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Emerald Group Publishing Limited
Article Type: Editorial From: Housing, Care and Support, Volume 17, Issue 4.
The issue of homelessness has been a central theme for this journal over many years. When exploring the role of housing in health and wellbeing and exclusion, the extreme case – the lack of any home at all – is at the very least an obvious point of reference. But homelessness has also been a perennial concern of policy makers – partly as an issue to be tackled in practical policy, and partly for what it says of social pressures; but also perhaps more symbolically, as a measure of a civilised society, and a touchstone of a just societies’ responsibilities to its citizens.
Nevertheless, homelessness throws up many thorny questions for research to underpin practical action with an evidence base. Homelessness itself, as an issue, is multi-faceted, and multi-causal (Jones and Pleace, 2010), as indeed are most aspects of exclusion (Rosengard et al., 2007; Fahmy et al., 2009). As research subjects, we are concerned with a population that is mobile, transient, often disengaged and wary, and sometimes downright hostile towards society's interventions (Haigh, 2012). Meanwhile there is a complex web of agencies, funding streams and policies each doing their bit in trying to remedy the problem. But there is equally a web of agencies’ practices and policies that together contribute to the exclusion of some from our society (Cabinet Office, 2006).
It has therefore been a constant refrain in this journal's editorials that:
Human health is generally assumed to be largely as generic and universal as the human frame; but social and cultural forms vary widely. The physical fabric of housing, and the financial frameworks for both housing and care are both highly “socially constructed”. Identifying what works in housing for care and support, and for public health, has to be highly sensitive to circumstances and the broader cultural and social policy worlds in which we operate (Johnson, 2012).
Bernadette Pauly and her colleagues’ paper on “Approaches to evaluation of homelessness interventions” starts precisely here – with the importance of locating any attempts at evaluation within the socio-political context of the services being evaluated. For reliably transferable research and policy implications, they argue, any evaluations of particular practice must be suitably contextualised in terms of local policy and culture. In particular, they make the useful point that failure of a programme may not be a matter of blaming these delivering the programme, but rather, of taking examples of “good” or “evidence-based practice” out of context, and assuming they can be “rolled out” with comparable results in what may actually be a very different social and political context.
They illustrate this approach with a case study, based on work they were invited to undertake in evaluation of a new “transitional shelter”, an alternative to simple emergency intake provision, in one Canadian City. (For North America, it seems, such a development is an innovation, and needs therefore to establish evidence of effectiveness.) From this initial study, wanting to give their evaluation a sound methodological foundation, they then extrapolate useful general guidance on how a case study approach may shed the most useful light on understanding and then evaluating successful or unsuccessful outcomes from homelessness programmes.
Pauly et al. then note two primary approaches to an identification of the original nature of the problem, which will give any specific intervention its rationale, or “logic model” – a useful term not so far in widespread use in the sector. A logic model is a way of getting at the fundamental thinking that leads those intervening in any problematic phenomenon – or those commissioning interventions from others – to believe that their chosen form of intervention is likely to be effective (conference findings).
So, on the one hand, we often see a structural analysis, which identifies homelessness as primarily a social phenomenon, rooted in wider issues such as economic decline or disadvantage, housing supply, and other features. But on the other hand, we have individual-focused approaches, which seek the explanation of cases of homelessness in the characteristics of the more vulnerable, whether seen in terms of socio-demographic groups, of biographical features (i.e. adverse life events as triggers) or more explicitly pathological phenomena (medico-diagnostic such as trauma, or disorders).
The paper then makes the case for the value of case studies of homelessness programmes – here meaning primarily frontline services – as an approach with adequate sensitivity to such circumstances of social context – provided, however, they argue, that the study has some theoretical framework or logic model in mind, so that the case study can be read as a test of the applicability of this framework in a real world context, with all its inevitable complexities.
Whatever the structural stresses or particular biographical precipitants, most services that would actually call themselves homelessness programmes are working on achieving remedial change with the individuals who are their first concern. They are focused on effecting change for the individual, often in the individual; and measuring the changes for the specific individual – what we these days tend to call “outcomes”. All such services do need at times to pause to assess the effectiveness of their interventions. Yet we also do know that this is particularly difficult, in the light of the growing realisation (Prochaska and DiClemente, 1982; Seal, 2005; Johnsen and Teixeira, 2010) that personal change, especially for those with complex and often chronic needs, is a journey with many false starts and turnings, detours and rebounds, through all of which the involved worker must attempt to support their client towards their identified goals.
