Social Exclusion, Compound Trauma and Recovery Applying

Psychology, Psychotherapy and PIE to Homelessness and

Complex Needs

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 Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1 Understanding the Problem

1. Social Exclusion, Complex Needs and Homelessness . . . 13
Dr Peter Cockersell

2. Compound Trauma and Complex Needs . . . . . . . . . 26

Dr Peter Cockersell

3. The Process of Social Exclusion . . . . . . . . . . . . . . 37

Dr Peter Cockersell

2 Solutions: Principles of Practice

4. A Psychological Perspective on Recovery . . . . . . . . . 61
Dr Peter Cockersell

5. Applying Psychology as a Response to the

Impact of Social Exclusion: PIE and Psychotherapy
in Homelessness Services . . . . . . . . . . . . . . . . . . 80
Dr Peter Cockersell

3 Solutions: Practice and Experience

6. Pre-treatment Therapy Approach for Single Homeless
People: The Co-Construction of Recovery/Discovery . . . 109
John Conolly

7. Psychotherapy with Homeless Women . . . . . . . . . . . 134

Nicola Saunders
 8. PIE-oneering Psychological Integration in
Homeless Hostels . . . . . . . . . . . . . . . . . . . . . 149
Dr Emma Williamson

9. PIE: What the People Say . . . . . . . . . . . . . . . . . 160

Dr Catriona Reid

10. Streetlight: Homeless Psychotherapy in

Britain’s Happiest Town . . . . . . . . . . . . . . . . . . 175
Dr Sally Read

11. I Held the Ticket in My Hand . . . . . . . . . . . . . . . 192

Terry Hutton

4 Conclusion: Contextualising the Problem

in the Culture and System of Care
12. The Problem and Potential of Complexity . . . . . . . . . 209
Dr Peter Cockersell

13. The Treatment of Multi-morbidity . . . . . . . . . . . . . 227

Dr Peter Cockersell

14. The Dependency Paradox . . . . . . . . . . . . . . . . . 242

Dr Emma Williamson

Authors’ Biographies . . . . . . . . . . . . . . . . . . . 254

Subject Index . . . . . . . . . . . . . . . . . . . . . . . 257
Author Index . . . . . . . . . . . . . . . . . . . . . . . 261
 Preface

The question this book is directed towards is ‘How do we understand

and effectively work with people who have experienced/are exp-
eriencing social exclusion and/or compound trauma?’
These people are found disproportionately among homeless people,
rough sleepers, people in psychiatric institutions or services, people in
the criminal justice system, people with drug and alcohol dependencies,
asylum seekers, refugees, and ethnic, religious and sexual minorities.
There are a lot of them.
There are also a lot of services involved with them. Yet, despite this,
they continue to be there, and they continue to need the services, and
in fact their numbers continue to rise, with many of those in the system
staying in the system, and new people coming into it all the time.
I once asked a young rough sleeper what ‘home’ meant to him;
he said, ‘Home means my mother’s blood sprayed across the walls.’
The idea that somebody coming from a place like that could be given
somewhere to live and then have a ‘home’ is simply absurd. ‘Home’ has
to be a place of psychological and emotional safety to be somewhere
we want to be: it cannot be a place of oppression, fear or terror.
It has been my privilege to work with homeless people and rough
sleepers – people of enormous courage and resourcefulness who have
often faced the most horrendous difficulties and experiences – for some
25 years now. I have worked as a volunteer, in resettlement, supported
housing, and as a ‘frontline’, middle and senior manager; I have also
worked for nearly 20 years as a clinician, providing formal psychotherapy
to homeless people, rough sleepers and people experiencing high
levels of mental distress including diagnosed and undiagnosed drug
and alcohol dependencies, psychoses and ‘personality disorders’.

