Developing best practice in Psychologically Informed Environments

Paper type: Research paper


Background
This paper draws on a recent study that explores the needs of men who have had multiple moves within projects for people who are homeless.It aims to further the practical understanding of what makes a Psychologically Informed Environment (PIE).PIEs, in the United Kingdom (Johnson & Haigh, 2010;2012), or international alternatives that locate trauma and relationships at the heart of care, are at the forefront of best practice to "address the more severe psychological and emotional needs of those who are homeless" (Johnson, 2016, p. 1).
The central task of a PIE is "creating and managing supportive relationships and aspirations", thus enabling change (Johnson, 2016, p. 2).PIEs were conceived in the UK as part of the Royal College of Psychiatrists' Enabling Environments Initiative (Keats, Cockersell, Johnson & Maguire, 2012).Five key areas of PIEs are identified as "developing a psychological framework, the physical environment and social spaces, staff training and support, managing relationships and evaluation of outcomes" (p.2).
To date, little research has focused directly on the views of people experiencing homelessness, particularly the chronic end of this population, those seen in the context of multiple-exclusion homelessness (Bowpitt, Dwyer, Sundin and Weinstein, 2011), severe and multiple disadvantage (Bramley and Fitzpatrick, 2015), or complex needs.Bowpitt et al. (2011) explain the term Multiple Exclusion Homelessness (MEH) as referring to people experiencing homelessness who "suffer deep social exclusion often due to a combination of ongoing issues in their lives and non-engagement with, or exclusion from, effective contact with support services" (p.3).In recent years consideration has been given to how systems have historically failed these people.With the introduction of PIEs (Johnson & Haigh, 2010), recognition of the value of psychological contributions has increased in the field of homelessness, particularly MEH.This study aims to further our understanding of MEH, seeking to learn from experts by experience, asking them about their experiences with help in order to identify potential challenges and blocks.Greater understanding of the issues allows us to plan for them and respond with foresight, improving the working practices within PIEs, Specifically, it aims to further inform some of the key areas for consideration within a PIE, namely developing a psychological framework, staff training and support, and managing relationships (Keats et al., 2012).

Design
A qualitative study was undertaken in order to answer the research question 'What are the experiences of men who have had multiple moves within projects for people who are homeless?'To counter the common view of 'the homeless' as a homogenous, dehumanised and stigmatised group, an ideographic design was used to draw out the individuality, humanity and heterogeneity of people experiencing homelessness.This population was seen to represent a group who have struggled to access support, with multiple moves as evidence that settling in one place had been difficult.This study was undertaken as the major research component of a Clinical Psychology doctoral course.Ethical approval was granted for this study by the University of Hertfordshire Research Ethics Committee.Informed consent was obtained, confidentiality explained to participants and all information gathered was held securely, consistent with the Data Protection Act.To ensure the quality of the research, Yardley's (2008) criteria for qualitative research was followed throughout, including sensitivity to context, commitment and rigour.

Participants
Participants were recruited from hostels designed for those with additional needs.Criteria for inclusion included having moved between at least three different homeless projects.In line with the methodology, IPA, sample sizes of three to six is seen to provide a useful balance between collecting meaningful and manageable data (Smith, Flowers & Larkin, 2009).The final number of participants was decided based on the richness and detail of interview data collected.Six men, between the ages of thirty and fifty, were recruited from two hostels in London.These men reported experiences of homelessness ranging from 3 years to more than 20 years.Many of them also reported involvement with mental health, forensic and drug and alcohol services throughout this time, had spent time street sleeping and experienced evictions from hostels.
A service-user consultation was used to develop a semi-structured interview schedule.Following this, during November and December 2016, one-off in-depth interviews were undertaken with each participant.Areas of questioning started generally; asking participants to speak about themselves and how they came to be at the current hostel.Further exploration moved on to current and past experiences with hostels, asking about positive experiences and challenges, experiences of leaving hostels or moving on, and participants' thoughts and ideas about the future of services.Finally, participants were asked whether there was anything further about their experiences in hostels that had not been covered.

