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Psychologically informed services for homeless people

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  • The PIElink
  • Community Housing and Therapy (CHT)

Abstract

The purpose of this paper is to help providers and commissioners develop or remodel services in order to address identified emotional and psychological issues amongst rough sleepers and young homeless people.
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
1
Acknowledgments
We are very grateful indeed to the many colleagues around the country
who contributed so much to this guide and who provided case studies.
Particular thanks are offered to:
Helen Keats, National Rough Sleeping Advisor,
Department for Communities and Local Government
Dr Nick Maguire, Chartered Clinical Psychologist and Deputy Director,
PG Dip/Cert in Cognitive Behaviour Therapy, University of Southampton
Robin Johnson, RJA Consultancy, joint Editor Housing Care and Support
Peter Cockersell, Psychoanalytic Psychotherapist; Director of Health & Recovery,
St Mungo’s; Director of Homeless Healthcare CIC
SPY Design and Publishing Ltd for design and production www.spydesign.co.uk
Psychologically informed services
for homeless people
Good Practice Guide
February 2012
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For further information on any aspect of the guide please contact:
helen.keats@communities.gsi.gov.uk
This document is interactive and has been linked for easy
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Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
2
Document Map
Introduction 03
Psychologically Informed
Environments (PIE) 05
Five key areas
JDeveloping a psychological framework 08
JThe physical environment and social spaces 17
JStaff training and support 21
JManaging relationships 24
JEvaluation of outcomes 26
Case studies
JPsychologically Informed
Environments (PIE) at St Mungo’s 28
JStamford St Complex Needs Unit –
London Borough of Lambeth 36
JWaterview Personality Disorder
Case Discussion Pilot Evaluation – June 2011 39
JLook Ahead Housing Association 46
JDeveloping St Basils as a Psychologically
Informed Environment 50
JSimple solutions for complex needs – an analytical
social care approach – Brighter Futures 56
JTwo Saints Housing Association 59
JThe Bristol Wellbeing Service for people
who are homeless or vulnerably housed 62
Appendix 64
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
3
Introduction
The purpose of this paper is to help providers and
commissioners develop or remodel services in order to
address identified emotional and psychological issues
amongst rough sleepers and young homeless people.
There is growing evidence of the extent and range of
psychological and mental health problems amongst
homeless people and rough sleepers. Up to 60% of
adults living in hostels in England will have diagnosable
personality disorder compared with about 10% in
the general population and all other mental health
disorders are significantly over-represented. (Maguire
et al, in prep; Cockersell, 2011; Rees, 2009). Also
over-represented are histories of neglect, abuse
and traumatic life events dating back to childhood
and continuing through adult life (www.jrf.org.uk/
publications/tackling-homelessness-and-exclusions).
The behaviour observed in people with personality
disorder can often be seen as a way of coping with
the traumatic experience of difficult childhoods and
the cumulative effect of adverse life events. It is
better described as ‘complex trauma’, in other words,
as a reaction to an ongoing and sustained traumatic
experience.
People with a history of complex trauma, including
the chronically homeless, , may behave in a range of
ways that suggest underlying difficulties with trusting
relationships, and with managing their own emotions in
the face of perceived adversity.
These services include
•hostels
•foyers
•supported accommodation
•rolling shelters
•night centres
•severe weather emergency provision
•winter shelters
•floating support services
•day centres
•assessment centres/Hubs
•street outreach.
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Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
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Introduction
Many of the people that homelessness and rough
sleeper services work with may for example:
•seem to have difficulty managing their emotions
•self-harm or have an uncontrolled drug and/or
alcohol problem
•appear impulsive and not consider the consequences
of their actions
•appear withdrawn or socially isolated and reluctant
to engage with help which is offered
•exhibit anti-social or aggressive behaviour
•lack any structure or regular daily routine
•not have been in work or education for significant
periods of time
•have come to the attention of the criminal justice
system due to offending.
There are particular issues to consider around 16-17
year-olds who may have had traumatic and abusive
childhoods. On top of the challenges of adolescence
which all young people go through, they may also
exhibit emotional and behavioural problems often
associated with antisocial behaviour, which can lead
to homelessness.
Psychologically informed environments are intended
to help staff and services understand where these
behaviours are coming from, and so to be able to work
more creatively and constructively with people with
so-called challenging behaviours. Evidence shows that
people affected by trauma, even lifelong experiences
of compound or complex trauma, can and do recover.
They have already demonstrated great resilience and
strength in surviving on the streets and seeking help
from homelessness services (many clients have sought
help from a whole range of services to no avail before
they even become homeless). Psychologically informed
environments are intended to use the latest insights
and evidence from the psychological disciplines to give
rough sleepers and homeless people the best chance
of sustainably escaping the cycle of poor wellbeing and
chronic homelessness.
One key outcome of a psychologically informed
environment is to reduce rates of eviction and
abandonment in order to reduce the number of
vulnerable people sleeping rough. Research by
Homeless Link showed that 47% of former rough
sleepers who were evicted from or abandoned hostel
places in London were subsequently found rough
sleeping again www.homeless.org.uk/evictions-project
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Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
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Psychologically Informed Environments
The concept of a PIE was originally developed by Robin
Johnson and Rex Haigh, as part of the Royal College
of Psychiatrists’ Enabling Environments initiative
(http://www.rjaconsultancy.org.uk/PIEconcept.html1)
It is linked to the current development of ‘PIPEs’
(Psychologically Informed Planned Environments) for
more high secure services in the criminal justice system.
In their original paper, Johnson and Haigh suggested
that “for the moment, at least, the definitive marker
of a PIE is simply that, if asked why the unit is run in
such and such a way, the staff would give an answer
couched in terms of the emotional and psychological
needs of the service users, rather than giving some more
logistical or practical rationale, such as convenience,
costs, or Health And Safety regulations” In that sense,
“psychology” is an aspect of emotional intelligence and
empathy, and should not bee seen as the preserve of
any one discipline or school of thought.
The purpose of a psychologically informed environment
is to enable clients to make changes in their lives.
This can be expressed in different ways but will usually
be changes in behaviours and / or emotions for example
an ability to establish and maintain relationships,
reduce drug or alcohol use, feel less depressed or fearful.
It is important that these changes are measurable so
that services can review their efforts, demonstrate to
clients themselves that change is being made,
and learn and adjust their response (see also reflective
practice, below). It will also be important that services
can demonstrate to commissioners what difference
the therapeutic service made, through for example
reductions in chaotic behaviour, evictions or hospital
admissions or increased engagement with staff.
People who are homeless or insecurely housed
are among those most in need of psychologically
informed help, but are also among those least
able to access mainstream psychological therapy
services. Psychologically aware housing services
cannot be a replacement for clinical services.
Health commissioners must be involved in the
development of PIEs to ensure that services have
the support they need. It is also important to ensure
that there are referral routes into appropriately
designed and accessible clinical services, including
those for people with dual diagnosis.
Services for rough sleepers and young homeless people
currently use a range of techniques and approaches to
manage clients whose behaviour puts them at risk of
eviction or abandonment.
References
www.enablingenvironments.com
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Introduction
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Psychologically Informed Environments
Those services that have developed a psychologically
aware approach will recognise that clients with
challenging behaviour have particular support needs,
often arising from earlier trauma and abuse. As part of
this approach, they will be working within a broadly
therapeutic framework, enabling them to develop clear
and suitably consistent responses to clients who may be
chaotic and distressed and who have learned not to trust.
The term “therapeutic framework” describes the
thinking underpinning an approach to psychological
needs. There are a number of frameworks to choose
from, including humanistic, psychodynamic, CBT
and DBT (see complex trauma guidance for more
information) There is no single right approach to
addressing someone’s emotional and psychological
needs and organisations may decide to use more than
one framework.
An explicitly psychological framework can legitimise
and informs the different approaches staff can use and
gives them additional insight into how people may
behave. Training all staff within an agreed framework
or combination of frameworks will help them work
more effectively with clients with complex trauma. This
approach will help clients who often behave chaotically
to gain an understanding of their behaviour, take
responsibility for themselves and develop negotiated,
positive relationships. This in turn will help them move
away from a street lifestyle and rough sleeping.
Psychologically aware services will aim to risk manage
clients as well as risk assessing them, so that vulnerable
and chaotic people with for example, multi drug use
and mental and physical health needs are not excluded
from services. That means they will work with the
challenging behaviour of clients rather than restricting
access until behaviour changes. They may, for example,
operate what is sometimes called “elastic tolerance” so
that behaviour that might normally result in eviction
and a return to rough sleeping can be tackled creatively
and with flexibility, addressing the behaviour without
rejecting the individual.
