Improving multiple exclusion homelessness (MEH) services: frontline worker responses to insecure attachment styles

Nikoletta Theodorou (Institute for Social Policy, Housing, Equalities Research, Heriot Watt University, Edinburgh, UK)
Sarah Johnsen (Institute for Social Policy, Housing, Equalities Research, Heriot Watt University, Edinburgh, UK)
Beth Watts (Institute for Social Policy, Housing, Equalities Research, Heriot Watt University, Edinburgh, UK)
Adam Burley (Department of Psychotherapy, NHS Lothian, Edinburgh, UK)

The Journal of Mental Health Training, Education and Practice

ISSN: 1755-6228

Article publication date: 25 August 2021

Issue publication date: 6 October 2021




This study aims to examine the emotional and cognitive responses of frontline homelessness service support staff to the highly insecure attachment styles (AS) exhibited by people experiencing multiple exclusion homelessness (MEH), that is, a combination of homelessness and other forms of deep social exclusion.


Focus groups were conducted with frontline staff (N = 19) in four homelessness support services in Scotland. Hypothetical case vignettes depicting four insecure AS (enmeshed, fearful, withdrawn and angry-dismissive) were used to facilitate discussions. Data is analysed thematically.


Service users with AS characterised by high anxiety (enmeshed or fearful) often evoked feelings of compassion in staff. Their openness to accepting help led to more effective interactions between staff and service users. However, the high ambivalence and at times overdependence associated with these AS placed staff at risk of study-related stress and exhaustion. Avoidant service users (withdrawn or angry-dismissive) evoked feelings of frustration in staff. Their high need for self-reliance and defensive attitudes were experienced as hostile and dismissing. This often led to job dissatisfaction and acted as a barrier to staff engagement, leaving this group more likely to “fall through the net” of support.


Existing literature describes challenges that support staff encounter when attempting to engage with people experiencing MEH, but provides little insight into the causes or consequences of “difficult” interactions. This study suggests that an attachment-informed approach to care can promote more constructive engagement between staff and service users in the homelessness sector.



Theodorou, N., Johnsen, S., Watts, B. and Burley, A. (2021), "Improving multiple exclusion homelessness (MEH) services: frontline worker responses to insecure attachment styles", The Journal of Mental Health Training, Education and Practice, Vol. 16 No. 6, pp. 421-432.



Emerald Publishing Limited

Copyright © 2021, Nikoletta Theodorou, Sarah Johnsen, Beth Watts and Adam Burley


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Recent research has documented a significant overlap in experiences of homelessness with other domains of deep social exclusion, highlighting the complexity of needs faced by those at the sharpest end of society (Fitzpatrick et al., 2013). Building upon this research, this paper focusses on individuals with experience of multiple exclusion homelessness (MEH), wherein “homelessness” encompasses the experience of temporary/unsuitable accommodation, as well as sleeping rough and “multiple exclusion” refers to the experience of one or more of the following alongside homelessness: “institutional care” (prison, local authority care, psychiatric hospitals or wards); “substance misuse” (drug problems and alcohol problems) or participation in “street culture activities” (begging, street drinking, “survival” shoplifting or sex work) (Fitzpatrick et al., 2011, p. 502).

Individuals with experience of MEH are often labelled as “difficult to engage” and “care avoidant” given their failure to comply with the behavioural requirements of mainstream services (Dwyer and Somerville, 2011; Klop et al., 2018). They often “fall through the gaps” in the provision, failing to attend appointments, being deemed “not ready” or too “chaotic” to benefit from mental health services or too volatile to commit to an addiction recovery plan, for example (Patterson et al., 2013). Many are repeatedly excluded from temporary accommodation schemes for what is described as disruptive behaviour or non-engagement, thus perpetuating a cycle of repeat homelessness (Homeless Link, 2015).