Analysis
An interpretative phenomenological method of analysis (IPA, Smith et al., 2009) was chosen due to its hermeneutic foundation and its phenomenological focus, privileging the lived experience of participants.In line with the idiographic nature of IPA, the following stages, explained in detail by Smith et al. (2009) were undertaken with each interview.Initially, interview recordings were listened to and transcripts read and reread in an attempt to be immersed in the participant's world.Once familiar with the material, initial notes were produced, using the descriptive, linguistic and conceptual frameworks described by Smith et al. (2009).After the whole transcript had been analysed, and notes had reached a point of saturation, themes were constructed and labelled.Connections were then sought across themes and super-ordinate themes were developed.A summary table of themes and quotes was developed to provide an audit trail of how themes were reached.This procedure was repeated for each individual interview.Finally, each analysis was considered in relation to the whole dataset, and a set of master themes that brought together, and best reflected, all the interviews was developed.These themes provide a framework through which to understand the experiences of men who have moved round hostels for people who are homeless.They are reported in a narrative account which forms the basis for the results section.

Results
Four master themes were constructed from the data analysis.These themes were Looking forward and the role of hope, Relationships to help, Identity and stigma, and Trauma and separateness, intimacy and connection.These master themes will now be discussed, together with supportive verbatim quotes.

Looking forward and the role of hope
This theme describes participants' mixed feelings about moving forward.On the one hand participants could express hope and positivity about the future, but on the other, also conveyed a sense of feeling stuck.
Five of the men spoke about their hopes for the future, but this was often in broad, vague terms.Participants expressed hopes, desires and often intentions to move forward, but the steps often felt unclear or unplanned.

I want to get out of here. I think my objective or motive is to get out of here now and that's what I'm gonna do my best to do... (Francis 1 )
Over time, problems seemed to increase, waning hope and making progression feel less possible.
When you overdo it you know you lose your course.You know you, you lose something; you lose something over the years as it goes on because like it builds up (Charles) There were also some expressions of hopelessness from the men and it was clear that moving forward was not experienced as an easy or straightforward process.This suggests that men who have experienced multiple moves round services have a complex relationship with hope and unclear or unstructured plans for the future.
Many of the participants spoke of the prevalence of trauma and loss in their lives.The multiple losses in their stories could be seen to leave hope as a fragile thing.
I had a lovely girlfriend, well she was taking drugs also and you know she ended up, well I left her and she ended up dying.(Erik) Layers of traumatic loss appeared to relate to the challenges identified in moving forward, either keeping the men looking backwards to the past, or doubting the possibilities of a positive future.

I haven't got enough hours to tell you how many people I lived with that have died through drugs. (Erik)
Many of the men spoke of the numbing effects of substance use, helping them manage traumas and losses from the past, as well as the contextual challenges of homelessness, whilst also acknowledging how it connects them to a less hopeful position.

That's why I drink, to block it out. To stop me going through that sort of pain, day in, day out, man. I can't do that man. I can't see my son, 'cos of me drinking, just one thing on top of another and you get, basically what you do is just fricking drink yourself to death. (Anthony)
Use of substances was related to use of services and moves around services.Whilst many of the men expressed an interest in reducing substance use, it was often described as an incredibly difficult task, and this sense of challenge also contributes to our understanding of the fragility of hope.

(It's) like one of those… when you go to the fun-fair on those spinning wheels and stuff like that. Hard to try and get off and when, when you get off it, you're spinning. (Charles)
This quote epitomises how substance use seemed to lessen a sense of control for participants.Charles talked about substance use speeding up time, futures rushing past without recognition.He also named the habituation of 'just going with it'.Charles explained that even once substances are discontinued, the world still spins.This shows how substance use could fuel multiple moves, and keep people stuck, through a sense of disconnection from 'normal' life, and an inability to plan or connect with thoughts of the future.This quote also highlights the vulnerability of a person once they manage to stop or reduce substance use, suggesting that this point may not end difficulties.
Looking forward and the role of hope encapsulates the mixed feelings for men who have moved multiple times round the homeless system; expressing desire to move forward, but appearing to lack the resources or appropriate support to do so.The findings suggested limitations for the men existed in perceiving, and working towards, a different future.