A key element of a psychologically informed
environment is reflective practice (www.infed.org/
thinkers/et-schon.htm2). This term describes the process
of recapturing and analysing actions and processes
in order to learn from incidents and improve the
responsiveness of the service. It enables clients to feel
that their problems are recognised and that they are
being heard. It gives staff a perspective on the emotional
challenges of their work and also helps to develop
learning cycles and skills development. It encourages a
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
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Psychologically Informed Environments
climate that enables clients to feel that their problems
are recognised and that they are being heard. Where staff
work in teams – as they typically do – reflective practice
should be a shared approach, aiming to learn from and
support each other in learning. Shared, group learning,
especially in reflective mode, is particularly suited to
effect changes in a group culture.
Staff coaching, training and recruitment should
explicitly acknowledge the need for a psychologically
informed approach and dispel myths and fears
some may have around psychological approaches.
Staff will not be acting as therapists, but may be
adapting, developing and refining formally therapeutic
approaches in their work with sometimes challenging
clients. Effective staff supervision, both individual and
group, is an essential component of a psychologically
informed environment.
There are five key areas to consider when
developing PIEs
•Developing a psychological framework
•The physical environment and social spaces
•Staff training and support
•Managing relationships
•Evaluation of outcomes
For more information on psychologically
informed environments or PIEs see
www.nmhdu.org.uk/complextrauma
Homeless Link has produced a useful tool on
mental health and wellbeing which can be found at
http://homeless.org.uk/mental-health-guide
References
1 Johnson, R & Haigh, R (2010) “Social Psychiatry and Social Policy for
the 21st Century – new concepts for new needs: the psychologically
informed environment” in J. Mental Health & Social Inclusion, 14:4
2 Cockersell, P. (2011) Journal of Public Mental Health,
July 2011, 10:2 Maguire, N (in submission)
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Introduction
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Five key areas
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Developing a
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The physical
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and social spaces
Staff training
and support
Managing
relationships
Evaluation of
outcomes
To be effective, there needs to be corporate
commitment to the introduction of a psychological
informed approach, which ideally should then become
part of an organisation’s service commissioning or
business plan. Developing into a psychologically aware
service means transforming the way a service operates,
rather than being just an add-on to an existing way of
working. The positive effects will be seen in both staff
and clients and can be effective in both street based
and accommodation based services.
As a result, it is essential that any formal psychological
framework used within the service - any particular
school of thought on human development and personal
change- is made explicit to all staff. They should be
clear about what changes each approach is designed to
enable in the individual, how they themselves will need
to work and what support the organisation can offer
during this process. They should be free to question how
suitable, coherent or consistently applied any particular
framework may be.
There are a number of frameworks or paradigms which
describe the prevailing view or patterns of thought
between the different approaches to psychological
therapies. For example, the behavioural, humanistic
and psychodynamic paradigms provide three different
sets of assumptions, concepts, values and practices that
make up the different disciplines they inform.
The Psychodynamic Paradigm
All psychodynamic therapy is based on the idea that
how and who we are is shaped by dynamic processes.
‘Dynamic processes’ here means that we can and do
change, and that we change through our relationships
with the people and circumstances around us.
Relationships affect everybody involved, and changes in
one part of any system will affect the other parts. In the
case of human beings, there are four key dynamics of
relationships – between one person and another/others
(interpersonal), between a person’s own physiological,
emotional, and rational/cognitive selves (intrapersonal),
between a person and their environment, and between a
person’s past, their present and, potentially, their future.
Developing a psychological framework
Five key areas
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
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Good Practice Guide
9
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Developing a
psychological
framework
The physical
environment
and social spaces
Staff training
and support
Managing
relationships
Evaluation of
outcomes
Five key areas: Developing a psychological framework
One of the most important relationships is that
between the baby/child and his/her mother/primary
care giver. The experience we have as a baby/
child affects how we see and respond to all other
relationships. Not only does it affect how we think,
feel and behave, there is solid evidence that experience
shapes the very physiology of the brain (Schore, 1994).
These early experiences continue to colour how we
experience other relationships and ourselves. Positive,
thoughtful relationships help foment changes in brain
physiology that underpin sustainable change: we can,
and do, literally change our minds.
Evidence from neurobiology shows that these
processes continue to be dynamic – that is, open
and responsive to change – throughout our lives
(Siegel 2011). This is essentially a hopeful approach,
based both on the idea that what we think, feel
and do makes sense (or, often, once made sense in
a particular context), and also that we can and do
change how we think, feel and behave. However, we
may need help to change deeply unconscious patterns
of thinking and behaviour. In psychotherapy, change
is effected primarily through talking and feeling in a
safe and holding (or “containing”) environment, and
through the relationship between therapist and client.
Psychodynamic psychotherapy uses what the client
brings and the relationship between therapist and client
to make links between, and understand, the client’s past
and present, internal and external, experience. Thinking
about and understanding this experience within a safe
relationship/set of relationships enables the client to
work through it, and to manage and (re)mediate its
effects on their lives.
Psychodynamic psychotherapy has a very strong
evidence base as effective with people with
characteristics of any personality disorder, diagnosed
or otherwise, has a greater effect size with personality
disorders than other therapies, and has a longer term
impact; psychodynamic psychotherapy has been shown
to continue working long after formal therapy ends as it
enables people to develop themselves (Shedler, 2010).
It therefore supports sustainable recovery.
Psychodynamic thinking is not confined solely to
one-to-one therapeutic work between therapist and
client. The same perspective and values can also be
employed in e.g. group work, peer-to-peer support,
etc, and can inform service models and organisational
culture. When the impact of psychodynamic processes
in a particular service context or relationship is
consciously understood and explicit, we can talk of a
“psychologically informed environment“. Even when
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
10
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Developing a
psychological
framework
The physical
environment
and social spaces
Staff training
and support
Managing
relationships
Evaluation of
outcomes
such awareness is simply implicit, it is nevertheless
strongly influential. This is because psychodynamic
processes happen regardless of whether the participants
in any social situation are overtly conscious of them
or not: they are the natural processes of human
relationships and human ‘being’.
When working with homeless people, achieving
an initial engagement is crucial, and building and
sustaining a relationship of trust is central to
successful work. Psychodynamic approaches, which
prioritise the quality of relationships, have a lot to
offer here. However, one of the main reasons why the
psychodynamic approach is popular with the clients
themselves (apart from effectiveness) is that it does
not shy away from the actual experience clients have
lived, or the emotional impact of that experience,
and respects the reasons why individuals made and
make the life choices they do. In line with the recovery
approach, it recognises the often awful impact of the
past and the effects others and the environment have
had and continue to have on people and the validity of
coping strategies developed to deal with these stresses,
while at the same time working with them to picture a
better future in their own terms.
Cognitive and Behavioural Approaches
There are a number of interventions based on the
expression of the relationship between thoughts,
feelings and behaviours (between 40 and 50 at the
last count). Five of the major forms of this group of
psychological therapies are Cognitive Behaviour Therapy
(CBT), Schema Focussed Cognitive Therapy (SFCT),
Dialectical Behaviour Therapy (DBT), Acceptance and
Commitment Therapy (ACT) and Mindfulness Based
Cognitive Therapy (MBCT). To a greater or lesser extent,
all of these therapies are based on theories which have
received empirical attention to demonstrate their
validity. These therapies fall into two basic groups,
sometimes referred to as ‘second’ and ‘third wave’
cognitive therapies. CBT and SFCT are examples of the
former, the other three examples of the latter.
CBT: The original form of CBT as described by Aaron
Beck and colleagues (Beck et al, 1979) considered
the content of thoughts important, together with
how they led to particular emotions and behaviours,
and described typical ‘thinking errors’ which lead
to distressing experience. According to the theory
these ways of thinking are due to fundamental (core)
beliefs which are formed in interaction with childhood
Five key areas: Developing a psychological framework
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
11
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Developing a
psychological
framework
The physical
environment
and social spaces
Staff training
and support
Managing
relationships
Evaluation of
outcomes
experience. These core beliefs colour the way the
individual interprets their world and drive emotions and
behavioural attempts to cope with it. Typical therapeutic
interventions involve identifying these ways of thinking in
terms of content and testing them, using techniques such
as behavioural experiments, or setting up new activities
in a graded way, so as to set individuals up for success.
CBT is delivered in individual and group formats. CBT
is highlighted by the National Institute of Clinical and
Health Excellence (NICE) as treatment of choice for the
treatment of anxiety, depression, first episode psychosis
and antisocial personality disorder (in group form, with
people in prison). CBT can be particularly useful with
people who struggle to think about abstract concepts, as
it is designed to be easily communicated and is therefore
based around simple, concrete models and techniques.
Hostel staff have also reported finding the models useful
in thinking about their own reactions to client behaviours,
and making choices about how they behave in response.
SFCT: Jeff Young developed SFCT in response to the
need to treat deep seated interpersonal difficulties
and deal explicitly with fundamental ‘schema’,
i.e. clusters of beliefs about the self which drive
maladaptive behaviours. Eighteen specific ‘schema’
were empirically identified, together with modes of
operating and three broad ways of attempting to cope
the distress associated with them; schema avoidance,
overcompensation and surrender.