The challenge that such individuals present for support services, and especially frontline staff faced with what can be very challenging behaviour to engage with on a regular basis, are now widely recognised within the homelessness and allied sectors (Clinks, Drug Scope, Homeless Link and Mind, 2009; Waegemakers and Lane, 2019). The need to respond more effectively to the needs of this group has also been acknowledged at the national level within the UK context (Clinks, Drug Scope, Homeless Link and Mind, 2009). The recent ascendance of more explicitly person-centred and flexible support models, such as Psychologically Informed Environments (PIE) and Housing Firstly, is indicative of active attempts to respond more effectively to this population (Mackie et al., 2019). Allied with this has been increased cognisance of the effect of the quality and nature of the relationship between individual staff members and not only clients on user engagement and outcomes (Seager, 2011) but also the potential toll that working with this client group can take on staff given reports of vicarious traumatisation, stress and burnout (Waegemakers and Lane, 2016).

Core to these developments is increased recognition of the impact of trauma, catalysed by evidence indicating that the challenges this population present maybe attributed at least in part to the high levels of adversity they have experienced in early life. Adverse childhood experiences (ACEs) are disproportionality reported by individuals with experience of MEH in adulthood (Fitzpatrick et al., 2013), compromising individuals’ ability to seek and engage with care (Hopper et al., 2010). In a series of well-designed studies, ACEs have been shown to present a significant risk for poor mental and physical health in adulthood, problematic attachment to others, personality disorders, higher substance and suicide rates (Roos et al., 2013). High prevalence of insecure attachments in adult populations who report histories of childhood adversity have been reported in both clinical and non-clinical samples (Stovall-McClough and Cloitre, 2006; Arikan et al., 2016).

Highly relevant here is the concept of attachment style (AS), which refers to an enduring internal model of self and others developed in early years that guides interpersonal behaviour, information processing and strategies used to maintain a sense of felt security when under stress in early and later life (Hazan and Shaver, 1987). Attachment theory was initially conceptualised by Bowlby in the late 1960s and describes the instinctual disposition for proximity to prime caregivers in pursuance of survival. In brief, the theory explains the need of the individual to seek support from others for emotional regulation and for minimising the impact of stress in times of threat (Bowlby, 1973). Although there is a wide divergence in measures and categories of AS, the theory is based upon a two-dimensional model which distinguishes between secure and insecure attachment. Insecure styles are further subdivided and accordingly conceptualised into those examining developmental and psychodynamic aspects and those stemming from the social psychology tradition. This study draws upon a fourfold classification, whilst taking into consideration new perspectives examining adult support capacity. Two anxious styles (Enmeshed or Fearful), and two avoidant styles (Angry-dismissive or withdrawn), as well as those dual/disorganised and those secure, are identified. The angry-dismissive allows for some elaboration in terms of a hostile-independent style and a dual classification is applied based on the presence of two simultaneous insecure styles (Bifulco et al., 2002).

Perhaps surprisingly given that there is a substantial literature advocating attachment theory-based models in mental health (Berry and Drake, 2010; Adshead and Aiyegbusi, 2014) and forensic settings (Barber et al., 2006), the homelessness sector’s engagement with the concept has been extremely limited to date (Cockersell, 2011). Indeed, there are very few studies exploring the AS of homeless individuals and these are primarily focussed on causal and risk factors for homelessness linked to AS rather than on AS effects on service interaction (Stefanidis et al., 1992; Taylor-Seehafer et al., 2008).

A recent contribution to this literature was an exploratory mixed method study conducted by the lead author (Theodorou, 2020), which involved 30 individuals with experience of MEH in Scotland. This assessed participants’ AS, degree of insecurity, quality of the support context and ability to access support in times of need through a standardised AS interview (ASI) (Bifulco et al., 2002), which considers their actual engagement in support seeking. The vast majority of participants displayed a markedly insecure AS (N = 26) which entails a high risk in psychopathology (Bifulco et al., 2006) and the dual/disorganised AS was the most prevalent pattern (N = 22), with other styles identified including (4 = Fearful, 2 = Enmeshed, 2 = Withdrawn). Qualitative analyses revealed that attachment processes limited the capacity for healthy functioning, whilst also being an important influence upon interactions between frontline staff and service users.

Given the documented prevalence of service users who might score highly on measures of insecure attachment and supporting evidence that associated behaviours often make it difficult for support staff to understand and respond constructively to service users’ interpersonal needs, this paper draws on focus groups with homelessness service staff to consider their cognitive and emotional responses to service users through an attachment lens and reflects on the implications for service design and delivery. It argues that an “attachment-informed” approach may offer substantial potential in helping services meet the needs of some of the most disadvantaged members of the homeless population, not only by helping them avoid being drawn into potentially counter-productive interactions but also equipping them to promote more constructive engagement and relationships with insecurely attached clients. Study methods are outlined below prior to a detailed discussion of study findings, limitations and suggested areas for further research.


