‘Embracing ‘complexity’ — A psychologically informed approach…’

11.06.2021: As I reflect on the past week for this PIE blog as the Lead for Psychologically Informed Environments (PIE) at the national youth homeless charity: Centrepoint, it has been a busy week as is typical after a short break for half-term. However, it has also been very rewarding because I have had the pleasure of spending much of this week visiting our supported accommodation services to facilitate reflective practice sessions for our ‘frontline’ staff teams. This part of my role is something I enjoy the most because it enables me to connect with our amazing frontline staff as well as ensuring that I continue to appreciate and understand the ongoing complex challenges of their work. These reflective practice sessions also have an important function for our staff as the sessions give them some space and time out from the usual state of ‘do … do … do’ to a place of ‘do … think … do’. Thus, reflective practice sessions can create a chance to have a short break from the constant pressure of supporting very vulnerable homeless young people in the UK. These sessions also create a psychologically safe and confidential space for them to voice and reflect on the inevitable emotional impact of this often challenging work. This week, I have been reminded of the challenges as one of the reoccurring themes in our sessions across different teams has been the ‘complexity’ of their work. Therefore, for this blog I wanted to spent a moment reflecting on this to highlight what a psychologically informed approach can do to help or assist.

The word ‘complex’ means ‘consisting of many different and connected parts’ (Oxford English Dictionary, 2021). In our modern worlds, we are used to complexity, and we regularly operate within many different systems and roles in our lives in order to navigate many different competing demands. In other words, complexity is ‘normal’ for humans! Our personal and indeed professional worlds are often very ‘complex’. However, in my experience of working in mental health and forensic settings over the past two decades, I have seen the word ‘complex’ being inferred as something that is ‘negative’ rather than normal. For example, an individual referred to a service might be described as ‘too complex’ to be offered help and treatment by this service as they don’t easily fit into a narrowly defined set of referral criteria or a ‘care pathway’ in order to be able to access what is on offer. Conversely, the term may be used to describe why someone has failed to benefit from a particular intervention, thus locating the failure in that individual rather than perhaps the fact that the intervention was not the right one at that time, or perhaps there were systemic barriers to them successfully engaging and benefiting from it. This is of course why Centrepoint’s Health and Wellbeing team offer is so important, as statutory mental health services may not be accessible to a homeless population (c.f. https://centrepoint.org.uk/what-we-do/health/). Complexity is therefore often seen as something negative or ‘bad’ in an individual, and they can be dismissed by professionals who can’t (perhaps due to resources) or won’t (perhaps due to attitude) take the time to consider why that individual might be ‘complex’ and how they can ensure that they get the right support at the right time.

So what do we mean when we talk about ‘complexity’ in the homeless sector? I often hear staff talk about the ‘complex needs’ of the homeless young people that they support. In this sense, they are often talking about the multiple and interlinked issues that the young people in Centrepoint present with within our supported accommodation services. This can include their early adverse childhood experiences, which may have resulted in family breakdown and disrupted attachments and periods within the social care system, which can manifest as ongoing trauma responses and difficulties in developing appropriate relationships as they enter young adulthood. This trauma can then manifest itself in challenging behaviours such as hyper-vigilance to threat that can result in impulsive verbally or physically aggressive behaviours or mental health difficulties, including self-harm and suicidal ideation (c.f. https://centrepoint.org.uk/media/4650/prevalence-of-mental-health-need-report.pdf) as well as substance use problems. This ‘toxic’ combination of historical challenges, current vulnerabilities and the additional trauma associated with the actual experience of being ‘homeless’ often lead to our Centrepoint young people being described as ‘complex’. And of course, this ‘complexity’ can naturally lead to our staff feeling overwhelmed, burnt out, stressed and often unsure of ‘where to start’ when working to support a homeless young person at Centrepoint.