DBT: Developed by Marsha Linehan, DBT focuses on
reducing maladaptive behaviours (particularly self-
harming behaviours) and increasing functioning for
people suffering complex trauma issues (perhaps
diagnosed as borderline personality disorder). The
premise of the therapy is that clients are doing the
best that they can in life, but have not acquired
certain skills, e.g. manage emotions; establish and
maintain relationships (perhaps due to attachment
disruption and / or inconsistent, punishing or neglectful
parenting); or consider the consequences of behaviours
(leading to impulsivity). Emotion dysregulation is a
key issue, and interventions are often based around
teaching skills to manage anger and anxiety. Recent
evidence has indicated that emotion dysregulation
is an important factor in the relationship between
childhood abuse and antisocial behaviours, and that
it may be useful to consider not only under-control of
emotions, but also over-control. The former may lead to
outbursts of negative emotions, the latter suppression
of all emotional experience, both of which may be
problematic for the individual and lead to ways of
coping which have negative consequences.
Five key areas: Developing a psychological framework
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
12
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Developing a
psychological
framework
The physical
environment
and social spaces
Staff training
and support
Managing
relationships
Evaluation of
outcomes
The therapeutic relationship is an intrinsic aspect
of DBT treatment, not only as a model of a healthy
relationship, but also to reinforce behaviours which are
less harmful to the individual. DBT also makes use of
‘mindfulness’ techniques to enable clients to notice the
negative judgements that they make about themselves
and others. This form of cognitive intervention, based
around the process of thinking rather than the content,
is one of the factors distinguishing ‘third wave’ forms of
cognitive therapy.
Of particular use in homelessness is the concept that
many problem behaviours are associated with difficult
emotions and ways of coping with them, and that skills
can be taught to enable clients to deal more effectively
with distress, thereby reducing behaviours which result
in negative consequences (e.g. arrest, eviction). This
can result in hope that things may be different. DBT
is delivered in individual and group formats, often in
tandem. DBT is recommended by NICE as treatment
of choice for self-harming behaviours in the context of
borderline personality disorder.
ACT: Steve Hayes developed therapeutic processes
around acceptance of difficult life events, based on a
robust, empirically defined theory associating language
(internal dialogue) with distress. Some of the processes
of change are similar to those used in CBT, particularly
those designed to enable ‘cognitive flexibility’, i.e. the
ability to reflect on internal dialogue and moderate
the experiences associated with it. Of particular use is
‘values’ work, which enables individuals to articulate
what they value about themselves and the behaviours
that they may engage in which are in the service of
those values. This is particularly useful in engaging
people in change.
MBCT: John Teasdale and colleagues developed MBCT
to treat recurrent and severe depression. The practice
of mindfulness (purposefully paying attention to
experience, including thoughts) has been found to
be particularly useful in reducing the intensity of
depression experienced, and the lengths and frequency
of depressive episodes.
Cognitive and behavioural therapies and
Psychologically Informed Environments (PIE)
There are a number of concepts and practices which
may be of particular use in PIEs. Easily accessible
cognitive models have been shown to be useful
in enabling staff to be able to reflect on internal
experiences. By teaching staff groups to notice and
articulate beliefs about situations, others’ motives
and their own behavioural urges, it may be possible to
Five key areas: Developing a psychological framework
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
13
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Developing a
psychological
framework
The physical
environment
and social spaces
Staff training
and support
Managing
relationships
Evaluation of
outcomes
increase the amount of considered interventions and
reduce the number of ‘knee-jerk’ reactions to clients’
more challenging behaviour. Staff may also start to
‘catch’ thoughts about their own lack of efficacy with
clients, which may lead to hopelessness, burn-out
and absence or resignation. Generally, being able to
catch or notice thoughts enables choices to be made.
If a particular thought about another tends to lead
to a particular way of dealing with them, noticing
that this is just a thought enables the individual to
make a more informed choice about what they do.
This is particularly important when those thoughts
are negative evaluations of another. So the cognitive
models are a simple way of enabling reflection on
internal experience.
Staff can also be equipped with skills to enable
clients to develop cognitive skills which may then
underpin those challenging behaviours and distressing
experience. Clinical experience indicates that some
clients will work better with more concrete ‘thought
challenging’ interventions based on content, whereas
others may make more use of more abstract
mindfulness techniques to notice thought processes.
Either way, cognitive flexibility is facilitated.
All new activities set up for clients may make use of
‘graded hierarchies’ (i.e. breaking all tasks down into
manageable chunks) in order to ensure success and not
feed into existing beliefs about failure. Beliefs about
what is going to happen may be articulated, and all
associated activities set up as ‘experiments’ to test
those beliefs.
The concept of ‘skills’ can be a useful one. Most will be
familiar with developing practical, tenancy sustainment
skills, and it is only a short step to consider ‘emotion
regulation’ and ‘interpersonal’ skills as things that can
be learned.
Motivation to change is an important issue. Staff may
be taught to articulate their own expectations for
change. The ‘Cycle of Change’ published by Prochaska
and DiClemente in 1982 is a very useful tool to describe
what is realistic in terms of change at any stage. So
for those who are in the ‘precontemplative’ stage, i.e.
don’t see the need to engage in whatever change is
deemed useful, the changes that staff should expect
are only cognitive ones, i.e. change in the client’s
beliefs about the need to change. Behavioural change
should not be expected. Behavioural change will only
Five key areas: Developing a psychological framework
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
14
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Developing a
psychological
framework
The physical
environment
and social spaces
Staff training
and support
Managing
relationships
Evaluation of
outcomes
be possible when the person is in the ‘contemplative’
stage, so interventions should be designed accordingly.
A common mistake that we all make is to try to engage
a client in behavioural change when they do not see the
need to make it, or the costs of engaging in the change
outweigh any perceived benefits. The result of this
may be beliefs about failure for staff and client alike.
Articulating beliefs about change, and values work are
complimentary to Motivational Interviewing techniques
in engaging clients in the process of change.
The behavioural paradigm
The behavioural paradigm is a useful framework for
describing the way that people behave in terms of the
reactions of their environment. However, the strength of
a behavioural understanding (fairly simple explanations
relying on a theoretically strong, observation-based
approach) is also its weakness, in that it takes little or
no account of thoughts or internal narrative.
This approach can however enable staff to identify
and predict negative responses to their behaviours and
develop appropriate responses which are psychologically
informed and which will enable them to work more
positively with clients with a range of issues.
This approach also has strengths in accounting for
substance abuse and self-harm in terms of physiological
factors such as cravings and urges. There are two main
ways of expressing the way that people learn to behave:
1) classical and 2) operant conditioning.
Some clients in detox settings can display cravings
when confronted with drug paraphernalia as this is
associated with the drug itself. This type of conditioning
is classical conditioning, in which two or more stimuli
are repeatedly paired together (i.e. drugs works or the
environment in which they use are repeatedly presented
with the drug and the physical response), resulting
in a physical response to the works or environment
alone. This has in the past been treated using
repeated exposure to the stimulus (paraphernalia and
environment) in the absence of the drug. The cravings
reduce as the physiological response to the stimuli
reduces due to the repeated presentation.
Some clients learn that shouting at staff results in
the staff leaving them alone, which means he doesn’t
have to actively deal with the presenting issue. This is
described as operant conditioning through ‘trial and
error’ in which certain behaviours are reinforced and
Five key areas: Developing a psychological framework
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therefore repeated. For example the staff member
may withdraw and stops ‘bothering’ the client. In
order to reduce the problematic behaviours, staff, as a
whole group, have to develop a common behavioural
response, usually being clear about why the behaviour is
problematic for the individual in the long-term (despite
solving a problem in the short-term) and teaching the
individual to make their needs known in more useful
ways. If the whole staff group does not respond in this
way, splits can develop, where one subgroup of staff
reinforces the behaviours by responding as the client
intends and another tries to behave differently, by
e.g. not responding. This can be confusing for client,
and may actually make the problem worse through
intermittent reinforcement, i.e. sometimes being
reinforced and sometimes not. This intermittent
reinforcement is a very powerful way of ensuring
behaviours don't change.
Staff may be familiar with the following technical
terms which describe of some of the ways that clients
can behave:
Positive reinforcement: A client’s behaviour is more
likely to occur if it is suitably rewarded. This reward is
described as a ‘positive reinforcer’. If the reinforcer has a
consequence which the individual finds desirable it may
mean that the modified behaviour is repeated.
Negative reinforcement: Clients may self-harm, which
temporarily removes unpleasant emotions, or use
drugs, which remove symptoms of withdrawal. This is
a ‘negative reinforcer’, where the behaviour removes
negative feelings. Negative reinforcement is also often
used to refer to strategies that (usually unintentionally)
reinforce negative perceptions or behaviours. For
example, if staff give the highest levels of attention
to clients when they create a disturbance it creates a
negative reinforcement for disturbing behaviours.