Study design

This paper reports findings from one element of the earlier mentioned exploratory study (Theodorou, 2020), this being a series of qualitative focus groups with frontline support staff who work with people with experience of MEH. Data is collected in four case study services in two Scottish (UK) cities. These included drop-in and street outreach services, chosen because they are typical of those supporting MEH populations in Scotland. Each had a direct access service hub offering advice on housing and welfare benefits, support and information to those who are homeless or at risk of homelessness and an assertive outreach service providing support to those currently experiencing homelessness. Two also provided crisis or longer stay (up to six months) residential units. Each placed a similarly low level of behavioural demands on users, offered similar types of support/casework and targeted the same client group.

Staff members were purposively sampled and invited to participate in the study (n = 19, including 6 men and 13 women). To facilitate comparisons amongst groups, participants were recruited on the basis of homogeneity in regard to their job titles as support workers or support practitioners. Criteria for participation were as follows:

  • Their role involved regular direct interaction with people experiencing MEH; and

  • They had at least one year prior experience of working with this client group.

In practice, the tasks that such individuals were involved in included a combination of case management planning, crisis intervention, signposting, provision of guidance and advice on housing, employment and training options, advocacy and assistance with health care and rehabilitation.

The nature of frontline work in these types of services and the imperative of ensuring that staff coverage “on the floor” was not compromised dictated that each focus group involved a small number of participants (n = 6, 5, 4 and 4). All sessions were audio-recorded with participants’ permission and transcribed verbatim.

Procedure and materials

Focus groups were conducted using a semi-structured topic guide and vignettes – short hypothetical scenarios intended to elicit responses to common situations – were used to focus and structure the conversations. The content of the vignettes was informed by existing literature, previous research on AS in adulthood (Bifulco et al., 2002, 2008) and the lead author’s professional experience of working as a practitioner with the population of interest. Internal validity was assessed by sharing and discussing those vignettes with an expert psychologist in the homelessness field. The utilisation of uniform vignette scenarios across all case study services enabled consistent comparison of staff reactions.

Each vignette outlined a case exhibiting behaviours typically associated with a different insecure AS (enmeshed, fearful, withdrawn and angry-dismissive) and were gender and age-diverse [n = 3 men, n = 1 female, indicative of the gender balance of this population (Fitzpatrick et al., 2013)]. Each style has a characteristic trait that was emphasised in each scenario. The fearful style is primarily characterised by a fear of rejection, the enmeshed style by a fear of separation, the angry-dismissive style by increased anger and frustration and the withdrawn style by high self-reliance and high constraints on closeness. All constructed cases were characterised by high insecurity (marked inability to make and maintain relationships) to vividly reflect the reality of people’s lives when in crisis and distress and depicted challenging behaviours commonly encountered by homelessness service staff.

Vignettes were presented to all focus group participants in a plainly written form and described verbally. No reference to AS was made. Discussions lasted 50–70 min and for each vignette, participants were given an opportunity to reflect freely on the issues the case presented before then being asked a series of questions to prompt discussion. The following four questions were used:

  1. What is your understanding of the ways in which this person relates to the services?

  2. How would you engage or interact with them and why?

  3. What do you think would be the major challenges for you as someone trying to work with this individual?

  4. How does this sort of behaviour make you feel?

The data was analysed using thematic analysis, a theoretically flexible approach to analysing qualitative data (Braun and Clarke, 2006), which allows the researcher to combine the systematic element of the analysis of the frequency of codes with the analysis of their meaning in context.


Ethical approval for the study was obtained from Heriot-Watt University’s School of Energy, Geosciences, Infrastructure and Society Research Ethics Committee.