In human affairs, and especially with learnt, multi-faceted, entrenched and problematic behaviour, positive progress is rarely straightforwardly linear; the simple dose-response outcomes that are typical of medicine, for example, simply do not apply – although we should also note here that there is great interest currently in personalised medicine, that can reflect that fact that all patients are still individuals, and will vary. (The situation is made still more complex for both health and social policy evaluation by the fact that, outside the laboratory or the clinic, there is typically a far greater range of positive or negative contributing influences in the wilds of the social world.)
One of the most widely used tools developed in recent years has been the Outcomes Star – an individual-focused, “distance travelled” approach that nevertheless provides a coherent common framework for assessment. One great attraction of the Star is that it does allow individual service users, in dialogue with staff, to specify and prioritise their own goals – and for the agency worker to follow that path, even where the funders and the commissioned outcomes for the agency may be focused on a more narrow range.
The philosophical roots of this approach, in empowerment practice, were explored in an article in this journal, some years ago (MacKeith, 2010). But beyond philosophy and intentions, we still need to know that this evaluation tool does produce reliable data; and one question that bedevils all measurement tools that involve judgement, however, professional the judgement, is the question of rater reliability. In a field as inherent individual as personal change, and where neither the provider nor the recipient are disinterested participants, how far can staff assess objectively the progress of their own clients?
In our second paper, “Assessing the reliability of the outcomes star in research and practice”, Joy MacKeith and colleagues describe their own attempts to test the reliability of the measure itself, by comparing the scores given by different raters, given the same scenario, using one of their variants on the Star. (The Star model has the added benefit that it lends itself to adaptation to a range of specific client groups, by the addition or subtraction of axes to each star for issues that are more or less relevant to any particular client group, and the issues that are typically encountered.)
The scenario given is in fact a case study – a sample scenario as a cameo, written down with all its potential complexities, ambiguities and grey areas. But, by virtue of being in written form, this scenario is entirely replicable, and can be tried out on a range of disparate raters. MacKeith thus gives us a quite different use of a case study approach, as a testing ground for a chosen measurement tool.
Meanwhile, the choice of the family star in itself might be seen as a case study in evaluation of an evaluation tool, if this star is taken to be typical or indicative of others. This is here explored with some statistical method, as a pilot for a larger evaluation at a later stage – a pilot, therefore, for future work, as part of an on-going formative evaluation – and to be undertaken, they suggest, with providers and commissioners. Granted the inherent difficulty of any form of measurement and tool, this attempt at transparency and accountability is welcome; and we may hope it will spur further debate and similarly formative and collaborative approaches.
But before we leave the analysis of service evaluation and the tension between this individual-focused approach and more structural issues, we might pause to note one further angle to structural analysis of homelessness. The features of housing supply and economic circumstance are not the only structural features that can impact on the characteristics of those who find themselves driven to the brink of exclusion. We need also to recognise the focus and constraints – such as eligibility criteria – on health, social care and support services funding and policy which will also mean that some vulnerable groups are better or poorly served. These too are structural features.
As a middle ground, we have seen in recent years the emergence of public health and an epidemiological perspective to reconcile the structural features with the individual vulnerability. Social epidemiology, that is, recognises that the geography of the human world, and the concentration of some populations into locations such as a homelessness shelter, is principally a social construct, one produced by social processes, filters and pathways. Pragmatic concerns, from policy frameworks and cultural attitudes down to the minutiae of funding programmes, may provide the structural context, the “opportunity structures” (Ellaway and MacIntyre, 2004) in which particular programmes must operate. These are active filters; they create parts of the environment, which epidemiological analysis can illuminate. In this way we can aim for a marriage of structural and personal/pathological analyses, to understand the phenomenon – and there we have a potential new logic model, do something about it.
One way to identify a client group in a language that tries neither to locate all the problem in the individuals, nor to disregard their vulnerability entirely, is to speak of exclusion, and especially of multiple exclusion. In our third paper Louise Joly and her colleagues use the specific term MEH, to refer to Multiple Exclusion Homelessness – a term that is nicely poised between locating the core issues in the individual, and in the wider social and structural processes.