Punishment: Clients may repeatedly behave in a way
that results in something unpleasant for example,
pain, emotional dysregulation, stress or eviction.
This consequence is described as a ‘punisher’, leading
to consequences which are explicitly undesirable
but which are familiar to the client. However the
behaviour may not lessen despite the consequence
being punishing, which is where a more cognitive
understanding may be more useful.
Humanistic psychology
Humanistic psychology is sometimes described as
‘the third force’ in psychology, coming as it did after
the establishment of psycho-analytic and behavioural
approaches. Humanistic psychology is not a specific
technique or school, but rather a perspective in
psychology that focuses on and sets most store by the
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Five key areas: Developing a psychological framework
aspects of our existence that are uniquely human, such
as potential, meaning, value, personal responsibility,
choice, individuality and self-expression. More humanistic
approaches in therapy or treatment tend to work to
support and endorse these features and capacities in the
lives of those coming for assistance.
Work to engage marginalised and excluded individuals,
those with entrenched difficulties, and/or those who are
especially wary of authority or care services, may often
need to start with such issues, to achieve the engagement
with support that may even need to precede the offer of
shelter. This may, for example, mean that the therapist
gives at least equal weight to the person’s strength
and goals – their assets. Humanistic psychology, like
behaviourism, tends to keep at arm’s length the medical
model of psychiatry, and typically aims for a less-
pathology-focused view of the person.
A key ingredient in this approach is the encounter
between therapist and client and the possibilities for
dialogue. Humanistic psychology practitioners tend,
therefore, to allow their own personalities and concerns
to become part of the engagement process, rather
than attempting to remain neutral, as simply technique
providers, as behaviourist approaches imply, or to become
a blank screen on which clients may project their own
concerns, as psycho-analytic theory typically proposes.
In some respects, therefore, humanistic approaches offer
an alternative approach, but humanistic practitioners
are typically holistic in approach, and aim to integrate
a wide (or ‘eclectic’) range of insights and specific
techniques, as appropriate to each individuals’ needs and
circumstances. It may be just as accurate and helpful to
see humanistic approaches, not as a distinct third force,
but rather as the fertile meeting ground between the
other two. In fact, of course, all these different schools
and approaches draw from each other hugely, and
more skilled and confident practitioners may draw on
techniques and insights that underlie them all. However,
crucially, all schools recognise that learning and un-
learning are both most effectively achieved in some kind
of helpful relationship, and especially in a group.
References
An extract from Psychology in the environment
Johnson and Haigh (Eds) (2012) "Complex trauma and
it's effects: perspectives on creating an environment for
recovery". Brighton: Pavilion. Used by permission of the publishers
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Designing and managing the social environment is
central to developing a psychologically informed service.
Thoughtful design, preferably one with service user
input, based on thinking through the intentions behind a
service, can result in useful changes in the way a building
is used, and how it is valued by staff and clients.
The Housing LIN published a useful paper on how
to develop healthy hostels. The 5 outcomes to
be achieved are similar to those needed within a
psychologically aware service:
•Creating a healthy environment
•Reinforcing positive relationships
•Developing opportunities for meaningful
occupation
•Offering specific health related services
•Access to healthcare
www.dhcarenetworks.org.uk/_.../Report13_
healthy_hostels_final.pdf
Developing a psychologically informed service
doesn’t have to involve large capital works-small and
inexpensive changes can work equally well. Whether a
building is redeveloped or redecorated, it can signal that
there is a changed approach to the service, which is the
key message for staff and clients.
Ideally the building should reflect the different levels
of engagement required by individuals. Some will be
comfortable with a structured approach while others, for
example, chaotic drug users, may find a more informal
approach less threatening. The flexible use of space,
possibly incorporating drop-in facilities next to more
formal services, could offer clients a safe and private
environment, reinforcing appropriate social boundaries
without creating no-go areas that could result in conflict.
Some services have found that improving kitchen
and dining facilities has had a positive effect on the
behaviour of clients and also improving their diets and
health. For example, Look Ahead HA spent around
£60k on new kitchens and decorating and furnishing
common parts at Hopkinson House, a hostel for people
The physical environment and social spaces
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with alcohol problems. Residents were able to eat hot
food prepared for them, or cook for themselves, with
help. The new dining area gave people the option to
eat together or alone, and small communal areas on
each floor offered quiet spaces where people could
read or watch TV. These relatively minor changes have
transformed the way residents interact with each other
and with staff.
Other providers have replaced notices in reception
areas about rules and sanctions with information about
available services and how to access them. This has
switched the emphasis away from what will happen if
someone breaks the rules to one which offers support
and encouragement to change, and has helped to develop
congruence (Carl Rogers, 1951)or rapport with staff.
Brighter Futures takes this thinking one step further.
They argue that people with complex needs are
often systematically denied the right to feel proudly
and powerfully themselves. They are stereotyped as
members of a particular group, they lose their identity
and are oppressed. This oppression is usually, but not
exclusively, perpetrated by groups which are seen as
being more powerful than their target. Therefore any
interaction which creates or could be perceived to
create a “them and us” or makes an assumption about
someone’s behaviour based on a stereotype reinforces
their oppression and prevents the establishment of
good working relationships and rapport.
The safety of staff and clients is crucial, and providers
should aim to achieve this through good design and
lighting in common areas and without the need for
intrusive surveillance.
The principles behind the Hostel Capital Programme,
now the Homelessness Change Programme, fit very
well within a psychologically informed environment.
The programme emphasised the need for welcoming,
well decorated and well lit buildings, providing
a safe environment within which vulnerable and
often isolated people could turn their lives around
and move away from the streets. Key outcomes of
the programme included a reduction in evictions,
clients moving into independent or more appropriate
supported accommodation and people getting onto
training schemes or into employment. It is strongly
recommended that the principles behind Places of
Change and the Homelessness Change Programme
are incorporated into any remodelling of services to
make them psychologically aware.
http://www.homesandcommunities.co.uk/ourwork/
homelessness-change
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Evidence-based design
‘Evidence-based design’ is a concept which may be
useful when considering how to create a psychologically
informed environment. This stresses the importance
of the environment on the individual, and empirically
evaluates environmental interventions on such
outcomes as perceived wellbeing, negative emotions
etc. The Centre for Health Design links to a range of
resources which may aid the design of hostels
(www.healthdesign.org/).
Codinhoto and colleagues (2008) define a
set of four factors which found to influence
health outcomes:
•Ergonomics, including dimensions,
shape and layout of the environment
•Fabrics and ambient factors, including material,
lighting, acoustics, temperature and humidity;
•Art and aesthetics, including colour,
design and art;
•Services, including maintenance, cleanliness
and decontamination (where necessary).
These factors have been found to impact on
psychological, emotional and physiological factors
which contribute to or impede health. There are a
number of points to draw out from this approach.
1. Noise and acoustics can have a significant impact on
mood, which makes the consideration of materials
used in public areas important, those which dampen
noise being favoured. Noise is also cited as a significant
problem in sleep disturbance in large environments.
2. Light, whether natural or artificial appears to be
an important factor which may be beneficial in a
number of health areas, both generally and in specific
situations (e.g. seasonal affective disorder being
positively affected by broad spectrum light at 10,000
lux plus.). However, it is possible to get light levels
wrong in both directions, either too little or too much.
3. Open, green areas can promote a lower arousal and the
opportunity to socialise, although the evidence is mixed.
4. Art and aesthetics can be an important contribution
to health, both in terms of the activity and the
appreciation. However some evidence indicates that
‘inappropriate’ art can have detrimental effects on
mental health. The form of art should therefore be
carefully considered and piloted.
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5. Colours have been found to have effects on mental
health. For example greys, purples and reds have
been found to be associated with depression and
tend not to be used in therapeutic environments.
Reds and yellows have been found to promote more
anxiety than blues and greens.
These are just a few of the factors which may
affect mood and behaviour within hostel or other
environments. Others, such as the use of ventilation
systems, furniture, use of televisions and temperature
levels could also be considered in the light of evidence.
Given the large amount of work done in this area, it
would seem useful for the concept of evidence-based
design to be considered when physical environments
are being commissioned or improved.
Five key areas: The physical environment and social spaces
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Services for rough sleepers have traditionally been
shaped by the need to provide a crisis response. While
that remains an important role, particularly with severe
weather shelters and night shelters, psychologically
aware services require a different approach to key
working and this will affect how organisations recruit,
train and manage staff. Staff training and support is
therefore central to the transition into psychologically
aware services.
All services working with your clients should be
included in discussions about the development of
psychologically informed services. Supporting People
teams, PCTs, GP practices, adult social care, drug
and alcohol services, mental health teams, Probation
and education and learning services are part of the
process and should be included in discussions about
the development of psychologically aware services.