Analysis of the discussions indicated that service users’ specific AS tended to elicit distinct responses from staff members, and that these, in turn, affected their capacity to connect with service users, the nature of support and level of care offered and which groups of service users were perceived as the most difficult to work with. Discussions highlighted a number of behaviours that routinely arose in frontline services supporting MEH people (such as avoidance or sudden shifts from co-operation to rejection) which although commonly occurring and anticipated by staff members were incredibly challenging to deal with. Working with individuals experiencing high rates of powerlessness, emotional turmoil and hopelessness produced considerable work-related stress and anxiety, often leading to emotional exhaustion, frustration and diminished feelings of self-efficacy amongst frontline staff. The following subsections discuss staff members’ understandings of and reactions to each of the insecure AS considered. This is followed by reflections regarding the impact of such interactions on staff well-being.

Withdrawn attachment style

Vignette 1 described a female service user who has been sleeping rough for almost half a year. Her withdrawn AS was reflected in her high guard, suspicion and social distancing from staff members. She presents at the services on an almost daily basis using the basic facilities as someone who appears to know what she is doing and often minimises her problems. She exhibits high-self-reliance and a strong desire for privacy.

Defensive avoidance and high self-reliance were perceived by practitioner participants as key barriers for such clients to engage with services and make a transition off the streets. Staff members argued that service users who were assessed as withdrawn ones appeared to be more likely to fall through the net and ran the risk of being dismissed, given their reluctance to express needs, seek support and/or interact with staff. Practitioners suggested that this group’s presentation of self-sufficiency and associated disinclination to vocalise their needs openly restricted their likelihood of accessing support: “I think that people like her often get missed because of the work and the clients that are more like ‘I need help’”.

Participants argued that the risk of being drawn into a particular dynamic with avoidant coping patterns, thus “downplaying” the attachment needs of their service users, was high as follows:

I would find it hard to work with her. In a situation like this it is a shame and all but it is also a shame for everyone. And the service is there, if that lady is prepared to take the help then hopefully she can.

They may, thus “neglect” such service users’ needs as long as those remain unexpressed. Inadvertently, this neglect may form a re-enactment of the very early neglect that gave rise to the AS in the first place (Levy, 1998).

A lot of people might go “I can’t engage with her” because it makes them feel uncomfortable because she does not want to talk to you. There are other women that they will shout in your face and you know exactly what they want. It is kind of easier to work with them because it is obvious what you can do for them. Where when you got someone that is like a wall, there is nothing on it:

Service providers noted that “remaining interested” in the relationship with those service users and articulating this in a way that would not risk “pushing them further away”, could be challenging:

I would find it harder to work with her than with somebody who was in and has a burst of anger or some kind of emotion, she seems as if the emotions are so hacked in that it will be very hard.

Angry-dismissive attachment style

This vignette described a male service user in his 50 s that has been homeless for more than a decade. He often exhibited anti-social behaviour towards staff members and this led to the loss of accommodation numerous times:

When asked about his housing situation, he states that he does not need any support or help with it. Staff members describe him as volatile, with poor impulse control, and consider him a loner.

This style results from the subdivision of the avoidance category into withdrawn-avoidant and angry-dismissive. It is differentiated from the withdrawn one on the basis that is characterised by angry avoidance of others.

Participants explained that angry-dismissive individuals exhibited more often behaviours that can lead to active exclusion (i.e. being asked to leave). They reflected on the extreme challenge of engaging with those clients. The often unstable, rapid changes of mood and behaviour traits of angry-dismissive individuals represented significant barriers to “staying” in relationship with them. “People think that they are challenging those clients by saying no. Well, actually the biggest challenge is to be nice to them”. Their expression of intimidating and hostile attitudes when combined with distancing and avoidant strategies posed significant barriers for developing and maintaining relationships with staff. “In a way, I see this as a form of engagement in itself, they still come out of their way to abuse you, it is more a translating issue”.

It was further suggested that individuals who tend to exhibit hostile and dismissing attitudes were particularly vulnerable in times of psychological distress. In particular, staff members discussed how those individuals do not seek help when needed, but rather may approach services only when all other alternatives have been eliminated. Seeking support only when most at risk severely compromised their recovery, especially when enduring mental health and addictions were present:

I think a lot of the time the guys will shout for help when things are right at rock bottom and it tends to be a lot of health issues […] Sometimes it takes that crisis for them to actually engage, but having the trust in seeing you every day, they may know that they can go ‘Can you help me?’.