Relationships to help
This theme relates to the men's experiences of help, including the positive experiences that many of the men reported.It also speaks of their notions of conditionality of care, and how they have negotiated this, or how this has contributed to frequency of moves.Furthermore, it reflects some participants' experiences of a lack of help, and how this affected them.Finally, it included some of the challenges around perceptions of the temporary nature of the hostel system, frequent moves and no sense of permanence.Some of the men spoke about their experiences in previous hostels and how the provision of 'just the basics' meant that these were merely seen as a place to stay.These hostels were places through which the participants passed, without recognition of progress, and were contrasted with projects that offered more, demonstrating care and support.
So they (staff members) helped me… They were really supportive and then the other ones in other hostels really I just haven't been, it's just been somewhere literally for me to go and sleep at night.And somewhere to do drugs.I didn't try to better myself, engaging or anything.(Bradley) The social benefits of communal living were mentioned by some of the men.There was a suggestion that there were negative aspects to moving on that weren't often overtly acknowledged, in particular the horror of loneliness.
...the worst thing is loneliness, well who needs a 'isn't it a lovely flat' and you're sitting down all on your own.It's not a good feeling, yeah, and that's the reason why some people would rather be here, because in this hostel there is such a community, and it feels like, you know what I mean, there's someone around you and stuff.But, to put someone else out in the real wide world, to say, 'oh there's your keys ' and, it's like oh hell. (Doug) Participants communicated a fear of moving forward and a lack of confidence about taking next steps.Some of the men also talked about what they saw as the conditions attached to receiving help and how these linked to the multiple moves they experienced.

'Cos they see that I am engaging and everything I'm getting so much more help. I don't know if I would, I mean this is silly and I don't like putting the hostels down and that, but I don't think me personally if I didn't engage with what I was doing, I don't think they would help me. (Erik).
Anthony described why it was so hard to access help.He explained that the conditions expected of him felt unmanageable, particularly in relation to his past traumas and the associated pain.For him 'engaging' in the way expected did not feel achievable.

R: Why do you think you didn't take the help at that time? Cos I'm hurting, I still am. (Anthony)
Anthony spoke about how happy he was currently and how he would rather stay put, but he identifies that he has no control over this aspect of his future.The hostels have a limited time period that people can stay.

I don't mind even staying here for the rest of my life, you know what I mean, 'cos it's like a studio flat, that's the way I see it. Obviously it ain't gonna happen like that but, this is the best hostel I've been in. (Anthony)
Moves were frequent occurrences for the men.Bradley explained that the decision of when it is time to move can be made for you.
I've got X company come and see me on the 1st about moving on 'cos they say I'm ready to move, I'm not enjoying it.(Bradley) Some of the participants expressed a sense of being an inconvenience; that they couldn't stay anywhere too long, and that they could easily outstay their welcome.
I stayed there for a bit, but it was only meant to be for a little bit and obviously you know you've got, you can't stay in places too long, you've got to move on and sort yourself out and stuff.(Charles) Participants reported that the reasons for the limitations on people's stays weren't always made explicit, or the impact always considered.These implicit conditions appeared to create barriers to some people feeling 'at home'.There was a sense of always waiting to move on and not feeling safe or stable.Frequent moves were also identified as detrimental to developing relationships.
In Relationship to help it has been suggested that men who have had multiple moves experience the conditional nature of help as a factor in their trajectory round services.Participants reported some positive experiences of help in their current settings.It seemed that some men who have had multiple moves experience the impermanent nature of the hostel system as a contributory factor in their lack of stability.It was also reported that communication around moves was not always clear.

Identity and Stigma
This theme aims to capture the men's experiences of sense of self and identity.Participants reported being viewed in stigmatizing ways.Participants saw the negative perceptions of others as influencing the treatment and support they received.There was also reference to seeing themselves in negative ways, indicating internalisation of these perceptions.
Participants reported experiencing the attitude of services as critical and that this contributed to their 'disengagement' and to long-term homelessness.Eric describes that it was only very recently that he had had encounters with professionals where he had experienced respect and consistency.These encounters were profound for him and enabled him to begin to see himself in different ways.
... some of them they'll do it right, some do it wrong.But you know at the end of the day the ones that I met I'm glad I met them, because they're the first ones, the first like stone in the water and make the ripple.(Erik) Some of the men spoke of experiences of medical professionals treating them more negatively because of their homelessness.Bradley reported, that he was discharged prematurely from hospital.He believed that differential care was provided to him because it was discovered that he was living in a hostel and had an addiction history.
…when they find out you're an addict they treat you totally differently… (Bradley) It appeared that some of the men had accepted negative views of themselves, that they had internalised a lack of deservedness, viewing their healthcare needs as of less value or importance than that of others.
Identity and stigma has reflected on the differential and negative treatment that participants reported.It can be seen that this treatment led to the men 'disengaging' and feeling unable or unsupported to access help.It was also reported how these negative and stigmatizing views had been internalised, impacting on these men's sense of themselves.