Note that Joly and colleagues also take a case study approach, though here not in assessing interventions, but in assessing the significance and value to the subject of informal social networks, for those in this client group. The case study aspect here consists in a comparison of three locations – an urban, a rural and a metropolitan population – with subjects identified and nominated by services in all three sites.
Joly et al. argue that in epidemiological research, issues of social capital have been seen principally as risk factor, through the additional vulnerability of those with a paucity or loss of such informal supports. In more practical terms, indicators of low social capital may then at best be conceived as warning signs, reasons to strengthen and prioritise preventive support work. Nevertheless, in the course of this study, Joly et al. looked at how far different agencies seemed able to work with these networks.
It is not uncommon for an unexpected finding – one un-mistakable common theme or statistical association that was not part of the study and not articulated in the theory – to be so evidently significant that the authors cannot pass up the opportunity to comment, for further research. Paradoxically, the findings that were not expected – the bonus points – are often then the most convincing, perhaps precisely because they were not the original focus of concern. Here, the observation from Joly et al. that some services seem better attuned to addressing and working with networks has obvious implications for commissioning of services working with MEH social networks.
Otherwise, this study is a useful reminder that, whatever the objective facts, homelessness service users do not in fact necessarily define themselves solely in terms of the service user identity, and that a wider range of other social roles and emotional repertoires, and even of desired outcomes, may be available, to be worked with (Dwyer et al., 2012).
The fact remains that many service “users” – and especially those deemed hard to “engage”, may see their lives from quite other perspectives also takes us on to the issue of the actual skills entailed in engaging those who – perhaps from past experience – may now be the most reluctant to engage. It is customary publishing practice to place book reviews at the back of a journal; and sometimes they may get barely a mention in an editorial. But there are times when the subject matter of a book is so germane to the issues in the published papers, that some comment really is needed, in the editorialising process. One such is Jay Levy's “Pre-treatment guide for homeless outreach and housing first”.
The issues that Levy addresses in this short book, reviewed here by Lynn Vickery, go to the heart of the issue – the centrality of trusting relationships; and here Levy stresses the power of narratives and the subtleties of engagement. Levy does not just assert, but shows by example the role of shared language in creating relationships. These cameos accounts are not merely anecdotal, for educational purposes; this approach can also be deeply rooted in a fully elaborated theoretical background – in this case, linguistic analysis and social constructionism – and in turn this approach can start to form the foundations of a new intermediate level theoretical vocabulary of more immediate use to the pragmatist in frontline services.
Lynn Vickery's review also notes that this whole discourse is still carefully located within the framework of the approach known as Housing First (HF) – which in recent years has amassed a very impressive body of evidence, so that it now it seems the predominant paradigm of research and policy in the USA. In talking of “pre-treatment” as against treatment, and whilst stressing and clearly illuminating the personal baggage of many homeless people, and the need to address this with great care, Levy is careful not to take issue with the argument that “treatment” must wait. Nevertheless, what he is advocating is, by implication, not something utterly different, but on the same spectrum – a precursor.
For this, it is hard to disagree, if by that term “treatment” we mean those rather narrowly circumscribed interventions of conventional health and psychology services, whose evidence base for effectiveness is largely derived from a far more settled and willingly engaged population. But we know that demanding compliance with doubtfully appropriate treatments is in effect to operate an exclusion policy – and one for which we can then handily blame the “hard to engage” client.
As Vickery observes, there does seem a natural affinity and common purpose between greater recognition of the relationship skills in outreach work, and greater recognition of the necessary skills in building-based work, in hostels, refuges and foyers, such as we have been seeing in the UK with the growth of interest in creating more “psychologically informed environments”, or PIEs. There is a clear need to bring together these two parallel or contrasting discourses of progressive practice, between the more established US focus in research on HF, and the more recent development, especially in the UK of interest in exactly how services such as hostels refuges, etc. can work constructively.