Enmeshed attachment style

Vignette 3 depicted a male service user who has been in and out of temporary accommodation for two years. The service user is well-known to most staff members, is very vocal about his past traumatic experiences and staff members described him “as someone that they tend to spend a lot of time with offering emotional support”. He seems to be in a state of helplessness very often, needing reassurance during appointments but has a “push-pull” stance towards support over time.

Frontline workers described how these individuals initially appear to be easier to work with as they tend to be eager to respond positively towards support, keen to openly discuss their personal worries and difficulties, whilst presenting themselves as needy and dependent. They thus reported feeling more able to engage and empathise deeply with this type of behaviour than they did behaviours associated with avoidant styles (see below):

They will tell you an awful lot in detail and it’s a lot to take in sometimes. The most positive thing is that the person is engaging, where the other guys that we are discussing they didn’t really engage […] that makes our job a wee bit manageable.

Workers described being inclined to attend to the emotional needs of these apparently fragile individuals, as they tend to evoke feelings of compassion and sadness more often than do avoidant individuals:

It sounds like a child in some ways, how would a child know where to go… how to speak to somebody in a service […] it might be frightening. They are lost, overwhelmed and scared

Many of the participants reported feeling that working with these clients elicits gentleness, high attentiveness to their needs, consistency and patience. This presents a danger of staff members feeling quickly exhausted. For instance, some participants commented on the length of the support required by such individuals (often years) and questioned whether they may have inadvertently encouraged further dependency, rather than assisting the individual in developing ways of coping independently:

I have a client like this that he is quite needy and when he initially presents, he looks very vulnerable. He makes you feel you want to save him but you have to be really careful if you keep doing this.

Fearful attachment style

This vignette described a young homeless male with mental health problems and experiences of childhood trauma. The client “uses crisis services rarely and when he does, he is visibly distressed”. Occasionally he engages with staff members and appears to do well but then he disappears again for prolonged periods of time. Staff described him as distrustful, very vulnerable and “at times open to discuss not only his difficulties but also “shaky” and kind of frightened when doing so”.

Practitioners focussed primarily on these service users’ fear of engagement in the face of a potential disappointment. Those individuals were deemed to be highly vulnerable and often desperate for but concomitantly phobic of support. Staff highlighted the challenge of providing care with consistency without “scaring off” the service user. “When you offer help, you may push the client further or you can bring the client closer. This is quite an anxiety provoking for us; finding where exactly you stand”.

Overall, the AS was understood as leading to behaviours that were anxiety driven and having high emotional variability (i.e. showing ambivalence or approach-avoidance). Service users’ conflicting attitudes combined with their unpredictability was often confusing for staff.

I keep thinking that this is just a child and again about the engaging and non-engagement stuff […] I am thinking he would obviously trigger all kinds of feelings. If he disappears and then he is engaging, we would think why is he not engaging? So, there is still some level of engagement. An extreme side. Only on his terms, because he is engaging as he pleases.

Practitioners reported that a typical behaviour entailed demanding urgent same-day appointments but then not turning up. A significant challenge for staff was to be able to align their own personal expectations with a client’s processes. The need to provide support at any time and as required, even if the client was pulling away when help was given, was described as being exhausting by practitioners. Professionals discussed that when working with ambivalent individuals, increased tolerance to anxiety, intensified emotions and uncertainty was necessary to be able to respond appropriately:

You can get sucked into […] the behaviour and the cycles and fear and sometimes with certain individuals, it is like feeding the monster […] I think that you may end up containing a lot of the emotion.

Impact on support staff well-being

Frontline staff perceived their relationships with service users as the primary “vehicle” for fostering positive change in clients’ lives. However, as suggested above, supporting individuals with complex trauma histories who continually present with challenging behaviours and provoke difficult encounters generates a high emotional burden for staff. They reported that their inner resources are often pushed to the limits, leading to burnout, vicarious traumatisation and/or diminished feelings of personal accomplishment. These impacts must be borne in mind by service providers and commissioners given the impacts on individual staff members’ well-being and implications for staff turnover in a context where “relationships matter” (Petrovich et al., 2020).

