‘‘Doing with, not doing to’: A psychologically informed reflection on involving homeless young people in everything we do’.
12.11.2021: As I write this week’s PIE blog, as the lead for Psychologically Informed Environments (PIE), at the national youth homeless charity; Centrepoint, I wanted to take a further opportunity to highlight the importance of working with not just for the homeless young people that our organisation supports. In particular, the importance of keeping the young people experiencing homelessness at the centre of our work, even if our usual day to day roles don’t explicitly involve directly working with them. As a Clinical (and Forensic Psychologist) much of my training and experience to date consisted of working directly with a client at the ‘micro’ level, to assess, formulate and treat any specific mental health (or forensic) issues that they were presenting with and requiring help or support for in order to bring about positive change. However, since I joined Centrepoint, for the first time in my career I no longer work directly with the ‘client’. Instead as part of the PIE team, we are working at the ‘macro’ level or working with the wider system to effect positive change for clients instead. What this means in practice, is that it is our role to support our amazing frontline staff to work with the homeless young people (and our support staff who work behind the scenes to support them), through staff training, reflective practice, improvements to the physical environment and evaluations of ‘what works’ (i.e. the four key ‘ingredients’ of a PIE — see Keats et al, 2012). Nevertheless, although I rarely physically sit down in a room with a homeless young person these days, it is important that they remain central to all that we do within our PIE and/or anything else at Centrepoint through the creation of ‘co-production’ opportunities whenever possible.
Co-production is essentially ‘doing with’ rather than ‘doing to’ and ensures that decision-making power is shared appropriately amongst all stakeholders, not just those who traditionally hold the power or may have the loudest voices. For example, when our PIE was first developed back in mid-2019, we involved homeless young people (as well as staff) in its development through this co-production process. Our self-titled ‘PIEineers’ were brilliant in ensuring that our PIE placed our homeless young people at the centre of everything we proposed and have subsequently delivered. Examples of their contributions include utilising their stories / ideas within our PIE day training exercises (e.g. the ‘Attachment String’), as well as within our PIE strategic vision, incorporating their ideas into our criteria and process for changes to the physical environment, devising interview questions for the PIE team as well as input into some of our internal / external PIE communications. Importantly, it ensures that our PIE met the specific needs of our population (see a previous blog here: https://drhelenmiles.medium.com/the-pieineers-co-production-in-a-psychologically-informed-environment-pie-c82c86ae33a9 and here: https://drhelenmiles.medium.com/a-co-produced-conversation-about-pie-1f03ff760fba for further discussion of the ‘PIEineers’).
So why is it important to utilise co-production within a PIE? Of course, firstly, this is because ensuring that the ‘end users’ voice (in this case a homeless young person) is heard throughout the process ensures that the ‘end product’ is fit for purpose and meets the needs of those that need to utilise it. When services are set up, change initiatives like PIE are developed or research is undertaken to highlight an issue in order to campaign for policy change, without all key stakeholders being involved, the chance of something being impactful and/or actually working can be significantly reduced. Sadly, many aspects of services set up to help vulnerable people, even when they are developed with the best will or intentions in the world, can miss the mark and fail to have positive outcomes if those people that need to access them are not consulted in the development phase. I can remember in a previous role trying to set up a psychology group intervention for young offenders to support them with their transition to prison. Although we identified a high need for this intervention, initial take up was disappointing. However, after feedback from the target population (i.e. the young people) highlighted the stigma and shame of attending an ‘anxiety’ group in the mental health wing (and thereby admitting mental health issues), a simple rebrand / name change and a shift of delivery location from healthcare to the workshop block resulted in significantly higher participation and positive outcomes (c.f. Miles et al, 2012; https://www.tandfonline.com/doi/abs/10.1080/14789949.2012.719535).
Secondly, the process of co-production can be extremely empowering and positive for those engaging in it (e.g. see Mayer et al, 2017; https://onlinelibrary.wiley.com/doi/abs/10.1111/hsc.12418). Rather than being told what someone might need, the process of asking someone for their opinion (which is then included alongside any professional expertise or evidence base), can enable participants to take responsibility, build self-confidence / self-esteem and increase skills that can then be transferred to other contexts. For many of our homeless young people they may not be used to being heard and therefore may doubt that they are of worth or value. Creating space for them to speak as ‘experts by experience’ can enable them to view themselves differently. It can challenge their negative core beliefs about themselves and for them to perhaps reframe their past negative experiences of homelessness into something positive. They can see themselves as ‘survivors’ whose past experiences have not only given them an important perspective on the issues of youth homelessness but can be of benefit to others if they share their story as part of their own healing and recovery from trauma. This is why the Centrepoint featuring the voices of youth homelessness through their ‘real stories’ series is so important (c.f. see here for examples: https://centrepoint.org.uk/youth-homelessness/real-stories/). I am extremely proud that some of our original PIEineers have subsequently developed the confidence to subsequently go on to work in other co-production roles within Centrepoint, including the brilliant ‘Point Made’ podcast (c.f. https://pointmade.buzzsprout.com/) as well as work as Peer Researchers for our policy and research team (c.f. https://centrepoint.org.uk/media/5009/d235-uc-peer-research-report-a4-v5-screen-singles.pdf).