7
8 SOCIAL EXCLUSION, COMPOUND TRAUMA AND RECOVERY

The more I have worked in these fields, the more it has become
obvious to me just how important it is to work with the experience of
trauma and exclusion and what that experience means to the individual
affected. How someone sees the world, and the relationship between that
and their real experience of the world, is critical to understanding what is
going on for them, and to working with them to help them make changes
in their lives. Without recognising this interactivity between someone’s
past and ongoing experience of the world and how they think, behave
and live now – which means at the very least acknowledging the hostile
interventions of the external world as well as the reactive perspectives
of the individual – it is very difficult to help them change anything else
in their lives. It is also important to recognise the legitimacy of their
aspirations: just like the rest of us, they aspire to have somewhere to
live, something meaningful to do, someone to love and be loved by. In
the case of socially excluded people who have experienced compound
trauma such as chronic rough sleepers, they sometimes never had these,
and sometimes have had them often violently ripped away. What these
ordinary people with very difficult life experiences need in order to
achieve these ordinary but life-critical aspirations are emotional and
psychological support and access to opportunities to participate in
society, including stable housing. This book is about the emotional and
psychological support side of the deal.
The book is written mainly by clinicians working with homeless
people and rough sleepers in a variety of settings including hostels,
drop-ins, primary care and women-specific services; the authors
combine a huge wealth of experience and understanding from their
training, their clinical work and from years of learning from the socially
excluded people they work with. It is the latter part that illuminates
the theory and practice in this book. It is a book full of practice-based
evidence: this is not about academic theory applied in rarefied research
methodology situations, it is real-life practice-based evidence built on
practice-honed theory.
There is also a chapter written by a non-clinician, who had moved
on from homelessness. He gives a vivid account of the experience of
homelessness. It is deliberately not about histories of compound trauma,
though it could have been; rather, it illustrates the degree to which
homelessness and rough sleeping themselves are traumatic. One of
the reasons that most people experiencing rough sleeping and chronic
homelessness also experience compound trauma is simply because of this:
 Preface 9

homelessness and rough sleeping are themselves episodes of exposure to

traumatic emotional and psychological experiences, very often as well as
physical trauma of various kinds.
The main body of the book is about psychologically informed
interventions and the value they bring to enabling people experiencing
social exclusion and compound trauma to embark on their recovery
journeys. The vivid experience of the homeless and ex-homeless
authors gives a real perspective on where the psychologically informed
interventions properly sit: they are a part of the person’s experience,
and a part of their recovery journey – an absolutely critical part, but
still just a part. The majority of the work with the socially excluded is
not clinical in nature, and is provided by the often tremendously skilful,
compassionate and caring staff in outreach teams, hostels, shelters and
day centres. Psychologically informed interventions and psychotherapy
are an important, and often critical, part of the mix in enabling socially
excluded people and people affected by compound trauma to embark
successfully on sustainable recovery journeys, but they are an adjunct
to the services provided by the (largely) voluntary sector agencies who
support the people that statutory agencies let fall through the net.
This book is about understanding the psychological processes behind
compound trauma and its relationship to social exclusion, and about
the practical application of psychologically informed interventions to
help break that relationship; it is not arguing that there is a purely
clinical solution to social exclusion.
What the book is intended to do is give readers ideas, to stimulate
thinking about, and support and encourage taking action on, psychological
and emotional support for homeless people and rough sleepers. It
offers a theoretical perspective in the hope of stimulating thought and
discussion about why we need to offer psychological and emotional
support and how that works in enabling and supporting recovery. It
offers a practical perspective in the hope of stimulating and supporting
those who are developing or implementing psychological, psychotherapy
or psychosocial services for people affected by social exclusion and/or
compound trauma. And it offers an experiential perspective from both
clinicians and clients/patients in the hope of stimulating thought and
discussion about the experience of social exclusion and the experience
of working with people who have been or are socially excluded and/or
who have experiences of compound trauma.
10 SOCIAL EXCLUSION, COMPOUND TRAUMA AND RECOVERY

