The concept of a psychologically informed environment

Citation

Johnson, R. (2012), "The concept of a psychologically informed environment", Housing, Care and Support, Vol. 15 No. 2. https://doi.org/10.1108/hcs.2012.54615baa.001

The concept of a psychologically informed environment

Article Type: Editorial From: Housing, Care and Support, Volume 15, Issue 2

This, the second issue of the Housing, Care and Support journal for 2012, is a special issue, entirely given over to viewpoints and commentaries on operational guidance for homelessness services wishing to develop more “psychologically aware” ways of working, and to become “psychologically informed environments”.

In 2010, the Department of Communities and Local Government, which is responsible for homelessness policy in the UK, issued new guidance in conjunction with the National Mental Health Development Unit (CLG/NMHDU, 2010), to encourage the development of services that can recognise and respond constructively to the psychological and emotional needs of people who are homeless – those who have fallen through the various formal and informal “safety nets” that any society may offer to the vulnerable and disadvantaged.

This guidance document was accompanied by a wealth of statistics – mostly but not exclusively from developed Western nations, those with extensive welfare services – that indicated that a high proportion of those who become homeless, and a very high proportion of those who remain so, will have psychological difficulties and histories of trauma. In some cases these histories and their cumulative impact on the individuals are so extensive that, if seen by mental health services, they might well receive a psychiatric diagnosis, such as chronic post-traumatic stress disorder, or personality disorder.

But many are not in fact seen by such services; and their needs are met – if at all – by homelessness and settlement services. The need to bring together the perspectives and the respective strengths of homelessness and mental health services more effectively was one of the key themes of the guidance – with many examples cited of successful services doing so.

One such approach to this is the development of what the guide called psychologically informed environments, or PIEs, based on an original article (Johnson and Haigh, 2010). This suggestion was well received amongst homelessness “frontline” provider services in particular, as it attempted to put in words what the best of the services were already doing.

But many others asked for further, more detailed guidance on how they could go about developing as PIEs, and in response, in February 2012, the same team produced and distributed more detailed guidance (Keats et al., 2012) on the practicalities of developing PIEs, which was formally unveiled in April of that year at a joint conference of the National Housing Federation – the representative body for housing associations – and the NHS Confederation, representing health care providers.

PIEs in print

In this journal, we have seen references to PIEs before, in the article by Cockersell (2011) – himself one of the authors of the recent guidance[1] – and in papers by our sister journals in the Emerald Health & Social Care Collection (Cockersell, 2010; Johnson and Haigh, 2010, 2011a, b). The first issue of this journal of 2012 also included an article on PIEs (Haigh et al., 2012), describing the origins of the term and the underlying principles, in the context of new work being done to develop enabling environments in a range of settings, including the criminal justice system, hospital care, and community settings.

This last paper sets the development of PIEs in the context of the current revival of interest in therapeutic communities (TCs), and as part of the growing recognition within mental health circles of the need to develop more constructive responses to those who would have a diagnosis of personality disorder in, for example, the prison service. Yet it has also been argued that those seeking to find new ways to work with personality disorder would do well to look carefully at, and even learn from, some of the evolving best practice in homelessness services, working with the same needs.

Contributing articles

A number of agencies involved in this area of work, including those who helped develop the guidance, and some authors who have written on related themes for the journal in recent years, were invited to comment. Different commentators have tended to see different things in the ideas of PIEs; and there is no inevitable consistency between their responses. But this is no bad thing, if it may encourage readers to approach the actual guidance document itself with a questioning, open mind.

We would not wish to claim that this selection offers a representative sample of the views of all stakeholders in what is a very diverse sector. But the intention of this special issue is to stimulate further debate on the most effective way to meet the psychological and emotional needs – including a more international discourse on the problems that may underlie homelessness, and the demands on services.

The selection of commentaries begins with observations from Ian and Keith Walton, of the charity primhe – “primary care mental health and education” – who ask “why would we not want psychologically informed environments?” It is, they suggest “a no-brainer” (a question needing no thought to answer).

Yet it remains the case that there has been very little recognition to date of the degree of emotional intelligence, resilience and service sophistication required for this area of work; the task was seen as being of a largely practical or supervisory/custodial nature, with perhaps a little welfare rights advice and advocacy thrown in. Indeed, in the UK until recently, it was argued by funding agencies that homelessness services should only be providing low key counselling. Anything more demanding, apparently, should be referred to specialist services – which however, in many areas, simply did not exist, or did not engage with this client groups’ need.

Walton and Walton stress the need for services to gather better data on the outcomes they achieve. In fact, they suggest that a lack of attention to such data collection has been a significant weakness in the past, and argue that even some of the case studies cited in the guidance have very little to show – though this is an observation that other contributors to this issue would apparently contest. Be that as it may, it should be noted that in the PIEs guidance itself, there is a whole section devoted to the need both to gather evidence and to learn from evidence, as part of reflective practice, as well as for commissioners’ purposes. Services will need to be pro-active in adopting and even in developing the kind of data that more accurately reflects their real work and achievements.

