/or self- medication in order to

try and regulate these unmanageable emotions, resulting in (secondary) addictions


HOMELESSNESS & TRAUMA 2.

• Trust in the world and people has been lost, and sufferers are ‘hyper-vigilant’, on the lookout for danger and experience heightened levels of physiological arousal,– making them hypersensitive to further triggering

of their trauma responses. • This making the management of contacts and

relationships with others EXTREMELY challenging.


Change is Difficult• As has been seen there are many CHALLENGES to change

and ….

…. ‘fewer than 20% of a problem population areprepared for action at any given time.

And yet, more than 90% of behavior change programs are designed with this 20% in mind’

(Prochaska et al 2006).

11


Stages of Change 1-2Stage of change Characteristics Interventions To Move On1.Precontemplation -No Intent to change

- Problem behaviour seen as having more Pros than Cons

-DO NOT Focus on Change -Use Motivational strategies( Help person reduce their own Ambivalence)

- Acknowledge problem -Increase awareness of Negatives of problem -Evaluate self-management activities/skills

2.Contemplation -Thinking about changing -Seeking info re problem -Evaluating Pros & Cons of problem -Not prepared to change yet

-Consciousness raising -Self-re-evaluation -Re-evaluation of situation/circumstances

-Make decision to ACT -Engage in Preliminary Action(s) Engage with Peer Support Networks - e.g. Drop In Support & Discussion Group, AA and its offshoots;


Stages of Change 3-53.Preparation -Ready to change in

Attitude and Behaviour -May have begun to increase self-management and to change

-See above 2 -Increase commitment or self-liberation

-Set goals/priorities to achieve change -Develop Change Plan

- Regular Counselling

4.Action -Modifying Problem Behaviour -Learning new Skills to prevent full return of Problem

-Methods of overt Behaviour Change Behavioural Change Processes

Apply Behaviour Change methods for average of 6 months Increase self-efficacy to perform the behaviour change

5.Maintenance -Sustain Changes Methods of overt Behaviour Change ctd.

Ongoing Support e.g. ‘Leavers Group’, ‘Expert By Experience/Peer Mentor Forum’


A THREE STEPPED APROACHTO COUNSELLING

• In response to this the Homeless Health Counselling service has developed a ‘Three Step Model of Support & Counselling’:

1-Crisis Intervention

2-Appointment based interventions

3-Ongoing Recovery and Recovery Maintenance


DROP IN COUNSELLING• ‘Drop in’ individual and group sessions are offered

where people can self-refer and where there is no pressure from expectations of regular engagement.

• Every attention is given to fostering a relationship of trust where people are offered a safe, unpressurized, non judgmental, supportive space– where they can begin to make sense of their experiences

and reactions, – And delineate some possible alternatives. – They are also encouraged to move on to regular appointment

based counselling.


Regular Counselling Appointments • Here, following NICE PD guidelines, no less than

twenty sessions are offered• people are supported to think about how best to start

addressing their trauma, addiction, accommodation, employment, disability issues.

• There might also be a focus on transition management• new crises may be re-experienced in the process and

interventions may well be increased as appropriate. • Great attention will be given to ending the program so

as to avoid a repetition of previous traumatic losses.

17

Recovery and Recovery Maintenance

• Given the early age at which trauma was 1st experienced, homeless people when resettled are left vulnerable to re-experiencing psychological difficulties in the face of new life transitions and challenges, and are at risk of losing the gains made.

• It is therefore vital that some provision be made for them to have ongoing support as and when needed. Therefore the service is considering offering the following:


18

Recovery and Recovery Maintenance

RECOVERY A Schema Therapy Workshop – where people are taught to recognize their negative perceptions and reactions and to manage them better.

A Life History Workshop – where people are supported to develop the narrative of their past, present and future lives.

Women Only Interventions - It is also recognized that women need women only Intervention and support groups in order to feel safe, heard and validated.

RECOVERY MAINTENANCE

A Leavers Group – where ex service users can share their ongoing difficulties as well as solutions with each other

An Expert By Experience/Peer Mentor Forum - Where those more advanced in their recovery journey, e.g. Peer Mentors, ‘Experts By Experience’, may in confidence share the challenges and opportunities of holding such positions.



ReferencesAlwin, N., 2006, ‘ The Causes of Personality Disorder’, Chptr 3, pps 41-58, in ‘ Personality Disorder and Community Mental Health Teams – A Practitioner’s GuideSampson, McCubbin and Tyrer, John Wiley & Sons, Ltd.

Bleiberg, Rossouw and Fonagy, 2012, ‘ Adolescent Breakdown and Emerging Borderline Personality Disorder’, Chptr 18, pps 463-509, in ‘ Handbook of Mentalizing In Mental Health Practice’, (Eds) Bateman and Fonagy, American Psychiatric Publishing, Inc. Washington DC, London England.

Coid, J., Yang, M., Tyrer., et al, 2006, ‘Prevalence and correlates of personality disorder in Great Britain’, British Journal of Psychiatry, 188, 423-431.

20

References 2.Department of Health, 2009, ‘Recognising complexity – Commissioning guidance for personality disorder services’,

Livesley, J.W., 2003, ‘Practical Management of Personality Disorder’, The Guildford Press, New York.

Maguire, N. J. et al., 2009, ’Homelessness and complex trauma: a review of the literature’, Southampton, UK, University of Southampton

Ministry of Justice., 2007, ‘Predicting and Understanding Risk of re-offending: prisoner Cohort Study’,, Ministry of Justice, London



References 3.National Institute for Mental Health in England, 2003,‘ Personality disorder no longer a diagnosis of exclusion’,

Prochaska, Norcross and Diclemente, 2006, ‘ Changing for Good’, HarperCollins, New York.

Young, Klosko and Weishaar, 2003, ‘Schema Therapy’, Guildford Press, New York.

Documents

CLCH NHS TRUST HOMELESS HEALTH COUNSELLING SERVICE A THREE STEPPED APROACH John Conolly October 20151