Changes to the ways in which key workers interact
with clients will affect their work as well, and they may
find it useful to develop a psychologically consistent
approach, to maximise positive outcomes. Pathways
and transitions between services also need to be
thought through and carefully crafted.
A key element to psychologically informed services
is the introduction of reflective practice. This term
describes the process of continuous learning from
professional experiences, which encourages problem
solving and critical thinking skills. Key working
clients with complex trauma can be challenging
and exhausting, but adopting a reflective approach,
especially after difficult incidents, can enable staff to
learn from experiences and thereby improve the way
they respond when something similar happens again.
Reflective practice serves to enable the staff member
to make their internal experiences (thoughts and
emotions) explicit, thereby facilitating the possibility of
reducing the intensity of difficult emotions and possibly
altering behaviours. It also serves to enable a ‘learning
cycle’, whereby the staff member practices newly
acquired skills and has an opportunity to reflect on the
experience. This is essential if psychological skills are to
be effectively acquired.
Reflective practice can be developed within personal
development planning through self or peer assessment or
group work, and can significantly reduce staff burn out.
Staff training and support
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For example, Thames Reach's casework management
approach ensures that teams discuss cases regularly
and establish what approaches are working well. Staff
have regular supervision sessions which include talking
through all cases. There are good practice workshops
organised and action learning sets to encourage
reflective practice so that teams learn what works well,
and can aim to improve services further. There has also
been clinical supervision for some teams - where an
external professional will participate in the discussion
of cases at the team meeting - for example the Graham
House hostel.
St Mungo’s has developed a four-module training package
for the staff and management of its psychologically
informed environments. The theme of the training is
‘Managing Relationships’ Staff do three modules – one
on psychologically-informed understandings, including
attachment, behaviour, development, change processes;
one on psychologically-informed interventions, such as
motivational interviewing, empathic listening etc; and
one on client involvement and empowerment, developed
using Groundswell’s ‘Escape Plan’ (www.groundswell.
org.uk/the-escape-plan). Managers also do a module on
‘enabling management’, including leadership and change
management, and performance management.
These trainings are reinforced and supported through
clinician-led clinical supervision, and through reflective
practice groups, including a reflective practice group for
PIE Managers. The trainings were developed with and
co-delivered by clients.
The approach by all staff to clients, developed through
the theoretical framework, should be assertive and
consistent where appropriate, and staff should be
confident in managing conflict. The development of
a consistent reward and sanctions framework that is
adopted by all staff will help promote ownership of
behaviour by individuals and recognition of the impact
of anti social behaviour. However there needs to be
some discussion of when consistency is right, and when
flexibility and person-centred-ness is, and variations in
responses should be explained in terms of the values
used to make them. Every service needs to consider this
issue, in context – and keep it under constant review.
There should be ongoing evaluation, by staff and
clients, to develop a robust evidence base of outcomes.
This means that all staff must have a reasonable
understanding of the ultimate purpose of any data
collection, as a form of feedback on what is working, so
that any future changes in practice are informed by the
evidence that the service itself has generated.
Five key areas: Staff training and support
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Brighter Futures’ bespoke training offers a “box of
tools” which staff and customers can use creatively
and flexibly depending on the customers needs and
goals. The cornerstone of their support is motivational
interviewing combined with use of the Outcome Star
(www.homelessoutcomes.org.uk/outcomes-star-
system).
All staff, regardless of their role undertake elements of
the training. Courses last between two and three days.
Observations of practice and assignments are completed
in addition to classroom sessions. Many staff are ex-
customers or people with a lived experience and raising
self-awareness is a key component of the training.
Brighter Futures describes support as
“… someone from outside my cycle of
stresses, offering me their thinking so that
I get back in touch with my ability to do what
I need to be able to”.
This describes the way people learn to make choices
based on thinking rather than feelings. It is this thinking
which empowers them to become more independent.
This model is applied to support work with customers
and casework supervision with staff.
Reflective casework supervision sessions are undertaken
by senior practitioners who are “expert” team members.
Their role is being developed to ensure that staff are
effectively supported and learning from the classroom
is translated into practice and experiential learning is
captured in the learning cycle.
Five key areas: Staff training and support
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A focus on managing relationships is perhaps at the
heart of what makes a psychologically informed
environment different. In this model, relationships
are seen as a principal tool for change, and every
interaction between staff and clients is an opportunity
for development and learning. Rather than seeing
the management or staff role as simply trying to
contain,control or even manage behaviours, their main
role is to encourage the capacity to self-manage. In
terms of management, this means delegating more
responsibility and creativity to the staff team, and in
staff terms it means encouraging the development of
responsibility and autonomy in the client group.
The development of an explicit service philosophy and
practice that is discussed with and adopted by all staff
will help promote ownership of behaviour by individuals
and recognition of the impact of anti social behaviour. If
this is developed with the clients, then it will have even
greater ownership and will help shift the power balance.
This approach also results in a more predictable set of
outcomes for specific behaviours, enabling individuals
to make more informed choices about their actions.
Organisations should review their evictions protocol,
ideally with user involvement, to allow opportunities for
clients to modify behaviour through graded sanctions,
consistently employed. Psychologically informed
services need to think creatively about sanctions,
avoiding the usual warning letter – eviction route and
actively looking at examples of good practice.
Homeless Link has published research on eviction and
abandonment (http://www.homeless.org.uk/evictions-
abandonment-research) and also produced a toolkit
identifying best practice (http://www.homeless.org.uk/
evictions-abandonment-toolkit).
Relationships being key, group work and other shared
activity should be supported where appropriate and the
‘Escape Plan’ has an excellent section on this. Group
work should also be encouraged for the staff team,
with attendance at reflective practice and (if present)
group supervision strongly promoted, or obligatory.
To keep a group healthy, the ‘difficult conversations’
should not be avoided, but discussed openly, with a
facilitator if necessary/available. Honesty is a crucial
Managing relationships
Five key areas
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part of any sustaining and therapeutic relationship,
and in all honest relationships there will sometimes be
disagreements: these should be aired, and a negotiated
position achieved. The more staff and management do
this, the more natural it will become for this to happen
in staff/client interactions, and indeed in client/client
ones too.
The development of positive pathways within support
planning, which emphasise what clients can do rather
than what they can’t, will help staff promote a change
in aspiration and motivate change. For example, Thames
Reach has developed a person centred approach called
Planning Alternative Tomorrow with Hope, which asks
clients to identify the kind of life they want, and what
they will contribute and how they will stay strong, so
that the emphasis is on how resilient they are. Other
tools include "gifts and qualities" reminding clients what
they bring to support planning so that it becomes a two
way process.
The risk management approach they have developed
ensures that clients are encouraged to make informed
choices about behaviour, and develop the ability to
assess and take some risks in their lives. The purpose
of risk management is to ensure that clients have
a physically and emotionally safe enough space in
which to develop, not to protect the organisation from
litigation: it should be enabling, not limiting.
Many clients will have a history of abusive relationships,
in other words relationships involving an abuse of
power: many clients are therefore acutely aware of
power dynamics and of potential, actual or perceived
abuses of power. Power should be discussed openly, and
should be taken into consideration when conceiving
client interactions and client pathways. Change, as in
moving on, often require a person to re-evaluate their
own relationship to people with power over aspects
of their lives. This can be a difficult process, and some
boundary challenges can be seen in this light. If staff
and management are aware of the impact of unequal
power structures, it will be easier for them to manage
creative relationships.
Five key areas: Managing relationships
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Evaluation of outcomes is crucial in the development
of psychologically informed services. Evaluations are
crucial because they are a cornerstone of reflective
practice, which in turn is a cornerstone of psychologically
informed environments. If you do not know what impact
what you do or say is having, how can you know whether
it is positive and how can you improve it?
There is not a great mystique about evaluation: it is the
opportunity to know which things you do or say are
effective, in what situations and with whom. It is an
opportunity for staff and clients to learn. It also enables
funding to be drawn down, and better services for
homeless people to be developed, but in its most simple
form it enables recovery-oriented work to take place.
You cannot claim to deliver effective client-focused
services if you do not know what effect they have on
clients. This principle of knowing whether something
that we as staff are doing is positive or not is just as
applicable at the service level as with the individual.
There are three levels of evaluation that can be applied
1. Policy level measures, whether defined by government
or local commissioners . These may be fairly broad,
and more sophisticated than mere ‘targets’. Examples
may be reduction in overall antisocial behaviours,
reduction in rough sleeping; or shared outcomes across
multiple departments e.g. reduction in police time,
reduction in emergency care use.
2. Service level measures, defined by the services
themselves. These should map on to what the
service believes that their interventions may deliver,
e.g. quality of personal relationships, reduction in
antisocial behaviours, reduction in distress, increase
in cognitive flexibility etc.