Walton and Walton’s concern to stress gathering of evidence is also a timely reminder that the role of primary healthcare, in the UK at least, now covers commissioning of healthcare services, as well as direct provision. If general practitioners and other healthcare stakeholders wish to see such more PIE services, to tackle the client groups where we find the worst of health inequalities, they may need to use their influence to encourage commissioners to expect this of services; and provide the resources.

Nevertheless, Walton and Walton suggest, whilst PIEs might be particularly necessary in services for the most marginalized and excluded, this is simply “the tip of the iceberg”. We need to encourage such emotional intelligence in all services. The commissioners’ angle is so far rather under-represented in these papers – a perspective we may hopefully return to in future issues.

The commentary by Emilie Smeaton then provides us with an actual example of extending the principles behind PIEs into new areas, taking the same thinking, to apply it to young runaways. Smeaton’s comments on PIEs might be seen as a continuation of her article in the previous issue of this journal (Smeaton, 2012), in which she describes the emotional world of young runaways – their survivalist autonomy and resilience as well as their vulnerability – and argued that services need to be sensitive to both, if they are to re-engage young people successfully.

The next two articles – arguably two halves of the same article – then describe the efforts made by one local homelessness service, Second Step in Bristol, in the west of England, to develop a more Psychologically Informed Environment, initially via a pilot in one hostel, and later extending the same greater awareness into other areas of their service.

Aileen Edwards, Chief Executive of Second Step first describes their practical approach to development, with in-put from a healthcare professional. For their pilot service, Tollhouse Court, Second Step had approached a clinician, a psychologist working in local services; and their observation is that this initial in-put, drawing upon cognitive behavioural and dialectical techniques, helped them achieve a consistency in approach that they found valuable – just as the PIEs guidance recommends.

It is also noteworthy here that Edwards refers to the recognition of “transference” – the psychological mechanism first identified in psychoanalytic work by which the buried feelings of one individual may be projected onto and even expressed – in word or deed – by another. This eclectic blending of behavioural and more psychodynamic thinking may be emerging as one of the hallmarks of the uses of psychology in homelessness. The guidance itself suggested that there is no one correct or useful psychological framework, and the guidance mentions behavioural, psychodynamic and humanistic approaches as equally helpful. As we will see later, social psychology and sociology also have a lot to offer.

Edwards notes that engagement with their service helped to facilitate pathways into services, as well as out, towards independence. This may be an important point for commissioners and researchers to bear in mind, when collecting data and other evidence on the effectiveness of support services. The benefit of support may not be realised, in terms of “cash-able” cost savings, for many years in some cases; but may be no less real for that. Hence the importance of “in the round” stakeholder feedback in service development as well as in evaluation.

Pennie Blackburn then outlines the development of the Wellbeing service, which took the experience of developing the Tollhouse Court pilot service further, to inform a network of services. This article is a useful reminder that “an environment” does not always need to be a place, a building. One of the features of a PIE is that thought also needs to be given to the pathways, in, through and out of any one service, if we are to grasp what engagement means for any one individual in their own recovery journey. Blackburn’s paper also gives a nice example of the careful use of service use-derived data to inform future service development, just as the guidance document, and Walton's paper, suggests. Dr Blackburn then illustrates this development with the case study of one individual, here called Daniel, who has passed through the service. Appropriately enough, Daniel’s own comments on the groups he attended form a half of this piece.

Vic Rayner is the Chief Executive of SITRA, an organisation that provides training and consultancy to many services in the social housing and homelessness sector, and has worked closely with government in recent years to develop and promote best practice in this field. Rayner too echoes the concern for good quality data, to evidence successful outcomes; but is more optimistic about the prospects, having recently developed, for the UK Government, a programme of data collection – the common data framework – for housing support services (SITRA, 2012). Use of this framework is formally voluntary; but it is endorsed and highly recommended by the government department involved.

One of Rayner’s concerns, nevertheless, is the relative lack of reference to feedback from residents in planning services (and this is an issue which is also a concern for Annie Whelan, in her final paper in this collection). Furthermore, as she suggests, the inclusion of feedback from users re-asserts an element of “normalisation” in a development which otherwise may seem to be going off into some kind of technical specialism – an issue which Harrison’s commentary later also cautions against.

But her principal concern is for the likely impact of this guidance, granted the financial climate, and the “Age of Austerity” which has descended in the UK for all publicly-funded services, including those for the most vulnerable. Rayner notes the extent to which the additional guidance manages a careful balancing act – in complying with much current government philosophy in the development of services, whilst also reaching out to support the best practice in homelessness services that her own membership have described. But how far, she asks, can we really expect more of such services, when their own membership surveys indicate that many agencies are being forced to reduce their costs, and in consequence some are now employing staff on lower wages, with fewer relevant qualifications?

Equally concerned, though with a very different vocabulary, Christopher Scanlon and John Adlam apply the perspective they have gleaned from working in therapeutic communities (TCs), and subsequent consultancy practice with homelessness agencies. In fact, an earlier article by Adlam and Scanlon might be said to have originally sparked off one aspect of this discussion of the psychological and emotional impact of working with individuals with chaotic emotional lives, with an article in this journal on “the un-housed mind” (Scanlon and Adlam, 2006).