Staff members perceived their work with service users who might score highly on measures of insecure attachment, as being primarily psychological in nature, due to daily exposure to mental health issues, addictions and trauma. As noted, working with highly enmeshed and fearful individuals necessitated an increased capacity to endure uncertainty and intensified emotions. “I am just thinking about the effects that hearing about the trauma can have. I think we totally underestimate the effect it has on us”. Avoidant individuals on the other hand often evoke feelings of frustration, exhaustion and disappointment after multiple attempts to assist have been rejected. Such clients’ needs are not always obvious to staff who may fail to understand their patterns of relating, with the outcome that participants sometimes felt inadequate in their role.

These findings indicate that understanding AS and their impact on staff experiences offer substantial potential for the alleviation of the psychological burden that staff bear. The degree of perceived difficulty, sensitivity and responsiveness to distress and complexity of need appears to differ based on the length of professional experience and the personal characteristics of staff. Although all staff is exposed to severe levels of trauma, more experienced practitioners in this line of work may normalise certain behaviours and become desensitised to the challenges and horror of people’s circumstances. These findings further confirm that under constant exposure to trauma, practitioners’ empathy levels for their clients can be reduced, compassion fatigue levels can be increased and any previous unresolved personal experiences of trauma may be severely heightened (Howell, 2012).

Implications and recommendations for practice

The analysis presented above indicates that there is substantial value in taking AS into account in the day-to-day operation of low threshold support services, not least because they remain the main contact points over prolonged periods for most people with histories of complex trauma and multiple exclusion. Study findings indicate compellingly that an understanding of AS and their influence on staff-client interactions can provide a tool for staff to determine how to most effectively develop and maintain useful relationships with these individuals. Perhaps, most importantly and as noted by Dozier and Barnet (1994) in other service contexts, such an understanding can help staff avoid being “drawn into” interactions that are not only emotionally draining for staff but also may prove counter-productive overall because they reconfirm service users’ existing working models, expectations and beliefs. Within a caring relationship, certain behaviours and dynamics are strongly enacted in unintentional ways for highly traumatised individuals that can affect the personal and relational capacities for effective contact (Levy, 1998). When working with traumatised service users, the risk of reenactment is highly prominent and its result can be affectively detrimental to both parties. An important tool of intervention, amongst others, is acknowledging the importance of the relational histories of service users.

In practical terms, previous research has indicated that dismissive and avoidant service users may benefit from interactions that encourage them to verbalise their needs through a stance of ongoing support, exploration and curiosity (Berry and Drake, 2010). In addition, highly enmeshed individuals can benefit from encouraging their autonomy and enhancing their ability to cope with anxiety and uncertainty. When overwhelmed by emotions they may benefit from approaches which minimise the focus on emotional distress, provide regular but brief contact and avoid offering constant reassurance. Sensitive and appropriate responses to distress, consistency and continuity of input and flexibility are considered to be key in proactively engage such clients in support (Bucci et al., 2015). Professionals do, however, need to be able to “decipher” service users’ responses to increase engagement and tolerate uncertainty when encountering all these AS, which is why an appreciation of attachment has the potential to be so beneficial.

Study findings confirm that setting professional boundaries, dealing with stressful events and difficult emotions or simply working with service users who may seem difficult to relate to can be emotionally draining and lead to feelings of hopelessness, disappointment, irritability or defensiveness for staff. Service providers must understand, indeed expect, that frontline staff members will have their own triggers, hotspots and stressors which can be activated, re-surfaced and re-enacted within their work. Greater awareness of trauma and related behaviours through training, regular supervision and reflective practice can partly mitigate such difficulties (Maguire et al., 2009). For instance, weekly reflective practice sessions may help staff to make changes in the way they interact with service users, experiment with different responses, reflect upon one’s states of mind and vocalise tensions around their role and practice.

A fundamental challenge though is to prepare the whole service to foster more effective engagement practices that are cognisant of and able to respond positively to the complexity and apparent “chaos” that service users may display. This study indicates that an “attachment-informed” approach may offer substantial potential in helping services, such that prior to any form of psychological intervention practitioners would aim to establish a secure base that is characterised by psychological contact, empathic responses, regular and flexible meetings and an acceptance of service users’ psychological state of readiness. This approach can provide a potential whole-service philosophy that would complement existing approaches adopted increasingly widely across the homeless sector. Sharing common ground with the PIE approach, for example, an attachment perspective might offer more explicit and concrete practical guidance by allowing staff to identify and evaluate service users’ AS and degree of insecurity and thereby “predict” and respond to potential problems in day-to-day interactions. Such an approach offers substantial potential to increase the palatability of support to individuals with experience of MEH who would otherwise actively avoid or reject it. To increase validity and ensure that the reliability and variability of individual differences are adequately reflected, attachment interviews should ideally be conducted by professionals on the basis of prior training.