3. Individual measures, defined by the staff member in
collaboration with the service user. These should be
meaningful for the service user, realistic and – usually
– behaviourally defined (although relationships and
emotions as well as other factors may of course
feature). These measures may result from the
question ‘what do you want to change in your life?’
Evaluation of outcomes
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Evaluation and monitoring, particularly at the individual
level can also enable staff and clients to see progress
that is potentially significant but might otherwise be
hidden. For example, it can be easy to see the last set of
negative behaviours such as the last drinking binge or
arrest but if processes don’t monitor such incidents over
the longer term people may not spot that the number
of such incidences may have dropped. Another example
might be someone using a sharps box for the first time,
meaning that they have recognised the impact that
discarding sharps unsafely could have on staff and other
residents, a potentially significant behavioural change
but one which could be overlooked if not specifically
identified and monitored.
Five key areas: Evaluation of outcomes
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Case studies
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PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
Psychologically Informed
Environments (PIE) at St Mungos
Background
St Mungo’s recognised some years ago that there
was a significant contingent of our clients who
had undisclosed and undiagnosed mental health,
psychological and/or emotional disorders. This
underpinned what are known as ‘challenging
behaviours’, substance dependency and chronic
homelessness, including long term rough sleeping.
Seven years ago, we embraced the recovery approach
as our guiding ethos, and have since developed our
recovery practice through training and greatly enhanced
client participation, including founding and developing
an autonomous client-led organisation, Outside In.
In the absence of much statutory provision, four years
ago we developed our own psychological therapy
service, Lifeworks, initially funded through the Adults
Facing Chronic Exclusion programme led by the Cabinet
Office. We also then developed a model of working with
people with dual diagnosis – severe and enduring mental
illness and co morbid substance dependency – which
incorporated a psychotherapist into the support team.
When the concept of ‘psychologically informed
environments’ (PIEs) emerged, we saw it as a
development which fitted well with our other initiatives,
including access to psychotherapy, personalisation,
increased client co-production, and the deepening and
widening of our recovery orientation.
We are currently piloting PIEs at seven different sites.
The following case studies demonstrate the different ways in
which organisations working with rough sleepers and young
homeless people are transforming their services into ones that
are psychologically aware.
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PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
St Mungo’s PIEs
St Mungo’s pilots include:
•3 projects for people with diagnosed severe and
enduring mental health problems
•Rolling shelter for rough sleepers coming directly
from the streets
•Female sex workers’ project
•Project for people with dual diagnosis
•First stage rough sleepers hostel
They are situated in London and the South West.
The core elements of a psychologically informed
environment, as outlined in this paper, are:
•Psychological framework
•The physical environment and social spaces
•Staff training and support
•Managing relationships
•Evaluation of outcomes
We will therefore describe the pilots in terms of these
headings, rather than project by project. We have
placed ‘Managing Relationships’ first because of its
primary importance.
Managing relationships
Managing relationships is the most important point of
all, and in fact it could be said that a psychologically
informed environment is one in which relationships are
consciously managed with the intention of generating
positive experiences that lead to personal growth and
positive change. This is as true for staff (and managers)
as clients. It could also reasonably be said to describe
the recovery approach.
The common denominator of the experiences of
our clients, what has led them to become homeless,
is damaged relationships. Clients themselves cite
relationship problems as the cause of homelessness
more than any other single factor, and when we hear
the stories of our clients, they contain often multiple
relationship breaks; many of our clients come from
relationships that, from infancy onwards, were very
hostile, neglectful or damaging.
Positive relationships have the potential to repair
much of the damage from these negative relationships.
Positive relationships are ‘therapeutic’ in the broad
sense, meaning healing and enabling, whether they are
formally therapeutic as in our psychotherapy sessions
or informally therapeutic as in the relationship between
key staff and clients.
Case study: PIEs at St Mungos
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
30
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
Just as clients cite relationship breakdown as one of
the principle causes of homelessness, they also cite a
positive relationship, often with someone involved in
their support, as crucial to their recovery. This is very
empowering for staff too: as individuals, and through
their own actions and behaviours, they really can
make the difference. We see psychologically informed
environments as a way to provide the best conditions
we can for as many staff as possible to do just that.
Finally, two points that we have found are worth
emphasising. Firstly, relationships aren’t just between
clients and key staff. There needs to be a framework of
positive relationships – with management, with partner
agencies such as social services or primary care, with
commissioners, and with senior staff. And secondly,
relationships require work and attention if they are to
thrive, and this again doesn’t just mean between key
staff and clients, but between all those involved in
keeping the project happening.
Making PIEs a reality, therefore, becomes a whole
system project requiring the recognition that managing
relationships needs to be something that everybody
does. This again aligns with recovery, which is a whole
system approach. How do staff do it if their managers,
or senior managers, or HR, don’t? St Mungo’s have
therefore adopted an organisational change programme
incorporating the concepts of PIEs, personalisation
and recovery, and applied it across all our services and
central teams. We are changing recruitment, training,
appraisal, performance management, and a host of
other systems.
Psychological framework
We use a psychodynamic framework, for two
reasons mainly: the evidence base, and the fit
with the recovery approach.
The evidence for the effectiveness of a psychodynamic
approach both in formal therapy and in informing
staff interactions when working with homeless people
and rough sleepers is very strong. There is widespread
agreement that levels of (mostly undiagnosed)
personality disorder are around 60% or more in
the rough sleeping and hostel population (Maguire,
2009; Cockersell, 2011). There is strong evidence from
meta-analyses that the effect size for psychodynamic
interventions with personality disorder is greater than
for other therapies such as CBT or DBT, and that it goes
on working after the formal interventions have ceased
(Shedler, 2010): in other words, it enables people to
develop internal resources they can continue to apply
and learn from after they move on. This fits neatly with
the recovery approach.
Case study: PIEs at St Mungos
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
31
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
The evidence of our own experience is also that
psychodynamic approaches are effective in enabling
this client group to progress recovery further and more
deeply: our own psychodynamic psychotherapy service,
Lifeworks, demonstrated improved positive outcomes
across 100% domains of the Outcome Star, with >40%
of clients in employment or training placements, within
25 sessions (Cockersell, 2011). Other psychodynamic
therapy services (e.g. Westminster PCT’s Homeless
Health Team Counselling Service, Providence Row’s Just
Ask) for rough sleepers have also achieved impressive
results, and attendance rates of over 70% are common:
that is rough sleepers literally voting with their feet.
Secondly, the psychodynamic approach fits well with
the recovery approach. It emphasises relationships,
the potential for sustainable change within each of us,
the dynamic and changing nature of who we are, and
how that is impacted on by our interaction with our
environments, human and physical, and it emphasises
that everything we do and all that we feel is meaningful,
not just arbitrary. It values individuals over categories:
psychodynamic approaches work with the client’s
perspective and meanings, and on the topics the client
wants to work with, rather than imposing a structured
model on them, or channelling them into categories
and conditions, and then treating the category/
condition. Our own psychodynamic work is constantly
evolving, developing new ways of working in response
to interactions with clients.
We provide access to individual psychodynamic
psychotherapy with a fully qualified and highly
experienced psychotherapist to all clients of our
PIEs, and the psychotherapists also provide clinical
supervision to the staff teams.
We see PIEs as principally supporting a process
of recovery through positive relationships:
psychodynamics provides an evidence-based
explanatory framework for understanding, developing
and describing this process.
What doesn’t necessarily sit well with rough sleepers
(or many of our staff for that matter) is the technical
language of psychology or psychoanalysis: we have
therefore, with the help of our clients, reinterpreted
psychodynamic concepts through and in the language
of the Escape Plan (Groundswell, 2011). We use the
concepts of the Escape Plan, adapted and developed
though various training modules, to promote both
recovery and psychodynamic awareness.
Case study: PIEs at St Mungos
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
32
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
The Physical Environment and Social Spaces
The nature of the environment is that it is not always,
and certainly never totally, under our control: this is and
has been particularly true for most homeless people
and rough sleepers. We therefore try to return as much
control as possible to the clients in developing projects
and in their ongoing existence. Even this is not always
very possible: funding decisions taken by commissioners
can drastically alter a project with no input from, and no
possibility of appeal by, clients. This reflects the wider
world, and repeats the experience many rough sleepers
have had, that their views are not considered important
at all. This has happened to a couple of our pilots, where
recent funding decisions have detrimentally altered
their environments.
Within this caveat, we work with our clients to create
the best environment possible. This means somewhere
that they can feel reasonably comfortable in, that has
the basic facilities they need, that isn’t too institutional,
and so on – but particularly it means somewhere they
can feel safe. To embark on a process of change, as we
hope that people will when they come to a PIE, requires a
feeling of being safe, and that means safe psychologically
as well as safe physically. Both are important.