Here they update this original work, and subsequent papers exploring similar themes, with observations on the dynamics of homelessness services that are not working with shared emotional intelligence. They illustrate, from a systems psychodynamic perspective, the tensions that can arise when a workforce exposed to such demands does not have the opportunity to reflect on the experience, but instead may “act out” their reactions to these emotional demands, in various un-constructive ways.

For another more critical perspective, Tom Harrison, in his “PIEs, SPIEs and Homo SAPIENS”, questions the assumption that the key features to address, in a PIE, are essentially psychological, at least in the narrow sense of relating to individuals’ internal mental states, and the various individual remedies of psychotherapy, Cognitive Behavioural Therapy, etc. (which are now so identified with the term psychology that many assume that Improving Access to Psychological Therapy (IAPT) actually means Improving Access to Cognitive Behavioural Therapy (IACBT)). The need is to see the whole person as including their social relations, and work with those relationships.

Harrison has worked as a rehabilitation psychiatrist, and is currently researching the early history of the TC, when psychoanalytically trained medical staff first began to imagine the possibilities in using all the day-to-day interactions between patient and staff, patient and patient, as opportunities for personal growth and experiential, “social learning”, rather than simply relying on conventional therapeutic techniques and relationships. These early days of social psychiatry were a time of great experiment; and what was then called a “culture of enquiry”, which echoes contemporary calls for reflective practice as the key to the introduction of PIEs.

This is the spirit we need to rediscover, not just in homelessness but in the wider spheres of community mental health. As Harrison observes, our new commissioning cultures – and the paradoxical demand for an evidence base for innovation – have not always got this message. It may be worth re-emphasising at this point that the references to psychologically informed environments in the 2010 guidance were simply attempting to describe and recognise what the authors saw as already happening in the best of homelessness services.

We conclude with two further comments from workers who can relate this guidance to their own experience of developing frontline services and introducing awareness training. John Conolly’s article, co-written with Paul Ashton, in the 14.4 issue of this journal (Conolly and Ashton, 2011), has described with great honesty the steep learning curve for both parties in co-working between a staff member and a former service in developing groups for service users in a wet hostel.

Annie Whelan has extensive experience both of advocacy work, and of forensic mental health, including in the USA. Her observations therefore bring a somewhat more international perspective on the needs of people with complex needs – and the complexity of knitting services together to meet those needs more effectively. As she observes, the full extent of the “people skills” involved in such challenging work is often not properly recognised; and the two new guidance documents, taken together, may help to rectify this.

Between them, these papers offer an overview of the range of viewpoints expressed by contributors to the journal special issue and the operational guidance. They open a number of “critical friend” angles on the new guidance. Readers would of course need to refer to the original guidance document, as well as the earlier guidance on meeting the psychological and emotional needs of people who are homeless.

For any services in any particular setting wishing to become more psychologically aware, the guidance itself, sharpened hopefully by the observations of these contributors, is the best place to start. But, as the guidance insists, it is reflective practice that is the key to development of a psychologically aware service. The only way to truly understand what the concept of a PIE may mean, for any particular service, is to be one.

Internationalism and research on homelessness

The concept of a PIE, as an example of an enabling environment, may now be able to take the thinking and principles behind more enabling environments and into areas where the TC seemed less suited. There has been, over many years a quite international discourse over the nature, dynamics and effectiveness of the TC, as a treatment modality, on the understanding that human nature is universal, and treatments for mental health issues are therefore relatively culture-free.

Yet how far is the experience and the social meaning of homelessness variable according to climate, cultural beliefs and expectations, gross domestic product? Perhaps especially, how sensitive to social policy, funding frameworks, and the philosophical and philanthropic intentions behind welfare provision?

After all, to some extent the whole thrust behind the concept of a PIE is especially needed in the UK principally because for ten years service funding has assumed a clear divide between care needs, and healthcare needs, and support needs, which is a distinction that breaks down completely when we consider the psychological and emotional needs of those who have been, in the past, marginalized and largely excluded from mental health services.

How far can these concepts be as meaningful, as necessary, in countries where no such artificial divide was made – or where some other divide is made? How much will make sense in countries where there is no such development of services in the first place?

Similarly, with growing but still patchy recognition of the extent of complex trauma, personality disorder and other similar “failures to thrive” in the UK and the USA, how far can we expect these concerns to value this approach to reaching those most disengaged. How useful and how meaningful can it really be, to talk in terms of psychological needs, in countries where the principle motivation for philanthropic outreach is faith-based?

These and other concerns in the role of housing in the great debate on the social determinants of health housing will be a focus of future issues of the journal. For the present, we invite further responses to these ideas, from the UK, and elsewhere.

Note

1. As is, indeed, the editor of this journal and special issue; who was also one on the authors of the original CLG and NMHDU guidance from 2010, and of the paper in MHSI that first introduced the concept of a PIE.

Robin Johnson