‘Is it PIE? — How to ensure we are making a Psychologically Informed Environment (PIE)’

06.08.2021: For this week’s PIE blog, as the lead for Psychologically Informed Environments (PIE), at the national youth homeless charity; Centrepoint, I have been reflecting that this week I have been being one question quite a lot lately. That question has been “is it PIE?” Consequently, I have been wondering if ‘PIE’ can sometimes be at risk of becoming a ‘catch-all’ term that may be being used in a way perhaps not intended? Mission ‘drift’ is always a risk in any change programme such as PIE, and therefore I think sometimes it can be helpful to stop and reflect to ensure that our PIE journey at Centrepoint remains ‘on course’ and isn’t distracted, diluted or ‘weaponised’. This can sometimes be a challenge when there are different ‘versions’ of a PIE within different homeless organisations or other services. Therefore, what is critical is that we remain focused on our Centrepoint PIE, whilst obviously learning from and engaging with other PIE approaches within the sector.

A Psychologically informed environment or PIE when distilled down to its core elements is an approach that uses psychological theories, methodologies and interventions to improve outcomes for service users (i.e. homeless young people) and the staff that support them, in whatever role they are working within. The original concepts of a PIE were established by Keats et al (2012; https://eprints.soton.ac.uk/340022/1/Good%2520practice%2520guide%2520-%2520%2520Psychologically%2520informed%2520services%2520for%2520homeless%2520people%2520.pdf) and further articulated in the Westminster Council (2015) PIE Implementation and Assessment Guide (c.f. https://www.homeless.org.uk/sites/default/files/site-attachments/Creating%20a%20Psychologically%20Informed%20Environment%20-%202015.pdf). These documents note that the key objectives of a PIE are to create an organisational culture that is reflective, wherein principles from psychological approaches to working with complex needs are introduced, and staff can understand client needs in psychological terms (e.g. impact of early relationships / link between thoughts, feelings and behaviours). Most importantly, like of course any good PIE(!), they highlight the importance of five key ingredients and I will briefly reflect on each of these in turn within this week’s PIE blog.

However, I am first going to reflect on how our Centrepoint PIE does differ slightly to other PIE’s within the sector, mainly in terms of how we are delivering it within our PIE Team. This was highlighted to me recently, when I had the pleasure of attending the Network of Psychologists working in Homelessness Services meeting. This involves psychologists working in the homeless sector; both charities and statutory services (e.g. NHS) with homeless clients coming together from across the country to share best practice and reflect on our PIE work. It is a very valuable quarterly session for not only my own personal continuing professional development, but also in keeping me on track with the leading of our Centrepoint PIE and learning from those who have been undertaking this work far longer than I.

Of course, the implementation of PIE within these different sectors and organisations varies driven by commissioning processes, funding and resources, organisational influences and regional / local contexts. However, we are all united in the application of psychology to work more effectively with this often hard to reach and vulnerable population that has traditionally perhaps been somewhat neglected by conventional care pathways and statutory services. I am always extremely humbled to hear of some of the amazing work that my psychology colleagues are undertaking in PIE across the country. There are many similarities in our work (i.e. ensuring that we are delivering the key ingredients of PIE) but also some key differences. The most obvious for our PIE Team in Centrepoint is that unlike many other psychologists working in this sector, our work is ‘indirect’ to staff (i.e. we do not ‘directly’ deliver psychologically informed clinical interventions to homeless clients). This is because within our organisation, we are extremely lucky to have our brilliant Health Team, whose psychotherapists, drug and alcohol workers, mental health workers, relationship counsellors and dietitians are operating within that space to deliver psychologically informed interventions directly to homeless young people (c.f. https://centrepoint.org.uk/what-we-do/health/).