It is therefore not so much the quality of the building,
though undoubtedly a good quality building does
give people a sense of wellbeing, but the quality of
interactive space – is there somewhere private to have
conversations about important things? Is there a social
space not dominated by a TV or by a particular group of
individuals? Is there a sense of ‘my space’ in parts of the
project? Is there a feeling of ownership, even pride, in the
project from the clients? Is that shared with the staff?
This sense of ‘quality space’ is not (necessarily)
determined by the structural space. It has been
achieved in some of our PIE projects, despite being
severely constrained by the age of the building and
the funding available, through cooperative working,
client involvement, and making the best of what
there is: reducing the number of notices and notice
boards, breaking large areas up into more intimate
spaces, changing reception layouts, changing colours,
and encouraging client-led activities, and other client
groups, to use spaces in a varied and engaging way.
Case study: PIEs at St Mungos
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
33
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
Staff training and support
Fundamental to PIEs is reflective practice. We have
encouraged the development of local reflective
practice models in each of the pilots, recognising that
the very different services are not well served by a
single, centrally determined reflective practice model.
However, as mentioned above, we also provide clinical
supervision groups facilitated by psychodynamic
psychotherapists. In addition, the managers of the
pilots also have a reflective practice group of their own,
facilitated by another psychotherapist.
We have developed a set of core training modules which
collectively can be seen as providing some basic training
in various approaches to managing relationships. The
training is, of course, psychologically informed; it is also
informed by client experience, the recovery approach,
and management theory.
The training modules we offer are:
Managing relationships 1: how behaviours and
interactions can be understood through the concepts of
attachment, the processes of change (including Cycle of
Change), transference and counter transference, power
dynamics, respect, and the impact of expectations and
aspirations.
Managing relationships 2: techniques to help what
we do to impact positively on others, including
motivational interviewing, active listening, group
facilitation, open questioning, honesty, prosocial
modelling, coaching.
Supporting change: using client developed methods
such as the Escape Plan or 10XBetter (http://www.
mungos.org/about/clients/outside_in), and the recovery
approach to foster transformative actions and activities,
including co production.
Managing relationships 3, for managers: situational
leadership, empowering and enabling staff, managing
client-focused performance, managing co production
relationships with clients and commissioners.
Case study: PIEs at St Mungos
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
34
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
There is also access to a much wider training
programme both in house and externally, and we
are working towards personalised employment
experiences and individualised development as part
of the programme to ensure the recovery approach is
real for all our staff as well as our clients. Our training
programme also includes placements and formal
apprenticeships for clients who want to become project
staff (or to work in other aspects of the organisation’s
work such as central services), and support for client
volunteers who take on an aspect of service delivery
(for example, inducting other clients, staffing reception,
preparing food etc) for relatively short periods.
Finally, another important aspect of staff support is
that senior management support the development of
psychologically informed environments and understand
the implications, such as treating the staff with respect,
encouraging a thoughtful and creative environment,
and engaging in creative dialogues about aspects of
working practice that affect the staff (for example,
potential changes to working terms and conditions).
Evaluation of outcomes
Again like recovery work, psychologically informed
environments require measurement and evaluation of
outcomes. This is for two straightforward reasons: it isn’t
possible to be reflective if you don’t know what you’re
achieving (or failing to achieve), and because if PIEs are
to flourish they need to demonstrate their impact.
We use the Outcome Star because it (or a variation)
is widely used and known, and we have mapped
it against the Cycle of Change and various other
indicators (e.g. Treatment Outcomes Profile TOPS
www.homelessnessoutcomes.org.uk). We are also
measuring staff turnover and absences, and using
qualitative feedback from staff and clients and other
stakeholders.
We are in the process of agreeing the use of more
clinical evaluation tools, working with psychologists
and psychiatrists to measure the clinical impact.
Case study: PIEs at St Mungos
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
35
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
As it is early days for most of the pilots so far we
only have indicative results. Outcomes include:
•Reduction in hospitalisations and emergency care
•Increase in positive moves, and increase in
sustainment of moves
•Greater engagement in all sorts of activities,
from informal groups to accredited trainings and
employment placements
•Positive staff and client experience
•Reduction in staff sickness rates
•Reduction in serious incidents
Conclusion
We feel that, though there is undoubtedly still much to
be done, we have already achieved much to be proud of.
We will be publishing a preliminary report early in 2012,
and a fuller one in September 2012, when we will have
a more comprehensive dataset, including preliminary
clinical material.Until then, we leave you with a
comment from one of our clients:
I was drinking and using drugs for a long time. I used to
work in the music business but lost it and ended up sleeping
rough. I had a lot of family problems and for a long time,
thought it was all my fault…I now know it wasn’t just me,
it was all of us, none of us are perfect. May be if my parents
had used this service things may have turned out different.
I think it could have helped them. I now realise that the
drink, the drugs, [losing] the flat, the family, it’s all linked...
If it wasn’t for them I’d be dead by now, no word of a lie.
For more information contact Peter Cockersell at
Peter.cockersell@mungos.org
Case study: PIEs at St Mungos
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
36
Case studies
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
Stamford St Complex Needs Unit –
London Borough of Lambeth
The Stamford Street PIE is at an early stage of
development in terms of the psychological framework
and interventions. The models of intervention used will
be influenced by an initial comprehensive psychological
assessment of client need, and will develop in
collaboration and partnership with hostel staff. It
is likely to include elements such as psychological
individual and group interventions, staff training,
supervision and consultation/reflective practice,
following the best practice evidence in this guideline
and others, as well as relevant NICE guidelines.
Stamford St will be a purpose built, 19 bed, high support
accommodation service for entrenched rough sleepers
with multiple and complex needs. The project will
have skilled, 24 hour staffing who will work assertively
and responsively to individual needs and behaviours.
Support is aimed at assisting residents to maintain
their accommodation and to address the issues and
behaviours that have caused the breakdown of multiple
accommodation placements in the past. There will be a
high staff/service user ratio and staff will be expected
to work with the presenting behaviour of service users
rather than restricting access to services until their
behaviour changes.
The service will integrate accommodation with
psychologically informed health and support services.
It will support clients with the most complex needs,
for example personality disorder and complex trauma
coupled with substance misuse issues and anti-
social behaviour, self-harm, an offending history and
exclusions from other projects. Previous exclusions
show that normal hostel systems have not worked for
this client group. Stamford St will take a more flexible,
creative and personalised approach.
To support the service function it will host a
clinical psychologist and an assistant psychologist
who will provide:
•Clinical interventions with clients
•Clinical (group) supervision to staff
•Support to create a Psychologically Informed
Environment (PIE)
•Support and training to staff to recognise and
work with service users with complex needs
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
37
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
Stamford St will operate on a principle of ‘elastic
tolerance’ that can confront inappropriate behaviour,
but will never reject the individual. Service users may
be barred for a specific period but will always have
the option of returning and negotiating, through, for
example, changes to their behaviour, why they should
be allowed to try again. Support is both responsive and
assertive to needs and behaviours; behaviour that in
other settings might lead to eviction is challenged and
change is sought through consultation and realistic
goal-setting with the individual.
Co-operation and collaboration between agencies will
be vital to facilitate effective routes into and between
services and to enhance service capacity to work
with sensitivity and awareness. Project staff will build
up strong relationships with health, social services,
probation, drug and alcohol services, education services,
learning disabilities, local GPs and mental health teams
to ensure there is a multi-agency approach to meeting
service users’ needs. Working in this way will enable
us to address the housing needs of one of the most
excluded groups in Lambeth. There will be a team
approach: each worker having an in-depth knowledge
of the service users and can provide support when it is
needed, but each client also has a lead key worker to
co-ordinate support and provide consistency.
There will be a focus on health and daily living skills –
money management, attending appointments, cleaning
and food preparation – alongside substance misuse and
mental health specialist support. In addition, through
the use of therapy and motivational interviewing
techniques, service users will be given the opportunity
to take responsibility for their actions and change their
behaviour. There will be on-site sessions from local
specialist services and service users will be supported to
take part in activities outside the project such as basic
skills classes, gardening, music, art, job club, training/
education, leisure activities and day trips.
Expected length of stay at the project is 12-18
months with service users moving on once engaging
with services and ready to move on within the
accommodation pathway.
Evaluation of outcomes
The overarching aim of the project is to support:
•Those facing multiple disadvantage work towards
becoming self-reliant (e.g. to have jobs, stable homes
and to participate in their communities)
•Rough sleepers with a history of eviction and or
abandonment to sustain accommodation and move
on/through the pathway
Case study: Stamford St Complex Needs Unit
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
38
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
•Rough sleepers with a history of non-engagement
with services and treatment to engage with services
and sustain that engagement
In addition, the following outcomes are expected:
•A reduction in anti-social and chaotic behaviour
•An increase in the number of service users accessing
clinical therapy
•A reduction in negative outcomes for service users
such as hospital admissions and spells in prison
•Improved physical, emotional and mental health
•Improved personal motivation and taking of
responsibility
•Improved social networks and relationships
•Improved self-care and living skills
Further details from critchie@lambeth.gov.uk
or Clinical Psychologist emma.williamson@slam.nhs.uk
Case study: Stamford St Complex Needs Unit
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
39
Case studies
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
Waterview Personality Disorder
Case Discussion Pilot Evaluation –
June 2011
Summary
This paper describes the evaluation of the personality
disorder case discussion pilot that took place from
January to July 2011, aimed at providing new ways to
help workers engage with long term rough sleepers to
help them off the street. The paper goes on to outline
the pilot extension from Sep 2011 to March 2012.
