‘Building psychological safety and managing risk through ‘relationships’ in a Psychologically Informed Environment (PIE)…’

17.09.2021: As I write this week’s PIE blog, as the lead for Psychologically Informed Environments (PIE), at the national youth homeless charity; Centrepoint, I am reflecting on a slightly unusual working week where I took a few hours off mid-week to celebrate my birthday with family and friends. At my age birthdays are often quite a low-key event, as I hardly want to be reminded that I am now most definitely middle aged(!) but it has got me thinking about the importance of marking significant points in our lives, particularly as over the past year or so with COVID-19, celebrations may have been a somewhat restricted occasion. However, for many of the homeless young people we work with, significant anniversaries, birthdays or dates may not be the immediate cause for celebration that they might be for us regardless of pandemic or post-pandemic restrictions. Rather, they can easily become a reminder of past negative or traumatic experiences that can be re-triggering and lead to increases in challenging behaviour or difficult emotions such as anxiety, depression or anger. Therefore, it can be important when working with and supporting vulnerable young people to not only be aware of the key events in their history but also to be considering in advance what additional support they may need around these key dates in the future. In other words, considering how we might take a ‘trauma informed’ or ‘psychologically informed’ approach to the support we offer.

Reflecting on this further this week, I was recalling the concept of ‘relational security’ that I first became aware of many years ago when working in forensic mental health services. This approach links to PIE or other trauma informed approaches because it highlights the importance of ‘relationships’ in working with others, including how we not only support them but also how we might manage risk in a positive or proactive manner as a result of this awareness. The concept of ‘relational security’ is outlined in detail in a document entitled ‘See Think Act’ prepared by the Royal College of Psychiatrists (2015) and is endorsed by the Care Quality Commission (CQC) who inspect services in the statutory sector (c.f. https://www.rcpsych.ac.uk/docs/default-source/improving-care/ccqi/quality-networks/secure-forensic/forensic-see-think-act-qnfmhs/sta_hndbk_2nded_web.pdf?sfvrsn=90e1fc26_4). However, I think the principles outlined in this approach equally apply to third sector organisations or charities such as Centrepoint, because we are utilising ‘relationships’ to bring out positive change with the homeless young people we support. Specifically, relational security is defined as ‘the knowledge and understanding we have of a patient and of the environment, and the translation of that information into appropriate responses and care. Relational security is not simply about having ‘a good relationship’ with a patient. Safe and effective relationships between staff and patients must be professional, therapeutic and purposeful, with understood limits. Limits enable staff to maintain their professional integrity and say ‘no’ when boundaries are being tested’ (p.5).

When we think about ‘security’ and how we keep the homeless young people we support (as well as our colleagues) safe, we often immediately think about the ‘physical security’ of a service or building (i.e. any locks, lone working personal alarms, CCTV or COVID-19 restrictions or rules). We might also think about the ‘procedural security’, for example the policies and procedures that we have to maintain the safe and secure running of a service or workplace. However, ‘relational security’ is the third piece in the security jigsaw, and considers how we use our knowledge and understanding of another individual to help them feel (psychologically) safe and secure. For many of the homeless young people we support, when they first come to Centrepoint, they may struggle to feel this sense of psychological safety as their lives to date have been littered with broken attachments or relationships with significant others, rejection and negative or traumatic experiences (e.g. abuse, neglect) occurring within relationships. However, unless we address all three aspects of security (i.e. physical, procedural and relational) and ensure all three are in place at all times in the services we offer then we are not offering a psychologically informed environment or PIE. Moreover, if we don’t it also effects our outcomes because it is less likely that both the homeless young people we support as well as the staff within the organisation can participate positively in our ‘offers’ and ‘be the best they can be’ because they don’t feel ‘safe’.

A consideration of ‘relational security’ within the workplace or our supported accommodation services requires us all to consider four main areas as highlighted in the picture of the ‘relational wheel’ at the start of this blog. Of course, we need to substitute the work ‘patient’ in the wheel for our population (i.e. homeless young person or even staff member), but I think many of the principles outlined are very translatable to the work we do within Centrepoint and within a PIE approach. For example, as noted by Keats et al (2012) in the PIE Good Practice Guide (c.f. https://eprints.soton.ac.uk/340022/1/Good%2520practice%2520guide%2520-%2520%2520Psychologically%2520informed%2520services%2520for%2520homeless%2520people%2520.pdf), the ‘definitive marker of a PIE is simply that, if asked why the unit is run in such and such as way, the staff would give an answer couched in terms of the emotional and psychological needs of the service users’ (p.5). In other words, the management of day-to-day services (including risk) considers the ‘relational’ aspects and not just ‘logistical or practical rationales, such as convenience, costs, or Health and Safety regulation’ (p.5).

So what does this look like in everyday practice? What do we need to be considering in terms of ‘relational security’ and how does this fit with birthdays and/or anniversaries? The first area is that of the ‘Team’ and covers areas such as the importance of having clear boundaries in our therapeutic relationships with the homeless young people we work with, as well as with our professional colleagues. The specific importance of professional boundaries in this work has been noted in a previous blog (see here: https://drhelenmiles.medium.com/staying-fabulous-maintaining-psychologically-informed-boundaries-in-professional-relationships-1dd03507e92c?source=your_stories_page-------------------------------------) but in essence they are critical to keeping everyone psychologically ‘safe’. As a result, we have a specific PIE module training session in Centrepoint just covering professional boundaries within our sector. The ‘team’ part of the ‘relational security wheel’ also covers therapy in its broadest sense. This is not just psychological therapy but any support or therapeutic intervention that is offered to someone we are working with. The key aspect here is that any action or care plans ‘should make it clear to patients what they need to do to move on. They should be hopeful but also realistic’ (p.8). Taking such an approach helps us to build positive professional relationships as it is ‘psychologically containing’ (as everyone is clear regarding expectations and goals) and can empower those we are supporting to make positive changes towards ‘a home and a job’.

