‘Going upstream — Why is a psychologically informed approach to ‘prevention’ critical to #EndYouthHomelessness?’
25.08.2023: 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 following on from the previous PIE blog, that highlighted the new ‘Homewards’ programme recently launched by our patron — Prince William and the Royal Foundation of the Prince and Princess of Wales. It is a ‘five year locally led programme that will demonstrate that together it is possible to end homelessness: making it rate, brief and unrepeated’. More information on this initiative is available here: https://royalfoundation.com/prince-william-and-the-royal-foundation-launch-uk-wide-programme-to-end-homelessness/. One of the key focuses of this programme is ‘prevention’ of youth homelessness in the first place, and as an charity over the past year Centrepoint has been collaborating with other partners, to consider how we can end youth homelessness by preventing it from occurring in the first place.
This is critical work. It makes intuitive sense to most of us that by intervening early in any issue, the problem is going to be easier to fix. For example, if we have a physical health issue — the earlier we get treatment for that the better our prognosis or likelihood of recovery. One of the reasons that I joined Centrepoint, having worked frontline for many years with individuals with complex mental health needs, was that I had realised that to have the biggest impact and really #changethestory for an individual, the earlier I could intervene the more likely that person was to have a more positive outcome. Just as it is important to highlight the key role of prevention in physical or mental health issues, it is equally important to consider prevention in the homeless sector.
At Centrepoint, we want to prevent a young person in the UK from ever needing to ‘sofa surf’ or end up rough sleeping, as both may be potentially physically and psychologically damaging to them in the long term. Consequently, I would argue that a prevention focus needs to be part of any PIE approach in the homeless sector, so that we are not just responding to the issues resulting from homelessness, but using psychological approaches, methods and interventions to try to reduce the incidence in the first place. It has therefore been important for the PIE team (our PIE Educational Psychologist; Marc and myself) to work alongside our fantastic Pre-16 Prevention Pilot Team, led by Stephen Elder and Lisa Waring, and other colleagues in the organisation to look at a new initiative that is aiming to do just that.
The ‘UPSTREAM’ project is a psychologically informed approach that aims to identify young people at risk of homelessness and intervene early to prevent that from happening. This project really is critical, because for too long homeless organisations, Centrepoint included, have been focused on fixing the symptom — that of homelessness and perhaps have been less focused on the causes that underpin homelessness in the first place. As the famous quote from Desmond Tutu so eloquently notes at the start of this blog — ‘There comes a point where we need to stop pulling people out of the river. We need to go upstream and find out WHY they’re falling in’.
Consequently, for this week’s PIE blog, it is my great pleasure to hand over to Stephen and Lisa to speak further about their important work, and please do get in touch if you want to know more…
‘Centrepoint’s vision, to end youth homelessness by 2037, relies on four key points: Support, Optimise, Amplify and Prevent. Prevention is at the heart of this strategy which directs us to ‘work with and support organisations that provide direct prevention advice [particularly] those working in early identification of children and young people at risk, mental health of children and young people, [and] family mediation’. As noted above, preventing homelessness is key, not just for the socio-economic impact that homelessness has on society, but also on the trauma that can be consequence of the homeless experience. Therefore, prevention at an early stage can ensure that this trauma does not happen.
However, the language around ‘prevention’ in the homeless sector can be difficult to negotiate. One example of prevention is under the Homelessness Reduction Act (2018), wherein people may be placed on a ‘prevention duty’ if they are threatened with homelessness (rather than a relief duty for people who are already homeless). However, another use of the term prevention are schemes to support universal prevention with all population groups, not just those targeted. As a result it can be confusing as to how we are using the term, which creates issues in the sector as organisations can devise alternative names to try and explain the concept. For example, ‘Pre-Prevention’ (a term used to undertake work before prevention!), or different focuses of the prevention (e.g. Upstream/Midstream/Downstream — Coote, 2012), or different models or care pathways (e.g. Primary/Secondary/Tertiary public health approaches). Even these differentiations can be blurred, leading Fitzpatrick et al (2021) to note that “existing homelessness prevention typologies in the international literature… seem to veer between the excessively basic (courting ambiguity and leaving too many questions unanswered) to the bewilderingly complex (leaving readers disoriented by competing concepts and organising frameworks)”.
In order to make the concept of ‘prevention’ easier to understand, there is a somewhat easier model, which helps to remove the blurred lines and allows simple definitions. This is known as a ‘Five Level Typology Model’ (Fitzpatrick et al, 2021) and consists of the following:
· Universal: Preventing or minimising homelessness risks across the population at large.
· Upstream: Early stage prevention focussed on high-risk groups, such as vulnerable young people and risky transitions, such as leaving local authority care, prison, or mental health in-patient treatment.
· Crisis: Preventing homelessness likely to occur within a foreseeable period.
· Emergency: Support for those at immediate risk of homelessness, especially rough sleeping.
· Repeat: Prevention of recurrent homelessness, especially rough sleeping.
Adopting this model allows us to structure the way we think around prevention across the work that Centrepoint is undertaking in this area. For example, we already offer multiple supported accommodation and floating support services, as well as several ‘Housing First’ services, all of which work with homeless young people to prevent repeat and recurrent homelessness. In addition, Centrepoint’s Homelessness Prevention and Relief Service (HPRS) in Manchester as well as our National Helpline focus within at the crisis and emergency support area(s) of this prevention typology.