The Waterview Centre
The Central and North West London NHS Foundation
Trust Waterview Centre offers an evidence-based
treatment programme designed to treat clients with
personality difficulties/disorder, in the boroughs of
Westminster and Kensington and Chelsea. The multi-
disciplinary team maintains a therapeutic environment,
providing safe and consistent boundaries within a
psychoanalytically informed framework. The programme
is for those with a primary diagnosis of personality
disorder or other mental health problems where a
personality disturbance complicates their treatment.
Their primary objective is to help people develop better
ways of coping and avoid the unplanned use of inpatient
and emergency services. They provide group based
psychological interventions based on Mentalization
Based Treatment and Dialectical Behavioural Therapy.
The aim of this treatment is to enable people to
reduce maladaptive ways of coping and better manage
affect, to establish a more stable sense of self, to help
people engage in more constructive interpersonal
relationships and behaviours, and to enhance their level
of involvement in the community.
Because the Waterview Centre is targeted at non
substance using patients, only a handful of rough
sleepers had ever utilised this service and there were
few links between the Waterview and rough sleeping
services. As a first step, a discussion pilot was developed
to offer teams the opportunity to present and discuss
clients with personality disorders with the Waterview
Service Manager.
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
40
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
The pilot design
In November 2010 funding was agreed for the
Waterview to provide two hours clinical supervision/
action learning sets for staff working across the rough
sleeping outreach and hostel teams. The sessions were
facilitated by the Waterview Manager (and Deputy
when available).
The outreach and hostel teams were invited to propose
clients with suspected or diagnosed personality disorder
who they thought it would be useful to discuss in this
forum and suggest workers interested in attending.
The sessions included two 45 minute presentations
and discussion of individual clients.
For each client a basic information sheet was
prepared to assist the staff in presenting cases,
and included the following:
•Basic information: age, DOB, gender
•Length of time working with client.
•Vignette to include: presenting
difficulties/problems/risks.
•Specific concerns or questions
Attendees and nominated clients were coordinated
by the WCC Rough Sleeping Team, prioritising ‘205’
clients (a priority group of the most long term rough
sleepers). In total 16 of the 24 clients presented were
long term entrenched rough sleepers in London, known
as ‘205’ clients. The discussion group could have up to
10 people attending.
Initially funding was for six sessions over three months
from January to March 11. Due to the initial success this
was extended for a further six sessions between March
and July 11. In total of 12 sessions were delivered over
the 6 month period, with 24 clients discussed. Each two
hour session cost £100 and the pilot to date has been
funded from an under spend in the PCT mental health
commissioning budget.
Case study: Waterview
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
41
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
Evaluation form feedback
Feedback was obtained through evaluation forms
completed at the end of each session, from nine out
of ten sessions (one session’s evaluations forms were
unobtainable). Attendance numbers are listed below
Findings – The relevance of the supervision
Scored as Excellent – 47
There were no scores of Not Good or Poor.
Scored as Good – 17
Total – 54
Key points learnt from the supervision experience
Some responses had one or two key points. Responses
listed participants increased knowledge on:
Session Attendance Numbers
1 8
2 9
3Rescheduled due to
facilitator sickness
4 5
5 6
6 6
7 8
8 8
9 4
Total Feedback Sheets 54
Boundary management and limit settings 12 responses
Increased knowledge on practical
interventions relevant to the client group.
12 responses
Discussion in relation to planning
interventions for clients (including
managing risk and behaviour)
12 responses
No comment 9 responses
Increased awareness on different
perspective relevant to client group.
6 responses
Importance of understanding impact this
work has on worker.
5 responses
Importance of supervision 3 responses
Understanding use of empathy 2 responses
Reinforced existing skills 2 responses
Case study: Waterview
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
42
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
Least beneficial aspects of supervision
There were 8 responses, stating:
“Diagnosis mentioned but left unexplained”
“Sometimes there is no better way to work
with these clients”
“Lack of background information presented
about a client brought back for discussion”
“Lack of preparation in presentation of client”
x 2 responses.
“Not knowing the service user”.
“I was late”.
“Too much information and not enough time”.
Most beneficial aspects of supervision
There were 35 responses that varied in range:
“Opportunity to share knowledge” x 13 responses
All aspects of the supervision was most beneficial”
x 6 responses
“Hands on approach to supervision” x 6 responses
“Clarity of supervisor” x 5 responses
Other comments were individual and included:
“Understanding the importance of boundaries”.
“JHT involvement”
(The mental health team for rough sleepers)
“Supportive and safe place”.
“Opportunity to follow up on a client”.
Case study: Waterview
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
43
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
Qualitative feedback on the pilot
design from key stakeholders
In addition to the evaluation forms, which related to
each session, qualitative feedback on the pilot design
(along with its evaluation and future design) was
requested from three key stakeholders who attended
the majority of sessions - managers from the mental
health team for rough sleepers and two outreach teams.
Their responses are listed below:
Case study: Waterview
sessions to hear about progress made with people
as a result of the discussions at these groups.
Tracey has a knack of unpacking diagnoses and
assumptions and opening up ideas and possibilities
for clients. Thank you for arranging these sessions
as they are invaluable.
I think these sessions are invaluable. The facilitator
has a way of making the sessions very safe and
asking just the right questions and she has amazing
expertise and understanding of the issues of the
clients and how they affect the staff. It tends to be
the same people who attend and that makes it a
solid group who can bounce ideas about and who
can report back developments about clients. On the
other hand it would be good to have other people
from the teams attending as I think everyone would
benefit from the shared experience and knowledge
imparted there. I know it’s not everyone's thing but
having an understanding of how clients may be
feeling and developing different approaches should
be in everyone's toolkit. Be good to embed it within
the teams. Perhaps we could have some of the
I have really enjoyed and benefited from attending
the groups. I'm sure the group over a longer period of
time will help to reduce "burn out", so I don't know if
sickness levels, concerns about staff performance or
retention of staff could be measured.
I think that one of the best ways to assess the
benefits of the pilot would be to speak to the
people who have presented, and to document the
advice given which would then input into clients’
action plans, and to assess whether that has helped
workers to engage more positively with their
clients, towards accessing services (including those
peripheral to accommodation) and/or maintaining
engagement with services and accommodation.
I could provide you with a couple of examples,
myself, and am sure that there are others, too.
Document Map
Introduction
Psychologically informed
Environments (PIE)
Five key areas
Case studies
Appendix
Psychologically informed services for homeless people
Good Practice Guide
44
Click to go to
PIEs at St Mungo’s
Stamford St Complex
Needs Unit –London
Borough of Lambeth
Waterview Personality
Disorder Case
Discussion Pilot
Evaluation – June 2011
Look Ahead Housing
Association
Developing St Basils
as a Psychologically
Informed Environment
Simple solutions
for complex needs –
an analytical social
care approach –
Brighter Futures
Two Saints Housing
Association
The Bristol Wellbeing
Service for people
who are homeless or
vulnerably housed
Proposed pilot extension
September 11 – March 2012
Given the positive feedback, it has been agreed
that the pilot will be extended to March 2012, with
modifications to the pilot design to respond to key
feedback points. Funding will be identified from the
WCC Rough Sleeping budget.
Case study: Waterview
I know that I have also used advice and techniques
gained in the sessions when doing client supervision
with members of my team, so there will also be a
trickle down effect. Again, I could probably come
up with some examples here, too, although not
necessarily any that have borne any fruit, yet.
Additionally, given the number of ‘emotionally
disturbed’ (if not psychiatrically unwell) clients
that we work with, having this space inevitably will
reduce burn out, and help retain more experienced
workers, but again, I don’t know how you would
document this, especially in the short term.
I think one way to improve the sessions would
be to clarify who should be attending (e.g. even
where a team does not have a specific client being
discussed, there is benefit in being part of the
group) to somehow create more accountability
with attendance, e.g. my impression is that
attendance from specific teams has dropped off
more recently, while JHT have started coming (and
this has been incredibly good for our joint working!)
In my opinion, this is the most valuable resource
we’ve had access to, and I think it will definitely help
our teams to work better, all around. And we’ve
definitely got more clients we would like to discuss.
I also think some sort of written record of the
sessions would be really helpful, for reference, but
am unsure of whether this would be appropriate or
not, give it is meant to be a confidential space…