Therefore, our focus in our Centrepoint PIE has been slightly different, which can be challenging when as psychologists our primary training has been in ‘direct’ rather than ‘indirect’ delivery modes. Nevertheless, our psychological skills and knowledge are still helpful in ensuring that the key ingredients of a PIE are actioned and retained, when we are working at this ‘macro’ level across the whole system. Consequently, as per PIE, the first ingredient is to ensure that we have a clear psychological framework that underpins the PIE and highlights the central role of ‘relationships. These relationships may at the heart be between the homeless young person and the keyworker, but also include the relationships that we have with our colleagues. This means that no one person is more important that another. The well-being of the homeless young people we support is extremely important, but not at the detriment of the well-being of the staff that support them. Similarly, the well-being of the staff should not be at the detriment of those they support. This creates a fine balance in decision making that means when we are answering the question of ‘is that PIE?’ we need to ensure we are considering both.

In Centrepoint, our PIE framework is underpinned by Attachment Theory (e.g. Bowlby, 1967), a universal theory that describes the impact of our early relationships on our later sense of self, our relationships with others and our view of the wider world. It does not just apply to homeless young people, but the importance of the creation of ‘safe and secure’ attachments or relationships applies to all of us. Through these attachments, all of us are able to achieve our full potential. As Cockersell (2018) articulates so well, the “everyday magic of normative relationships is key to mental health and resilience”.

Taking such an ‘attachment informed approach’ therefore means that building consistent and reliable relationships between us all is the goal. Again therefore, when we are asking whether something is ‘PIE’, keeping these key principles in mind can be helpful. We should try therefore to consider the impact and influence of past experiences when understanding another person’s current behaviours, although of course this in PIE terms is seen as ‘an explanation not an excuse’ and there remains the need for clear and related consequences to negative behaviours or actions albeit within the confines of an ‘elastic tolerance’. Interactions and interventions will always work best within a culture of a strengths based praise rather than punishment model with the establishment of this ‘secure base’ (or boundaried professional relationship) at its heart. Psychologists also know that relationships work best when based on clearly defined roles, expectations and provide order and consistency. In addition, relationships that are ‘sensitive’ and ‘responsive’, particularly to distress, through good professional listening, emotional containment and showing care or concern create the valuable conditions of psychological security and trust. Moreover, the opportunity to connect ‘informally’ and provide non-contingent positive interactions (i.e. not just interacting for gain or if there is an issue) are noted by Rich (2006) to help build relationships.

Of course, not all relationships are ‘easy’. We do not always get on with everyone! It is PIE to experience challenge and conflict at times because we are all humans with different wants, needs and drivers. However, PIE views conflict as an opportunity for learning, understanding and change perhaps through restorative or mediation approaches and within the openness and safety of reflective practice spaces. Finally, we need to have ‘time’ to develop our relationships, which should always be prioritised over excessive or unnecessarily repetitive paperwork or non-contact activities, and we need to be able to process the natural endings of relationships (e.g. when a homeless young person or colleague ‘moves on’), acknowledging and planning with good communication about transitions, endings and changes. It is not PIE to ‘just let stuff happen’ when it can be planned and managed (unless of course we are dealing with those unforeseen crises that do sometimes occur within homeless work).

Another key ingredient of a PIE is staff training and support. PIE would advocate for staff to have time for continuing personal and professional development and an acknowledgement that this work can be difficult at times, which may require staff to take some ‘time off to recover’. This is not a sign of weakness but rather of awareness. Staff training also provides an opportunity to ensure that the latest evidence based psychological methods, tools or techniques are being utilised in order to improve outcomes. I love attending training as I see it as an opportunity to learn something new, as after all none of us know everything about everything! Of course it can be challenging to the ‘status quo’ to try to do things differently especially when we have been doing something a particular way for a long time. However, as the famous quote (attributed to Albert Einstein) notes; “the definition of insanity is doing the same thing over and over again and expecting a different result” and if something is not working, PIE would say let us look together at how we can improve or change it.