From my experience, many of the policy-makers, commissioners

and senior managers responsible for services to people who are socially
excluded and/or have experienced compound trauma have a tendency
to over-simplify what is happening and to look to systems‑based
solutions that work as management models but are actually not
founded in any understanding of either the real nature of the problems
people encounter, or the real likelihood of their resolution. This makes
sense from their internal world perspective full of management studies
and theories, and is supported and colluded with by their peers who
also have a vested interest in the same models. If only it were that
simple, then the problems of social exclusion and the psychological
and emotional impacts of trauma would have been resolved by
now. Doing the same thing gets the same results: the manufacturing
production-based models of management theory fail in the field of
health and social care because they are inappropriate. At the end of
this book, we offer alternative perspectives; throughout the book, we
offer theoretical, practical and experiential accounts of why we need
alternative perspectives to work effectively with the people we are
charged with helping.
In the last few years, I have moved from working mainly with
people who are homeless and rough sleepers to mainly working
with people who are experiencing high levels of mental distress.
The ideas in this book are just as relevant in this field of work as in
homelessness services, maybe even more so: they are directly relevant
to any work with people who have been or are socially excluded
and/or have experienced compound trauma – this might include ethnic
or religious or sexual minorities, refugees and asylum seekers, adults
who have been abused as children, children who have been abused,
and people in the psychiatric system or the criminal justice system.
I think that the ideas and practices in this book, if implemented by
services working with any of the severely disadvantaged groups or
individuals in our society, would enable higher levels of recovery and
better outcomes, both for the clients/patients of the services and for
the services themselves.
Finally, I’d like to propose this as a ‘thinking and doing’ book –
please, dear readers, think about the ideas put forward here, and see
what it feels like to apply them to your own situation and practice.
Best wishes
Peter Cockersell
 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.

13
14 SOCIAL EXCLUSION, COMPOUND TRAUMA AND RECOVERY

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
 Social Exclusion, Complex Needs and Homelessness 15

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).
16 SOCIAL EXCLUSION, COMPOUND TRAUMA AND RECOVERY

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
 Social Exclusion, Complex Needs and Homelessness 17

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.
18 SOCIAL EXCLUSION, COMPOUND TRAUMA AND RECOVERY

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.
Although a number of models have been proposed, few have
been empirically evaluated (e.g. Martijn and Sharpe, 2006).
3. Evidence from research with young homeless people supports
the complexity of the relationship between multiple traumas,
homelessness, and mental health outcomes. Young people are
more likely than adults to have experienced earlier trauma,
abuse, or neglect and been accommodated in care; but are also
more likely to experience similar traumas in later life (Taylor
et al., 2006).
 Social Exclusion, Complex Needs and Homelessness 19

Complex trauma in relation to other factors in homelessness:

1. Early traumatic experiences are associated with such factors as
low levels of social support, low levels of family support, and
‘deviant’ peer associations.
2. There is an association between traumatic experience and
maladaptive behaviours such as: drug and alcohol abuse;
conduct disorders; sexual risk taking (and other sex-related
behaviours). Other behavioural factors include sexual
victimization, increased use of health and social services, and
reduced participation in the labour force.
Mental health and homelessness:
1. There are higher rates of mental health problems, both
Axis I (anxiety disorders, depression, dementia and psychosis
disorders) and Axis II (personality disorders) than non-clinical
populations. Evidence indicates that rates are comparable with
psychiatric populations.
(Maguire et al., 2009, pp.4–5)
Dr Maguire used formal academic and clinical research papers for his
literature review, i.e. published research that met the standards that are
seen as best practice in medical research. Research methodologies vary
from discipline to discipline, and what is seen as ‘gold standard’ in one
field is not necessarily seen as best practice in another field of study
(see Cartwright, 2007). Most homelessness and other social agencies’
research does not use the same methodologies as clinical research does.
I published further evidence, some taken from my work at St Mungo’s
(where I was by this time Director of Health and Recovery), and some
from other homelessness agencies and researchers, in an article on
psychotherapy with homeless people (Cockersell, 2011).
I found a very high prevalence of experiences of trauma in
childhood – adverse childhood events – in data gathered from homeless
and rough sleeper clients through the work of the psychotherapy team
that I set up in St Mungo’s in 2007:
• forty-seven per cent experience of neglect/emotional abuse
• thirty-four per cent early loss of parents through abandonment,
separation or divorce