Trauma and separateness, Intimacy and connection
This final theme aims to describe the ambivalent, fragile nature of relationships for the participants.All of the men spoke about relationships.Many gave examples of relational traumas, which had impacted on their capacity to trust and invest in future relationships.The experiences appeared to create a perception of intimate relationships as highly fragile, that the men dealt with in different ways.Many men reported keeping themselves at a distance.A fear and avoidance of intimacy can be seen to maintain a lack of stability and perpetuate multiple moves.
Many of the participants expressed a longing for positive, supportive relationships, highlighting the reciprocal nature of healing and the benefits of being connected.

When you are the state like I was in, an alcoholic, and depression, you need people that you can actually talk to. Cos if you're on your own ... you do silly things man, you slit your wrists or you might hurt someone else. (Anthony)
Despite the many relational challenges described, for some of the men, positive connections with others were shown to elicit positive responses.Erik explained that when people 'invested' in him, he felt a responsibility to 'step up'.

…that person might go out of their way, push that little bit extra which I do believe happened to me, yeah... And do you know that makes me, it's made me a different person because I'm getting more support. I feel good and I don't feel like I want to let them down because they've gone out their way to help me. (Erik)
Many of the men, within the context of the numerous traumas and losses highlighted, described fearing intimacy or avoiding it altogether.They reported ways of coping, or minimising the anticipated hurt, by keeping themselves separate.

I don't really get too close to people. You don't want to be alone, but you don't wanna get too close… familiarity breeds contempt. There's too many people might know your soft points innit… I don't like people knowing too much about me -if they know your weak points then they can play on it… I don't like to open up. (Doug)
This theme has demonstrated how participants' experiences of previous relational breakdowns, losses and traumas have created fear or trepidation regarding future intimacy.Many of the men reported avoiding intimacy as a strategy to keep them safe; however, it was acknowledged that this risked isolation and loneliness and the men movingly described their longing for connection.
The findings presented here bring to light factors that can make hope and progress complicated, problematic and at times untenable for men who have had multiple moves round the homeless system.A clear context of trauma is evidenced, impinging on hope, plans and the development of relationships.Help was presented as positive at times, but also could be lacking, discriminatory, conditional or temporary, demonstrating some of the many challenges these men are required to navigate in their search for safety.These findings will now be considered in the context of existing theory and literature and in relation to best practice within PIE.

Discussion
Whilst participants identified issues in the care they received it is essential that these findings are contextualised within the current social, political and economic context of austerity, cuts to services and increasing inequality.In their review on the impact of cuts to local government budgets Hastings, et al. (2015) found that cuts have and continue to "hit the poorest people and places the hardest" (p.26).Reports go some way to highlighting the extent of pronounced poverty and the impact of austerity on service provision in the UK, this should be held in mind to avoid locating the blame within professionals or services.The findings, however, do raise some important considerations for practice which will now be discussed.

