‘Psychologically Informed Research — What impacts on staff working in youth homelessness services?’

12.02.2021: For this week’s blog as the Lead for Psychologically Informed Environments (PIE) at the national youth homeless charity: Centrepoint, I have great pleasure in handing the blog over to Dr Louise Peters (Clinical Psychologist in the PIE Team). Following on from last week’s PIE blog topic about the importance of psychologically informed research, Lou has agreed to share her first published research paper: ‘Shining a light on the experiences of staff working with young homeless people: A grounded theory study’ (https://authors.elsevier.com/a/1cXFzhNfKpCfZ) and some of her reflections on the research process.

‘Academic research doesn’t come naturally to me. I have never been someone who excelled in this area in school particularly, despite going on to complete a doctorate! So to see my work in print is something new and unfamiliar. To produce a piece of work and then see it tangibly as a final outcome is not often experienced by a Clinical Psychologist, who is perhaps more used to working face to face with people. However, I have felt throughout this process that I needed to get this research published. Not for myself, but for the Support Workers that took the time to take part in my study. I wanted to do them justice, to get their voices heard, and act with integrity, following through on what I said I was going to do. What has propelled me to continue to push through the barriers and obstacles to getting this out there, to continue to be determined, resilient and not give up, has been a desire to act in accordance with my own values: ‘to do as I say I will’ and to truly shine a light on the amazing staff that give their time and energy to helping one of the most marginalised groups in our society.

I have also had a desire to add to the literature, to help systems change and to highlight what is required to effectively support our staff and the young people they serve, and to have something positive and enduring to come out of such a personally difficult process! The staff I met touched me in the selflessness of their perspectives, their wisdom and lived experiences. These spoke to me of something bigger than individual gain. Moreover, how they shared what they had learnt through the delicate interactions and relationships they had built with the young people, embodied a perspective and mentality that I respect — one of flexibility, working for a greater good and not seeking individual power and gain necessarily. Furthermore, these admirable traits were in the face of significant challenges — challenges that have only increased during the current global pandemic.

So how did I come to carry out this research? I was previously familiar with Psychologically Informed Planned Environments (PIPEs) having worked in prisons and other forensic settings in the London area. PIPEs are designed to support transition and personal development at important stages within an offender’s pathway (National Offender Management Service (NOMS); NHS England 2015). I was also aware that the PIPE model had been employed within a number of community-based hostel settings (known as Approved Premises PIPEs), aiming to support those released from custody. I later worked for the Royal College of Psychiatrists Centre for Quality Improvement (CCQI), where I became aware of the ‘Enabling Environments’ project. The CCQI is where Psychologically Informed Environments (PIEs) were initially developed by Johnson and Haigh (2010). I subsequently worked in what was then termed a ‘Dangerous and Severe Personality Disorder’ service — an NHS service at HMP Whitemoor. This service had a Trauma Informed Care (TIC) approach to intervention and treatment, and now forms part of the Offender Personality Disorder Pathway (NOMS, 2015).

Following this post, I worked for Turning Point, a charity supporting people with drug and alcohol issues. I encountered people experiencing homelessness and liaised with services supporting them. Here, I began to develop an interest in how people with histories of complex trauma are supported within the community. I later worked in an NHS Personality Disorder Hub Service, providing community-based assessment, treatment and care-co-ordination for individuals with a diagnosis of personality disorder. Moving on to complete a DClinPsy placement in a Developmental Trauma Service for Looked After Children, I reflected on having witnessed the ‘full cycle’ of those with histories of complex trauma. I became interested in how service provision for homeless people, who often have histories of complex trauma and insecure attachments, relied heavily on the charitable sector. Each service appeared to function as an individual silo, with little joint working or communication, perhaps in part due to social care being ‘marketised’ with short term contracts awarded based on cost and outcomes (Phipps et al, 2017). I witnessed unrealistic goals and pressure placed on staff as a result of funding cuts due to the economic climate (Homeless Link, 2013).

Conducting this research required me to collaborate with a number of key individuals with academic and clinical experience in this area, including Dr Katherine Shelton, Dr Victoria Samuel, Dr Christopher Hobson, and Professor Nick Maguire. Conversations with them shaped my ideas, and I conducted a brief review of the relevant literature, which lead me to a key paper by Hopper et al (2010) on ‘Trauma Informed Care in Homelessness Service Settings’. This paper would be pivotal in forming my ideas particularly around the importance of conducting qualitative studies that explored the emotional experiences of staff working with young homeless people. This research was also a collaboration with a Welsh youth homeless charity, who kindly allowed me access to speak with their staff as part of the project. However, in liaising with this third sector service for young homeless people in Wales, it became clear the role of support staff was complex and multi-faceted. Support staff carry out a plethora of different roles and they are not a homogenous group, varying in levels of experience and responsibility.

So what did my research involve? After an initial review of the literature on young homeless people, I visited the host organisation and spent time talking to senior members of staff. The discussions helped me understand the complexity of the support worker roles and gather more contextual information about the service. I learned that the organisation intended to become a PIE and my research would provide useful information about how staff could be better supported and therefore I felt a responsibility to contribute something valuable to the service. The research process involved further collaboration with staff within the services in designing an initial interview schedule that was relevant and engaging to those taking part.