However, what is new is that Centrepoint is now working with under 16 year olds as part of an innovative prevention scheme known as ‘Upstream England’, which is working on an even earlier stage of prevention of homelessness. The Upstream project is a revolutionary approach in identifying early factors contributing to homelessness in secondary school children. Centrepoint’s Upstream England project follows in the footsteps of Llamau’s Upstream Cymru (Wales). The Upstream survey was created by Llamau and Cardiff University, and was itself modelled on the successful approach of the Australian Geelong Project. The project is divided into two key parts; the initial survey in which data is gathered within secondary schools and the support put in place once children and young people have been identified and referred for further psychologically informed support.
The initial survey is comprised of 42 multiple choice questions, split into four key sections, (1) ‘Wellbeing’, (2) ‘Resilience’, (3) ‘School Attainment’ and (4) ‘Homelessness’, with this last section being split further into ‘Risk of Youth Homelessness’ and ‘Risk of Family Homelessness’. Each of these sections have been developed independently, with the Wellbeing questions consisting of the seven questions from the Warwick — Edinburgh Mental Well-being Scales (WEMWBS, 2007; https://warwick.ac.uk/fac/sci/med/research/platform/wemwbs/about/), and the resilience questions coming from another validated psychological assessment. Throughout the project we are working, as per a PIE, utilising an evidenced based approach, evaluating the process at each step of the project as well as potential outcomes.
Moreover, by utilising a strong network of partnership contacts and resources, we are able to provide three integral areas of psychologically informed support to those young people identified as being at risk of homelessness. This involves mentoring approaches, mental health interventions, and family mediation support. Given that, one of the key reasons for homelessness is relationship breakdown (Centrepoint, 2022), the support offer aims to prevent this occurring for those young people identified as at risk of homelessness and embodies the PIE approach to working with children and families. For example, developing good communication between children and parents, enabling young people and their families’ time to reflect and repair relationships, and providing training and support for children through the mentoring work.
The ‘Upstream’ project is essentially a two-stage approach; of survey and support, and the composition of that psychologically informed support, needs to be ensured to maintain the fidelity of this as a model. This model or approach was originally developed by Professor Pete Mackie at Cardiff University and Llamau, a Welsh homelessness charity, who first began to undertake this work in March 2020 (a date that might stick in our minds for another reason!). Centrepoint were first made aware of the work that Llamau were doing in Wales through a period of consultation around preventing youth homelessness a few years ago. Working together with Llamau, Centrepoint then started working in schools in March 2023, a much better year than 2020!
This project sits firmly within the ‘upstream’ area of the prevention typology, hence the name. Of course, work that we undertake with specific over represented groups at risk of homelessness (e.g. Care Leavers, Asylum Seekers and people with Mental Health issues or Learning Difficulties/Disabilities) in our supported accommodation services can be considered to be at this upstream level. However, the difference for this project is rather than responding to need once identified, we are now operating an early identification process. Each of the above over represented groups are already identified by a specific trait, whereas the upstream survey is actively screening for potential risk factors. This enables us to identify a cohort who are perhaps by virtue of not having a specific trait noted above are at a hidden risk of homelessness.
Centrepoint are leading on the ‘Upstream England’ Prevention work, and have piloting this approach in Manchester currently, soon to expand to London. However, whilst we are working towards ending youth homelessness, we know we cannot do this alone. Consequently, we are working in partnership with local organisations to deliver the psychologically informed support (e.g. mental health / family mediation). We also aim to support other organisations across the country to be able to deliver this approach in their local areas because we recognise that our strategic goal to #EndYouthHomelessness is and must remain a joint effort.
Finally, again as per PIE, our ‘Upstream’ project will be evaluated along with our partners, so we can contribute to what works in the homeless sector. As Keats et al (2012) note in the ‘PIE Good Practice Guide’; ‘evaluation of outcomes is crucial in the development of psychologically informed services … If you do not know what impact what you do or say is having, how can you know whether it is positive and how can you improve it? There is not a great mystique about evaluation: it is the opportunity to know which things you do or say are effective, in what situations and with whom’ (c.f. https://eprints.soton.ac.uk/340022/1/Good%2520practice%2520guide%2520-%2520%2520Psychologically%2520informed%2520services%2520for%2520homeless%2520people%2520.pdf, p.26).
However, even with this planned evaluation, there will be core questions about this approach to early screening and psychologically informed intervention for youth homelessness that we will not know the answers to for many years to come. To put it another way, if we are undertaking this project with 11 year olds, then it will be 15 years before they turn 26, and are no longer young people, so it will take 15 years to know if this has worked (i.e. that they never became another youth homeless statistic). Moreover, how might population movement effect the risk of homelessness? For example, what happens to children we have supported in Manchester or may in the future present in London? What other factors that we have not identified and addressed impact on the future risk of youth homelessness? Of course, we will continue to reflect (as per a PIE!) on these questions as we continue with the upstream project, but for now, let us get on with this innovative psychologically informed approach to preventing homelessness….’