Planning the future
In order these men to move on from their current situation it would require them to imagine a different life and see this alternative life as a true possibility.However, whilst hopes were expressed, and direction occasionally identified by these men, hopes tended to be fragile and plans general and unspecific.Focusing on a model of recovery can overlook that for these men there may not be a 'better' past to return to or even clearly imagine.Using a stages-of-change framework (Prochaska & DiClemente, 1983), participants in this study could be seen to be in pre-contemplative or contemplative stages, either not yet considering or beginning to consider change, but with little evidence of actively working on change at this time.In this context therapy needs to be adapted to the needs of the client group, being flexible, working within a context where substances are used and with an emphasis on building relationships.Cockersell (2011) demonstrated that for people experiencing homelessness who undertook therapy, movement from pre-contemplation to action was facilitated, providing evidence for the possibility that hope could be held within the system, even when it feels too fragile for service users.This can be linked to Weingarten's (2010) concept of reasonable hope.Reasonable hope refers to hoping for something attainable, the first step of many potential steps between individuals and their preferred lives.Within a PIE, therefore, best practice would remain mindful of the difficulty in even clearly conceiving a better future, let alone the steps required to get there.With people experiencing homelessness this would involve supporting the development of achievable, more temporally close goals, such as for the next hour, day or week.Whilst these would be informed by a broader direction, identified by the individual, staff would need to assist in mapping out individual steps on this journey.This suggests that training staff in approaches that work with goal setting in the here and now, and creating hope through relationships, would be useful in PIEs.It can be seen that there is also value in supporting staff, through supervision, reflective practice and complex case discussions, to consider what 'reasonable hope' looks like for these individuals, rather than what we, as professionals, perceive a 'better future' may be.

The relational nature of hope
This study demonstrated the need for greater scaffolding in regards to hope, including how a fragile hope can be sustained within the contexts of the lives of people experiencing homelessness.This would support one of the international concepts related to PIEs, namely pre-treatment (Levy, 2010;2013).Levy explained that progress "hinges on two people developing a trusting relationship and an effective communication that becomes goal centred, while always believing in the possible" (2013; p. ix).This model recognises the importance of a strong and trusting relationship, based in a shared language, to inform specific and focused goal-based action towards greater permanence.Within a PIE, best practice can be seen in professionals recognising the fragility of hope for many service users and maintaining hope, even when service users can not.It would involve continually looking to scaffold small, manageable, service-user led steps forward, celebrating each one of these achieved and reviewing and revising when steps go unmet rather than lose hope.

Conditions of help
A further finding of this study related to participants' perceptions of a conditionality to the help that they received.Previous studies have identified a similar sense of conditionality to care (e.g.Oudshoorn et al., 2013), whilst Thompson et al., (2004) framed this differently, as the necessity for 'willingness' from service users.This would support a view that the required compliance, proposed by those in the current study, could also be viewed by services as a need for 'engagement', locating the problem within the service user.However, seen through the lens of hope as conceptualised above, it could be argued that steps might need to be taken by services to provide security and containment, before 'engagement' becomes a real possibility for service-users.This supports the PIE value of placing relationships at the heart of the work and particularly for practitioners being mindful of not placing conditions on these relationships.
Multiple issues with impermanence were identified in this study.Firstly, moving often felt out of the participants' control, whether this was promoted as 'moving on' (forward) or not.Negative aspects of 'moving on' were highlighted, as were issues regarding who decides what 'moving on' means and when it occurs.It was suggested that impermanence was not overtly acknowledged, or helpfully managed within systems, leaving individuals feeling relationally or psychologically unsafe and abandoned or devalued.For people for whom trust is already fragile, from previous losses and relational traumas, this could feel particularly damaging.Participants felt that helpful services attempted to create a community; however, the temporary nature of this 'community' was seen by some to undermine its value.While some participants wanted to believe and invest in relationships, most acknowledged that a required departure always loomed on the horizon, meaning they held back.Explicit, or more often, implicit needs to move were identified as barriers to developing a 'home' and contributed to a lack of safety, and thus, at times, also 'engagement'.Other models, such as Fairweather Lodge, (see Bermingham, Manlick & Liu, 2015, for further information about these projects), promote alternative arrangements for developing interdependent living and community involvement.This highlights the need, within PIEs, to be explicit about time restrictions and limitations, to acknowledge and empathise with the impermanent nature of projects and explore the impact of this directly with clients.