I obtained ethical approval for my research study from Cardiff University, and considered the potentially emotive nature of the questions, as well as the need for debriefing post interview, and ensuring appropriate staff support mechanisms were in place. All data was anonymised and confidential. Staff who participated were interviewed either face to face or by telephone outside of their normal working hours. There were also several revisions to the interviews as the process developed. These included enhancing the clarity of questions, and expanding on several themes that developed (e.g. learning from the young people, role of parenting, political influence and support available). Finally, I utilised a Grounded Theory approach to analyse the information obtained from the interviews with staff, which involved transcribing and reviewing the interviews to generate codes or themes that were emerging from the data, as well as the links between concepts. The use of mind mapping software enabled me to plot out these links and develop an initial model (see picture at the start of this blog). Although this research process was challenging at times, I used supervision and support to work through these issues and consequently have confidence that the final model generated can aid wider understanding of staff experiences, as well as potentially inform and develop future staff training.

So what did my model show? Seven main concepts were identified in the analysis: the need to be “a certain kind of person”; the rewards and challenges of the role; the impact of the organisational context and culture; individual approaches to coping; possible adverse impacts of the role; enjoyment of the role; and personal growth. The interaction between these concepts was considered and conveyed via the proposed model pictured above.

The model depicts the core conceptual dilemma identified within the data, which was the challenge of enabling and maintaining engaging and safe relationships with homeless young people (many of whom have a history of trauma). At a conceptual level, this was influenced by the pressures of coping with multiple complex challenges, within a constrained organisation that is seeking to address a wider societal and political problem. A theory of balance was developed within which a pivotal process was the fluctuation between feeling supported by the organisation and coping well, and feeling unsupported and struggling to cope. When organisational support was high, and the individual had a strong repertoire of coping strategies and feels skilled and efficacious in building supportive but boundaried relationships with service users, the role can feel rewarding and enjoyable which can progress to personal growth. Conversely, when staff felt unsupported by the organisation and the work was traumatic or excessively demanding, coping may be overwhelmed with the potential to result in adverse impacts, such as stress and sickness. A fluctuation between all the involved factors renders this dilemma of achieving balance vulnerable to tipping/being tipped.

So how does my psychologically informed research contribute to the wider field of youth homelessness? The theory of balance identified within this research has the potential to inform a PIE within the host organisation as well as within other similar organisations such as Centrepoint. For example, ideas around Cognitive Load Theory (Sweller, 1994) could be further considered in staff training and support to help manage the necessary balance identified. These ideas could also be incorporated into future Support Worker Job Descriptions and Person Specifications to assist in staff selection, and to enhance fit within the organisation. Further work on enhancing the wellbeing of staff could include: the provision of mindfulness and self-compassion groups to enhance self-care and resilience, Acceptance and Commitment Therapy (ACT: Hayes, 1994) training around working in line with staff values, and peer mentoring schemes encouraging a culture of openness within the organisation. Most importantly, it is also hoped this research will help validate the struggles faced by support workers.

More specifically, three possible ideas that could be incorporated within a training package or reflective practice sessions for support workers, and other staff working with homeless people, could include:

1) The use of a general measure of psychological flexibility with staff (for example a compACT, (Francis et al, 2016). People may be more vulnerable to burnout if they are experientially avoidant (Iglesias et al, 2010), so training in psychological flexibility where staff reflect on how their own personality interacts with the demands of the role could be beneficial. This may allow for different strategies to be offered and supported for differing personality types within a staffing group.

2) The addition of clear, and genuine, organisational and supervisory validation of the complexity and difficulty of the support worker role.

3) The use of some compassion focussed ideas (e.g. Compassion Focused Therapy: CFT; Gilbert, 2009) for working on self-compassion, compassion within the team, and compassion for service users could also be helpful.

Societal and political issues are also highlighted as having an impact on homelessness (Cockersell, 2011, Hopper et al., 2010). Support staff within the study highlighted their new levels of insight into the lack of investment in youth, an inequality in opportunity, and the need for a greater community approach within the role. There was a feeling the contextual landscape had worsened over time, and together with the findings from this study which highlight the immensely challenging role of working with this complex group, I feel it is vitally important that more comprehensive feedback around these issues is provided to policy makers.

In terms of my own learning, my research competencies, which are crucial to being a scientist-practitioner, have developed throughout the process of conducting this research. I have learnt specific techniques of qualitative methodology (Grounded Theory), have gained confidence in my ability to engage with an organisation and conduct clinically relevant research, and I have realised the importance of conducting research in practice. As a Clinical Psychologist researcher, I found it a challenge to balance my passion for the subject with the selectivity required in the process. However, in conducting this research, I have attempted to remain as objective and scientific as possible. I developed my abilities to make decisions on the centrality of concepts and the relational links between ideas. Although, at times I found it hard to let elements of the analysis go, reflection within my supervision has hopefully enabled me to ‘do justice’ to the experiences of the staff that gave their time to be involved in this research and I am proud that their ‘voices’ have now been formally acknowledged and published within the wider academic literature on youth homelessness. I now look forward to working with the PIE Team, and the wider organisation of Centrepoint, to see how we can take these ideas forward to the benefit of all of our amazing support staff that work each day with homeless young people in the UK…‘