Of course, not all homeless young people want or are able to share their stories or contribute in co-production activities and even if they do, not all of them want to be publically visible when doing so. Therefore, whilst we can encourage as many young people as possible to get involved, any refusal must be understood and respected. For some of our homeless young people, their time at Centrepoint marks a turning point in their life that once they move on from they want to forget about. For others, it might not be the right time yet as they are still processing and recovering from their experience of homelessness. For some others, they may want to make a more anonymous contribution, for fear of publically speaking out due to perhaps the circumstances surrounding their homelessness (e.g. fleeing from a violent relationship or past gang involvement) or online attacks from less sympathetic members of the general population. This means that we need to be flexible in how we co-produce and work with the homeless young people in Centrepoint, and offer a range of possible options.
For example, perhaps it is enough for them to contribute to the design or upgrading of their physical environment in their local service through sharing their ideas in a residents meeting. Maybe their contribution might directly link to a skill or interest that they have, such as art or design, as our homeless young people in Manchester have done within our Oldham Street refurbishment project (c.f. see previous blog here: https://drhelenmiles.medium.com/co-producing-the-physical-spaces-in-a-psychologically-informed-environment-changing-the-story-9fbb7c74bfb5) or through the creation of a mural in another hostel (see the picture above for this blog). However, other homeless young people may want to share their stories as part of their own recovery and/or in order to help others, or they may want to get involved in our campaigning or research work. The key is to ask but not to pressure. Consent to involvement in any co-production activities must be informed.
Finally, in order that we remain psychologically informed in our co-production work, it remains important that we consider what support we offer a homeless young person who is willing to get involved. This may include how we provide compensation for their time and contributions. Those of us that are employed within the homeless sector, whilst we may feel passionate about and dedicated towards our roles, do not provide our expertise or work for free. If we do not, why should we expect our ‘experts by experience’ to do the same? It is co-production not exploitation after all. Of course, the reward may not always be monetary (especially if a one off payment could jeopardise a homeless young persons’ longer-term entitlement to benefits), but we can be creative in order to provide meaningful rewards that are appropriate to the co-production work undertaken. For example, for our PIEineers we offered lunch and travel expenses as well as advice and support about how they could apply the skills / knowledge they were learning within the PIEineers sessions to college course(s) and/or add to their CV to increase their future employment prospects.
Moreover, we should remain mindful of the emotional impact of co-production on our homeless young people. I am acutely aware from years of delivering individual or group psychology intervention(s) of how sometimes merely just talking about past traumatic experiences can in and of itself be re-traumatising. As a result, we need to be mindful about the impact upon homeless young people if they get involved in co-production work, whether this is telling their story, and/or undertaking campaigning or research work within the area of youth homelessness. As noted above, the impact of co-production can be positive, but it can also be difficult, emotionally challenging, triggering and painful. We cannot assume that just because they are willing to engage in this work that the process of undertaking it will be easy. It is important to remember that they may need support from their keyworker / other staff within the organisation; they may decide that it is too much and dropout half way through or they may need to access further specialist mental health support as part of the process. Therefore, organisational support structures need to be considered carefully and put in place to provide this support if needed. For example, our PIE team, just as we support the paid staff in Centrepoint, are also on hand to offer support through reflective practice sessions for homeless young people involved in co-production work with the charity.
In summary, ‘doing with’ not ‘doing to’ is a key part of developing a psychologically informed environment approach that will have the highest likelihood of positive outcomes. It ensures that we keep the homeless young person at the heart of everything we do, even if as in the case of the PIE team, the majority of our daily work is not concerned with directly working with homeless young people. Every decision we make as an organisation needs to keep this focus on the homeless young people within our minds, and involve them where possible to hear their voices. I am therefore excited about future proposed developments in Centrepoint around ‘Young People Influencers’ that take co-production and young person involvement to the next level. If we are to #endyouthhomelessness by 2037, then we need to remember to keep homeless young people front and centre of everything we do, even if like our PIE team, we are not directly working with them in our daily role.