The next part of ‘relational security’ considers ‘Other Patients’ or in Centrepoint’s case, the other homeless young people who are living within a supported accommodation service. The ‘home’ we are trying to create in a PIE is of course subject to constant changes and shifts. The dynamic between or mix of individual young people or within staff teams can be impacted by the arrival or departure of just one person, or even conversations between different young people or staff that we might not be aware of. This can be a challenge to consider in our day-to-day work but it is important that we do monitor and consider both the dynamics within the young person population but also within our staff teams as it can effect outcomes. This is certainly an area that commonly comes up for teams in reflective practice sessions as we reflect on recent incidents between different young people or we consider the impact of team dynamics on different staff. This is also an area that is worth considering in terms of risk management, including everything from which rooms a young person is allocated within a service to whether meditation or restorative justice approaches may be helpful when there might be an issue or a toxic dynamic between two individuals (staff or young people).

The third part of ‘relational security’ is the consideration of the ‘Inside World’. This involves us being aware of the other persons ‘personal world’ as well as the impact of the ‘physical environment’ upon this. Specifically, we know that how an individual feels inside their own head makes a big difference to how they may present externally in terms of their behaviour. It can also affect how well they engage in any support offered, how connected they feel to others and their ability to take responsibility for their own actions. This is where events such as birthdays, anniversaries or other triggers can be so important to understand. Luckily, I do not feel too depressed at getting another year older and I had well wishes, gifts and cards from those around me that I love and care for. However, as noted above, many of the homeless young people may have a different experience of a birthday or Christmas for example. This may be a significant trigger for anxious or depressive feelings, or even anger if they feel they have been ‘let down’ by others in the past. Therefore, external events can act as triggers for internal thoughts and feelings, which can then in turn lead to external reactions (e.g. challenging or other negative behaviours such as aggression, self-harm or substance use). As a result knowing the history of those we work with, can help us to understand how they feel and plan our support accordingly, in order that we can preempt what support they need, ‘nip in the bud’ any issues and help them to develop more adaptive coping strategies to manage in the future. This not only helps build our therapeutic relationship with them but also is part of a positive risk management approach as it reduces the change of risk incidents occurring.

Of course, in a PIE, the physical environment is acknowledged as important (see previous blogs on this such as here: https://drhelenmiles.medium.com/the-impact-of-our-physical-environment-on-our-psychological-well-being-a-psychologically-3ae63b740dd2) and this is highlighted within a ‘relational security’ approach too. We know that the physical environment has an impact on our sense of psychological well-being and safety, as well as the ability to manage risk. The importance of the physical environment in relational security however is more than just creating a ‘home’ or pleasant place to be. It is also about ensuring that the physical spaces where we work create opportunities for positive social engagement, allow safe monitoring of risk through clear observation lines, encourage those that use the space to care for and take pride in the environment, minimise noise and overcrowding and have space that allows access to fresh air. Physical spaces that are crowded, noisy or lack confidentiality can create tension, hostility and fear in those that use them resulting in a lack of psychological safety and an increase in the likelihood of risk incidents.

The final area of ‘relational security’ is that of the ‘Outside World’. Managing psychological safety and security also needs to consider the contact and relationships that an individual has with the outside or wider world. In the case of our homeless young people, do we know their social network? Is this network of external relationships prosocial and supportive, or is it placing them at risk or increasing the risk of anti-social behaviour (i.e. gang involvement, domestic violence)? Obviously, what is important is we promote positive and supportive external relationships rather than toxic or negative relationships that whilst perhaps appealing to that individual (because it is all they have known and something with a family member may be better than nothing) are not psychologically healthy in the longer term. We might also want to consider the impact of visitors to the service, not only in terms of the policies or procedures around this (e.g. visiting times, information provided beforehand, how we welcome them on arrival and monitor if appropriate their stay), but also the potential psychological impact upon the young person that are visiting or the other young people who are also living with the service.

Consequently, I think there is clear relevance of the concept of ‘relational security’ to a psychologically informed environment or PIE. Relationships in a PIE are the critical mechanism by which we bring about change and work together, whether we are staff or a homeless young person. The importance of firstly being willing to ‘see what is going on around you’ and then reflecting and thinking further ‘about what behaviour you observe might really mean’ is key. Having an awareness of the concept of ‘relational security’ is arguably just as important as the physical or procedural security awareness that we also need to cultivate. This might be something that is considered in supervision, team meetings or reflective practice sessions and then of course it is critical that this awareness leads to us ‘acting before something goes wrong’.

Our relationships with each other and the homeless young people we support are not just a ‘consequence’ of the work we do wherever we work within the organisation (i.e. ‘frontline’ or ‘support’) but are the ‘lever’ or ‘driver’ of it. In order that we continue our journey to be PIE at Centrepoint, maybe we can take a moment to reflect on these ‘relational security’ concepts further within our own area or workplace. For example, do we know what might be the significant events or anniversaries for our young people and our colleagues that might suggest that they need some extra support? Moreover, if these concepts are not in place, and we (or the young people we support) do not feel psychologically safe as a result, we may need to reflect on what we need to do to change this in the future. Whilst our leaders within the organisation may be extremely important in creating this culture, I would argue that we all have a responsibility within a PIE to influence this moving forward…

Consultant Clinical & Forensic Psychologist & Centrepoint Psychologically Informed Environment (PIE) Lead @orange_madbird