Prior to coming to Centrepoint, I have spent the last two decades working with individuals across the age range that would be considered ‘complex’. Despite the obvious challenges of working with this client group, I have personally found it some of the most rewarding work that I have ever undertaken and I cannot imagine as a psychologist working with any other population. When an individual who has perhaps been ‘written off’ by traditional services makes a positive change, however small, the impact can actually be immense (as well as the personal satisfaction or reward!). Therefore rather than seeing complexity as a negative, I think it is important that we reframe our ideas of complexity to see it as something that we can and want to work with, and in fact is something that is possible to work with. Of course, positive change with ‘complex’ individuals is rarely easy or quick — it is a marathon not a sprint! — but to change the trajectory of someone’s life course away from a lifetime perhaps on the fringes of society to becoming a positive and valued member of society with ‘a home and a job’ is something that makes our frontline staff’s role so vitally important and powerful for the homeless young people that they support. Their work is the ‘bread and butter’ of what makes Centrepoint an organisation that can legitimately claim to be the national voice of youth homeless in the UK and somewhere that I remain proud and privileged to work for.

Consequently, during reflective practice sessions this week, when the issue of ‘complexity’ in terms of the homeless young people we are discussing was raised, this has been addressed through psychologically informed or PIE approaches. First and foremost, this has been about exploring the complexity and helping staff to break this complexity down into a more manageable pieces. Psychologists do this through the process of ‘formulation’. ‘Formulation can be defined as the process of co-constructing hypothesis or ‘best guess’ about the origins of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them’ (Johnson, 2017; p.3). Therefore, formulation can provide a structure for thinking together about how to understand an individual’s complex experiences as well as how to move forward. Of note, this approach can be used by psychologists with individuals themselves in therapy, or used as a way of considering complexity in reflective practice sessions with staff. In other words, a psychological formulation is a structured approach to understanding the factors underlying distressing states or issues in such a way that it informs the changes needed, as well as the possible mechanisms and interventions needed for positive change to occur.

Formulation is also the tool that psychologists use ‘to relate theory to practice’ (Butler, 1998; p.2). Unlike a psychiatric diagnosis, which locates an individual’s distress or problems within a medical framework (i.e. an underlying problem with the brain that needs medication to resolve), a psychological formulation considers the wider systems and context, as well as importantly the personal, social and cultural meaning of the issue. Formulation also considers an individual’s resources and strengths in surviving what may have been a very challenging situation to date (i.e. homelessness), and is not just focused on their deficits or risks (Johnstone & Dallas, 2013). Formulation is now a valid, scientific and acceptable approach (c.f. Division of Clinical Psychology (2011): Good Practice Guidance on the use of Formulation: https://shop.bps.org.uk/good-practice-guidelines-on-the-use-of-psychological-formulation).

Consequently, when discussing complexity with staff in reflective practice sessions, there is a key role for formulation in order to help staff to understand complexity and to support them to work out ways that they can work with it rather than fear it. This team formulation approach, wherein a group of staff develop a shared formulation about a service user is increasingly becoming common practice in a variety of statutory and voluntary sector organisations (Johnstone, 2013). In this approach, the facilitator of the reflective practice session has a role in reflecting, summarising, questioning, clarifying and encouraging creative and ‘free thinking’ about the individual under discussion in a psychologically safe space, so that the team can work together to understand the individuals difficulties, identify and address any ‘stuck points’, and consider their own feelings and reactions to the individual (Johnstone, 2017). Of note, taking a team formulation approach has been demonstrated in research studies to improve staff — client relationships and to reduce staff burnout (Berry et al, 2009).

The most straightforward and commonly used formulation approach is the 5P’s model. This approach has therefore been adopted in both reflective practice sessions in Centrepoint as well as underpinning our Risk Assessment and Management Plans: RAMPs (and the associated RAMP and generic PIE training sessions that recommenced this week at Centrepoint as part of our new HOMES strategy — see previous blog here: https://drhelenmiles.medium.com/creating-psychologically-informed-homes-reflections-on-the-launch-of-centrepoint-s-new-d4015359eaca). Whilst there are many ways or models that psychologists can use to formulate a client’s difficulties, I have personally found the 5P’s approach particularly helpful over the years in dealing with ‘complexity’. Essentially in a reflective practice session, I facilitate a discussion with staff that enables us to think together about the complexity by breaking it down into 5 areas or ‘P’s’ — each P standing for one of these areas.