These findings emphasise that the ongoing and dynamic nature of the relationship between staff members and service users is critical. It facilitates the establishment of a stable contact and offers a vehicle for change and empowerment. Findings also suggest that having an expert psychologist on site coordinating reflective practices and establishing a “drop-in counselling intervention” within services may offer the reprieve from the high demands currently made of frontline practitioners. Doing so would also go some way to countering inadequacies in the provision of mental health support for people with experience of MEH (Bramley et al., 2015), given that existing provision tends to be based on short-term and often behavioural-focussed counselling provision and uses inflexible admission requirements. This study reiterates the need to shift attention away from the unproductive focus on the “difficult” service user and use of fixed entry criteria, towards investment in more proactive and flexible interventions that meet the psychological needs of some of society’s most disadvantaged individuals. Finally, as in any relational model, staff supervision and skilled reflective staff groups are integral components of services’ day-to-day work. The study indicates that staff needs to be supported in reconciling their roles as active helpers and reflective practitioners for countering the stressors of working with multiply excluded individuals.

Limitations of the study and future research

Whilst this study highlights the substantial value of greater attention to an attachment within this policy field, it is important to be aware of its limitations. The small sample size limits the reliability of conclusions and the claims that can be made from the data. Future research could replicate at a larger scale and vary the gender/age of vignette cases to test in more detail whether factors other than AS impact on staff response. Furthermore, future studies might valuably consider including moderate and/or more complex (e.g. dual) styles of relating.

Information regarding participants’ educational backgrounds was not collected. Future research might valuably assess practitioners’ backgrounds as this may influence their perceptions. Further to this, including mental health specialists who support homeless individuals will assist in proving a more complete picture of staff members’ affective and cognitive responses.

Vignettes described hypothetical scenarios and each AS was represented as accurately as possible, with input from an expert psychologist specialising in homelessness. Standardisation of vignette presentation with contributions from a panel of experts might improve vignettes’ internal validity and allow for more rigorous inferences to be drawn. Including multiple reviewers blind to the precise methodological nature of the study should further address any validity concerns.

Future research might also consider assessing the AS of staff members, given other evidence suggesting that staff perceptions towards service users’ behaviours may be influenced by their own AS (Berry et al., 2008). For instance, practitioners with an avoidant style are reported to be more likely to perceive highly insecure service users as “difficult” to work with, whilst anxiously attached staff may be more prone to be compulsive caregivers in their daily practice (Barber et al., 2006). Furthermore, staff members’ AS have been related to difficulties in empathising with others (Britton and Fuendeling, 2005); anxious or avoidant staff may be less insightful concerning service users’ needs, whilst their responses to work stress may differ altogether. It would be interesting to investigate correlations between professionals’ AS and approaches to service users, as they may be influential in the development of more effective staff and service user relationships by making staff more attuned to their own reactions and potential biases.


The authors would like to express their sincere gratitude because of the study participants who share their thoughts and experiences. This work was supported by the Scottish Graduate School of Social Science – Collaborative Scholarship (grand number 1857521) and Streetwork at Simon Community Scotland under the collaborative scholarship award. This publication was further supported by UK Research and Innovation.


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Corresponding author

Nikoletta Theodorou can be contacted at:

About the authors

Nikoletta Theodorou is based at Institute for Social Policy, Housing, Equalities Research, Heriot Watt University, Edinburgh, UK.

Sarah Johnsen is based at Institute for Social Policy, Housing, Equalities Research, Heriot Watt University, Edinburgh, UK.

Beth Watts is based at Institute for Social Policy, Housing, Equalities Research, Heriot Watt University, Edinburgh, UK.

Adam Burley is based at the Department of Psychotherapy, NHS Lothian, Edinburgh, UK.

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