Managing endings
For some of the participants in this study, 'moving on' from a hostel they saw as the most stable, safe and supportive place they had been in was not a desirable outcome, and could in fact be a daunting or overwhelming one.Within a context of therapeutic containment and support, endings within services appear highly significant.Many (2009) suggested that endings should be "controlled, predictable and paced" (p.23).Cognitive Analytic Therapy (CAT, Ryle, 1989) offers one useful example of providing better endings.In CAT the ending of therapy, and the feelings surrounding this, are used to explore unresolved endings and develop alternative ways of managing them.The number of sessions remaining is made explicit, and highlighted each week to enable planning and consideration.'Goodbye letters' are also a key component of how CAT manages endings, summarising work that has been undertaken during therapy, as well as issues that remain.It is a vehicle through which to identify potential future difficulties, reiterate progress made thus far and how this can be used to manage any setbacks.CAT is one example of a therapeutic model that would be useful when working with people experiencing homelessness and providing a structure for better endings that can be used beyond traditional therapy, for example by key workers.Within PIEs offering a good ending should be a priority with this population.

Developing sense of self through being heard
Finally, considering a sense of identity for those who experience homelessness, Williams and Stickley (2011) suggested that, whilst for the stably housed population identity is largely constructed in relation to family and occupation, for people experiencing homelessness identity can often be constructed in relation to substance use, 'illness' and exclusion.Hydén (2008) explained a commonly held view that "it is through creating ... narratives of our own lives that we come to develop and possess an identity and a sense ... of self" (p.37).Construction and reconstruction occurs, he suggests, through the telling of and listening to stories of self.For many of the participants in this study, there has been very little opportunity to speak and be heard, to be supported to develop a coherent sense of self, especially given the context of complex trauma histories.The negative identity conclusions described by the men have significant implications for hope, engagement with services and a sense of self that can move forward.Within a PIE, a space to be heard, without judgement, is imperative to co-constructing a coherent, preferred, sense of identity.

Service development
The findings of this study point towards the importance of creating secure and containing environments; of facilitating trusting relationships where beginnings and endings are thoughtfully managed and communication is clear and inclusive; where spaces are created to share life stories and experiences, including histories of trauma, allowing for the co-creation of preferred identity; and where moving on is broken down into small and attainable steps.All of these endeavours demonstrate practical approaches to building and developing a PIE.These are challenging areas for staff to work in.Therefore, it is also important to consider how best to support teams in creating and sustaining such environments for service users.Reflective practice and complex case discussion can be seen to support teams in many of these areas.Staff reflective practice has been widely demonstrated to increase staff wellbeing and improve outcomes for service users (e.g.Hargreaves, 1997).Kurtz (2005) found that reflection was particularly useful for staff working with people with complex presentations, as is the case when supporting people experiencing homelessness.A philosophy of reflective practice underpins PIEs and this study strongly supports this as a practice and a philosophy to support processing emotional aspects of the work, whilst also advocating for the value of complex case discussions and formulations to support staff and inform client work.Clinical psychologists have been identified as "potential leaders in this work" (Heneghan, Wright & Watson, 2014, p. 324).

Strengths of the study
The strengths of this study can be seen as its qualitative, idiographic design, enabling us to learn directly from users of services.The researchers were separate from services (non-affiliated, no dual roles).Validity criteria were met and demonstrated using Yardley's (2008) framework and suggestions for clinical implications span across professions and theoretical models.

Limitations of the study
The sample size of this study could be considered a limitation; however, the methodology used, IPA, encourages smaller sample sizes to allow for richer data and analysis.The danger can be seen, when researching in this area, particularly when looking at individuals, of minimising the context, moving the blame from an individual to a service or provider.This is not the intention of the researchers, and it is hoped that these findings are viewed in the context of the overt current financial challenges we are working in.Finally, it should be recognised that those who agreed to be interviewed may reflect the least 'hard to reach' of a 'hard to reach' population.

Future research
This study shows the value of listening to experts by experience.It is hoped that future research takes this further so that any subsequent guidance is truly informed but the voice of the people using services.Positive examples of this include participatory and peer research.Further research could also look at staff's views and experiences of the themes identified here.The role of reflective practice, including complex case discussions, has been highlighted here and it may be useful to investigate this further, particularly, querying how this can best work in the current context of austerity and challenges to staffing, such as zero hour contracts.Women's experiences of homelessness and multiple moves around projects would be a further area of study.As Clinical Psychologists we join a small section of our profession in advocating a role within the homelessness sector.It may be that this role can be developed in collaboration with the wider PIE community, and whilst it may involve some direct individual work, there are many other potential avenues for contribution here, for example working with staff teams, research and advocating with commissioners.