Therefore, we may start by thinking about the immediate issue that has led the staff to want to talk about a particular homeless young person in that session — otherwise known as the ‘Presenting Issue or problem’. This can also include some space for staff to reflect on their own natural reactions and feelings about this. Sometimes this can be difficult because we often feel in this work that we should not have any personal reactions or feelings about an issue because we are professionals. However, we are also human so of course, we will have these. Therefore, a key part of this discussion is to normalise these feelings and reactions as well as exploring ways that staff can process or ‘hold’ these in order that they do not negatively affect their working relationships with the young person.

Next, we break down the ‘complexity’ further into ‘Predisposing factors’ or early experiences, often the young person’s history before they came to Centrepoint. Sometimes this identifies key experiences (e.g. attachment disruption, trauma, social circumstances) that are influencing the young person’s current presentation. Sometimes these discussions also identify that we do not know this information, because it has not been on a referral form or it is something that the young person has not been able or willing to discuss with others. Consequently, this can highlight to staff that we may need to obtain further information. Then we spend some time exploring and reflecting on both the ‘Precipitating factors’ (or the triggers to the presenting problem or issue) as well as the ‘Perpetuating factors’ (or what might be keeping the presenting problem or issue ‘live’ or ongoing). This can be helpful in order to consider what may be current explanations for the presenting problem or issue. Finally, and arguably very importantly, we consider ‘Protective factors’ (or what strengths or positives that the young person may have in the midst of all the concerns or issues). Often this final area may be neglected when we are dealing with crises or complexity. However, this can be particularly helpful for staff to reframe their emotional response to a young person and enable them to see that perhaps the young person has resources and positives, thereby giving them a sense that the young person is more than just the ‘problem or issue’.

At Centrepoint, we have slightly adapted this approach to make it a 6 P’s approach — as the final stage is to develop a ‘Plan’. This is where we think as a team about how we can reduce the triggers or factors that are causing or maintaining the presenting problem or issue. This can include changing our responses to a young person, offering particular support, referring them to appropriate interventions, or anything else that we can do to modify or change to reduce the likelihood of the presenting problem or issue in the future. We also include in the plan ideas about how we can build upon the young person’s existing strengths or protective factors. This plan often considers what needs to be addressed first (i.e. prioritisation) but creates a way forward that feels manageable as we move from a position of being overwhelmed by the complexity of a young person to a position of having a greater understanding of the complexity by breaking it down into manageable parts. This process can also often highlight where small gains may have already been made, especially as sometimes these can be forgotten when the sheer weight of the ‘complexity’ can be overwhelming. This can increase staff motivation to continue to feel that further progress is possible and that they can help this young person even when previously it may have felt hopeless.

Finally, of course as noted above working with complexity is challenging (as well as rewarding). Therefore, any discussion about the complexity of the homeless young people we support in our services also includes the importance of staff self-care. Acknowledging our feelings of perhaps hopeless or powerlessness in the face of the complexity (and/or wider system challenges) and sharing these with our colleagues is helpful. It can build team support mechanisms as we hear that we may not be the only person overwhelmed by the complexity as well as a shared understanding and ownership of the complexity. Moreover, it gives us permission to ensure that we are looking after our own well-being when undertaking this type of support work, an essentially important part of our role in order that we can keep helping others and avoid the risk of compassion fatigue, burnout and staff attrition. Consequently, in a PIE, ‘complexity’ is not something to be fearful of, even though it can cause anxiety in staff as they manage this on a daily basis, but rather it is just a natural part of working with some of the most vulnerable young people in the UK. However, with the right approach, we can break down this complexity into something we can manage and deal with. And when we do this, we can #changethestory for homeless young people in the UK, many of whom have been deemed ‘too complex’ for other services to support, something that I think every frontline staff member in Centrepoint should be incredibly proud of achieving.