It is tempting at times to talk as if it is only the clients or “users” of services that are on a journey of discovery; but of course, it is not so. We may talk of training as a means to developing skills and awareness; but in real life, for most of us, it is learning by experience that is the principal learning journey. Although the value of lived experience cannot be assessed, as a specified, costed training programme might be, it can certainly be encourage and boosted. Indeed, in recent guidance on developing PIEs, it has been argued that reflective practice, especially at team level, is the golden road to developing more needs-sensitive services.
But when a few individuals in the practice community do get the opportunity to travel, to see and learn from what others are doing, the value is undeniable. Our next article, by Jo Prestidge, is explicitly an attempt to bridge these two worlds of US and UK practice; and is also a working example of how personal narratives can enliven a more theoretical discussion with vividness, honesty and reflection – without which no amount of research can really help us engage with.
“Using trauma-informed care to provide therapeutic support to homeless people with complex needs: a transatlantic search for an approach to engage the ‘non-engaging’” is Prestidge's account of her study tour of services in the USA, and it has much of the same vivacity that Vickery sees in Jay Levy's account. Prestidge, an experienced outreach worker who, by her own account, was becoming frustrated and disillusioned when some of her clients seemed particularly reluctant to engage, went to visit services in New York that have developed a model known as Trauma Informed Care (TIC).
This approach is so far relatively less well known this side of the Atlantic – though it clearly has many points in common with, for examples, the PIEs approach. Both grew out of a recognition of the prevalence of complex trauma in the lives and histories of those in entrenched homelessness. Both stress the centrality of forming relationships, and then designing and managing services with a recognition of what these needs mean, in practice.
“Marinated in violence: therapeutic intervention for victims of domestic abuse” is our last paper in this issue, and is similarly a narrative, by one of the great pioneers in the field. Erin Pizzey founded – almost by mistake, according to her account here – the first ever women's refuge network, in London in the 1970s. Pizzey is a true original; and her account – although here we describe it in more research language as a case study of development and action learning – must stand as a reminder that truly innovative work does not start with any evidence base, but with pressing needs.
Likewise innovation may not always arise from any well-developed theory, which tends to follow only long after the frenetic turmoil of learning from experience – what Schoen, the original theorist of reflective practice, called “knowledge in action”, in “The Swamp” (1995). In fact, in her other writings, Pizzey (2011) has been highly critical of those who approached such issues via a too theoretical – or ideological – lens. (There is a particular irony and paradox here, in that the very ideology that she adamantly rejected – marxist feminism –argued that that “correct” theory only comes from those in the teeth of “the struggle”; and Pizzey was certainly that.)
In the years since Pizzey's original work, there has been a huge change of heart within mental health circles, and it is no longer seen as appropriate, or even acceptable, for mental health services to simply shrug off the difficulties in living that many such people have, with the “dustbin diagnosis” of personality disorder. Now we are seeing new services attempting to engage and meet these chaotic needs, and something or a revival of the thinking behind post-war therapeutic community as a treatment modality well suited to this client group. It seems particularly then to hear again the testimonial and the unique voice of one of the great pioneers in creating the refuge movement.
In this context, one particular suggestion, derived from her extensive experience both of her own background in a violent family, and her work with women – and some men – who have been victims of their own and others’ violent histories, is the possible value of what she calls “therapeutic chaos” – the apparent need for services and for social and emotional environments they inhabit to have just the right amount of turmoil and disruption for disruptive individuals to be absorbed, their violence deflected and deflated, and some new more healing process to then come though.
It must be hard to confirm any such concepts or findings with anything like formal research. Rather than being the kind of case study with an explicit research-theoretical question to explore, as advocated by Pauly and her colleagues, we have the opposite end of the action learning spectrum. Is this, then, a research paper at all? Does it really belong in an academic journal? But this does not mean we can simply ignore that suggestion.
In the meantime, if the intention of research is to have impact – and if the intention of a publisher is to publish research with impact – it is essential that this is not all simply couched in a language and style that people in frontline work cannot relate to. We hope to see further papers in future from Ms Pizzey, now looking at the relevance of the Chiswick Womens’ Aid's iconoclastic dynamism to other models of social therapy, such as the therapeutic community, and other such positive or “enabling” environments.
Certainly we can now better recognise the havoc of past trauma in the genesis of personality disorder; and the extent to which contemporary psychology and neuroscience now endorses the view that recapitulated trauma may lie at the roots of some of DV. There is something important in Pizzey's account; and it is for the research community to see if it can ever hope to find what that is.