Creating the space for learning, innovation and support can also come through the next key ingredient of a PIE, that being reflective practice. As Homeless Link (2017; https://www.homeless.org.uk/sites/default/files/site-attachments/Reflective%20practice%20briefing%20March2017.pdf) note reflective practice is the process of learning through experience and gaining new insights into ourselves and our practice. Thus, it facilitates our professional development as well as safe and compassionate practice. As noted by Dewey (1933) nearly 100 years ago (!) reflective practice enables us to “know what we are about when we act”. Reflective practice is therefore PIE, and creating the space and time for it within any organisation that claims to be PIE is essential across the whole organisation. For example, this week I have had the pleasure of facilitating reflective practice with some of our ‘frontline teams’ as well as ‘support teams’ and our Senior Executive Team (SET) and CEO. Centrepoint is ‘walking the walk’ with reflective practice and I will fascinated to look at the first results of our reflective practice audit of the offer over the past year in the next few weeks so that we can continue to evolve and develop our PIE Team reflective practice offer over the coming year to ensure that all staff can have access to this valuable resource.

Another key ingredient of a PIE is that of the physical environment and the recognition of the impact that our physical environment has upon our psychological well-being. Our PIE physical environment fund is ongoing and it really is such a highlight in my role to see how often small changes (at relatively small cost) to some of our supported accommodation services (e.g. furniture, gardens, decoration) can have such a significant impact on both the homeless young people that live within them as well as the staff that work there. When thinking about the question ‘is it PIE?’ with regard to the physical environment, I think this is probably the easiest to answer and I always answer this question with another question — ‘Would you want to live there?’ If the answer is no, then we have to consider changes. Of course, not all changes can be instant or easy, and sometimes we have to ‘make do’ but I think we have a responsibility to do the ‘best we can where we can’.

The final key ingredient of a PIE is that of ‘evidence-based practice’ and ensuring that we use our data and insights from evaluations or audits to inform our decision making and actions. This is both at a service level with how we operate as well as within our policy and research team, whose role it is to work for positive system change (e.g. https://centrepoint.org.uk/what-we-do/policy-and-research/) in youth homelessness. It is PIE to ensure that we are always coming from a place of understanding and evidence, rather than a just ‘guessing’ what we need to do. Of course, sometimes there is a lack of evidence, so we need to try out something new or innovate. Nevertheless, PIE would argue that we need to routinely evaluate or audit this so that we can continue to contribute to the evidence base of ‘what works’ in the homeless sector and/or ensure that we understand issues within our organisation by looking at the evidence of what is happening rather than making assumptions.

Although these five key ingredients of PIE are critical to hold in mind when answering the question ‘is this PIE?’, my final reflections are that we can also think of PIE and it’s reach more broadly. For example we are continuing within Centrepoint to consider our policies and procedures and ensure that they hold ‘psychologically informed’ principles at their heart (e.g. supportive, clear, evidence based, collaborative, reviewed regularly and in line with the psychology principles such as safety, strengths focus and positive risk management). Another specific example of the wider use of PIE is within our language (c.f. previous PIE Blog here: https://drhelenmiles.medium.com/the-power-of-words-the-importance-of-using-psychologically-informed-language-a5010ad5af05).

For example, I have been involved in discussions with several teams recently about whether ‘house rules’ are PIE. Of course, we all live within boundaries within society and ‘rules’ that keep us safe and allows society to function, but I personally prefer the term ‘house responsibilities’. In other words, what do we all need to do to keep each other psychologically safe and our ‘home’ functioning for everyone? Consequently, things such as respectful and tolerant behaviour, being kind and compassionate to others sharing your space by clearing up after yourself, and not acting in a way that leads to risk events are all reasonable ‘responsibilities’. These should be co-produced with those that they impact in order to be truly PIE and consequently, ensure that we are empowering our homeless young people to take ‘responsibility’ for their actions rather than creating the conditions for defensiveness or challenging behaviours resulting from paternalist demands or ‘rules’.

In conclusion, when considering the answer to ‘is it PIE?’ I am going to do that typical thing that I know that psychologists can be criticised for — I am going to sit on the fence! Whilst some things are obviously not PIE, all of us wherever we work within the organisation can I believe with some collaboration, reflection and consideration (holding in mind the key ingredients noted above) answer that question. The exact expression of PIE in one place might be slightly different in another, but it is also that flexibility and consideration of an individual, whilst holding true to the key PIE principles, that is important. I would argue that wherever we work in a PIE organisation, we can all ‘keep’ PIE in mind in our daily roles so that the answer to the question ‘is it PIE?’ is not the exclusive preserve of just the ‘PIE Team’.

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