A double conclusion
The connections between housing and care and support needs, inclusion, wellbeing and public health affect all vulnerable populations; and sooner or later, that means all of us. Even within the specific area of homelessness, the range of possible perspectives and issues is wide – and all this without any established academic discipline to furnish a stream of research questions and keen young researchers, wanting to establish core frameworks and debates.
What, then, might we conclude, from such a wide range of papers, subjects and styles, about the state of research, and even the nature of research, on homelessness and especially of homelessness amongst those with highly complex needs? The first perhaps is the inevitable breadth of the field. Case studies, learning narratives and evaluations in homelessness form the core content of this issue, running through each of our papers, appearing a reappearing in many guises.
In the first, by Pauly and colleagues, we have seen the importance of context – in this case, in programme evaluation – and a useful reminder of the wider frameworks of policy and culture, as well as more objectively structural issues, impacting on any efforts expressed in terms of individual outcomes. With Mackeith's paper on the Outcomes Stars, we then get in depth into the intricacies of devising a measurement tool for assessing these essentially personal journeys. This is followed in a paper in the tradition of epidemiology as a marriage of structural and personal/pathological analyses, by Joly et al., with a more analytic study of working with social networks and MEH – evaluating here, that is, not services but un-met needs and un-tapped potential.
From here, with Jay Levy's work, as reviewed by Lynn Vickery, we move to an in depth look at the skills in engagement – a learning from the client philosophy – and the importance of appreciating personal narratives as a tool for understanding. Next, a narrative in its own right, with Jo Prstidge's account of her own journey – literally as well as metaphorically – to explore and learn from TIC services in New York, an example of the worker learning from others’ practice. Finally, with Erin Pizzey's account, we see the central role of the narratives and learning journeys of truly pioneering individuals, and a reminder of the importance, in a world dominated by evidence-based policy, of trailblazers, provocateurs, and simply learning from the needs of the situation.
Some years ago the UK Government decided to commission a comprehensive overview of research and knowledge in mental health that might inform future policy. This vast field was, for practicality, sub-divided into a number of specialist areas, and experts in each of these fields were asked to sum up the state of the art in their respective specialism. The resultant reports (Mental Capital and Well-Being Project, 2008a) highlight the great diversity of approaches to so complex an issue, with perspectives entirely at odds with each other nestled side by side in a compendium volume, like lions and antelopes in a contemporary zoo, separated only by barriers of habitual familiarity.
The elegantly written overall summary (Mental Capital and Well-Being Project, 2008b) was a masterpiece in covering over the methodological pluralism and ontological incoherence under the surface. But few people if any ever read the whole; preferring naturally to dip into those sections with state of the art of their own field. As a result each specialist can continue to believe and argue that their work is evidence-based, giving them greater confidence, and so encouraging further study and research, adding to the field. All's well that ends well.
What is good enough, and what works, for a country the size of the UK, and an issue as vast, pivotal and complex as mental health, is surely also good enough for a subject as vast as housing as a social determinant of health; and this may be the state of the art, at this point in time, and for journal of this nature.
For my part, as overall editor for the past four years, with 16 issues of such rich and varied content, I have decided that this must be enough. I have decided to stand down as overall Editor of the journal, after this last issue of 2014, to make time for other projects. Specifically, I mean to devote time and energy to increasing a more international discourse over society's response to homelessness – beginning with the new thinking on psychologically informed environments, to meet the complex needs of the multiple exclusion population; and especially through a new social enterprise that I and colleagues have created, by name of HomelessInsight (n.d.).
The project exists to showcase effective and innovative work, and to promote new research and evidence-generating practice, as advocated in the guidance on PIEs. As an on-line community, we will be able to put fellow travellers in contact with other, for practice exchange; and also to use to the full the range of functions that the web can offer, with video, webinars, and other inter-activity, which we are developing currently via the PIELink (n.d.).
This is not exactly a case of leaving the field, therefore. I intend to remain for a period as an adviser and occasional associate editor. Meanwhile, at the helm of this journal will come a new team, and doubtless another focus, balance or perspective; and we shall what course the journal may chart for the future. For a publisher, just as much as for a researcher, a provider or a member of the public, what's to come is still unsure.
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