‘The ‘How’: Introducing new guidance on what it means to be working in a psychologically informed manner in the homeless sector’.
21.07.2023: As I write this week’s PIE blog, as the Lead for Psychologically Informed Environments (PIE) at the national youth homeless charity — Centrepoint, I would like to build on the previous PIE blog, that focused on the importance of ‘soft skills’ (see here: https://drhelenmiles.medium.com/soft-skills-or-psychologically-informed-skills-why-are-these-important-in-a-pie-7cf5b9a15515). This is because in the past couple of weeks, guidance for psychologists working in the homeless sector (that I alongside other psychology colleagues working nationally in this area contributed to) have been published. For details of this specific guidance, supported by Homeless Link, Association of Clinical Psychologists (ACP) and the University of Nottingham (Wells et al, 2023) — please access the link here: https://frameworkhousing-my.sharepoint.com/personal/anna_tickle_frameworkha_org/_layouts/15/onedrive.aspx?id=%2Fpersonal%2Fanna%5Ftickle%5Fframeworkha%5Forg%2FDocuments%2FClinical%20guidelines%2C%20briefings%20and%20resources%2FWells%20et%20al%20Practice%2Dbased%20guidelines%20CPs%20homelssness%2Epdf&parent=%2Fpersonal%2Fanna%5Ftickle%5Fframeworkha%5Forg%2FDocuments%2FClinical%20guidelines%2C%20briefings%20and%20resources&ga=1.
Although the document is fairly long (running to just over 30 pages), I would argue that it is a very useful document, the reading of which is time well spent as it has lots of good practice examples as well as a detailed resource list in the appendix. Moreover, when I was reviewing this new professional guidance for psychology about working in the homeless sector, I was struck by how much of it was arguably not just relevant for clinical psychologists, but rather anyone working with homeless clients.
Therefore, I wanted to outline the guidance in more detail in this blog, noting how the PIE focus that runs throughout these guidelines is actually very useful for all ‘frontline’ staff when reflecting on how they are working with homeless clients (as well as for those in management or planning service delivery). Most importantly, I would encourage readers of this blog to reflect upon where they might be working in this ‘psychologically informed’ way for the points raised relevant to their day to day work, and where they might need to action changes, modifications or adaptations to their approach to be more ‘PIE’…
To summarise, the guidance is divided into both direct and indirect delivery work, with sub-sections on multi-agency working and systems change. The former referring to when you are working with a homeless young person ‘in the room’ and the latter, when you are supporting other staff within an organisation to do the direct work with the homeless individual or considering how you work with other partner organisations. All the guidance points raised are included because they have been shown to be effective when working with homeless clients; in other words, they are evidence based from either research studies or the experience of those working in this area over many years.
So to the specific guidance…. The first section is related to direct work and importantly starts with the central tenant of PIE — ‘Relationships’. The first point is ‘be flexible in your approach, holding the person at the centre of your work, encouraging all opportunities to engage’ (Wells et al¸ 2023; p.5). This means ensuring that we consider when, how and where we engage with others (i.e. both in services and in outreach), ensuring we are taking every chance to build that valuable relationship with the individual and are not demanding they engage with us only on our terms (e.g. fixed sessions) or if there is a problem. The reason for this is highlighted and explained further in the second point: ‘prioritise relationship building as it can take time to build trust and engagement’ (Wells et al, 2023; p.5). The Centrepoint young people stated exactly this point in our PIE development noting that they had been rejected, let down and hurt in past relationships, which meant that they often afraid to build a relationship with staff for fear of the same thing happening in the future. We need to understand this, and not expect our work with them to follow any pre-determined or ‘perfect’ route, that can be de-railed by other life events or re-triggering of past traumatic experiences.
Consequently, when we are working with homeless clients we need to ‘attend to the therapeutic relationship, being mindful of the interaction between trust and attachment’ (Wells et al, 2023; p.6). It is also noted that we need to be mindful of the relational and power dynamics between ourselves and those we support as well as ensuring that we ‘consider the likely trauma history of service users you are working with, appreciating engagement can be a long process, as it is likely that trust has been violated multiple times’ (Wells et al, 2023; p.7). This can be frustrating at times, after all we all do this work to help others! However, as I often discuss with staff in reflective practice, it is important we do not take rejection personally and understand that it might be that the homeless young person does not feel safe to engage with us yet and/or maybe testing us to see if we will ‘give up’ on them too.
The guidance also highlights that ‘many people who are homeless have lost touch with hope, so it is important to actively maintain it’ (Wells et al, 2023; p.7) and we need to ‘have a realistic sense of optimism, having a sense of it being worth trying even with a deep level of complexity’ (Wells et al, 2023; p.8). Sometimes this can be very powerful to communicate to the homeless young person because it highlights that we believe in them and their ability to #changethestory. This can be a challenge however, especially when we are operating in challenging socio-political contexts and systems, so it is important to utilise supervision and reflective practice spaces to hold onto our hope — ‘have strong self-awareness and reflective practice, for example through … supervision’ (Wells et al, 2023; p.9).
Moreover, with regard to direct working, it is advised that we should try to ‘encourage curiosity in both staff and service users, and their wider support network (e.g. family members, other staff)’ (Wells et al, 2023; p.8). This approach of curiosity can be helpful to validate experiences and help them to consider what other approaches or support may be helpful. The question should always be ‘what has happened to you’ not ‘what is wrong with you?’ and we should remember that we have not had their individual experiences, but that does not mean we cannot seek to understand and empathise with them by being non-judgemental, open and curious. Again, this also helps us build those critical relationships in a PIE that support positive change and recovery.
There is also some specific guidance that is applicable to psychological interventions although again I would argue these points are also relevant when offering individual support or key-work sessions to some degree. For example, it is noted that we ‘do not exclude someone from psychological therapy because of their presenting difficulties (including dual diagnosis/substance misuse’ (Wells et al, 2023; p.14). Instead, it is suggested that we adapt our practice to be inclusive and work to ensure we give a homeless young person the best chance to engage with us, perhaps considering practical or tangible actions to build rapport or consider motivational conversations. We need to remember that ‘working with the pre-contemplation stage is critical — you have to work with where the person is at regarding their sense of self, motivation, and values’ (Wells et al, 2023; p.14) as often those we support might not be used to being supported or feel they need support as they have had limited experience of this previously.
Consequently, we should ‘follow a graded model of care that includes flexibility and creativity and allows people to come into contact and take support at their own pace, starting with informal engagement’ (Wells et al, 2023; p.15) and that ‘it is important that goal setting is done collaboratively’ (Wells et al, 2023; p.17). This approach helps create a psychologically safe space for the homeless young person, that builds engagement and does not overwhelm them because ‘trauma is highly prevalent in this population (both historic and current/repeated patterns of trauma’ (Wells et al, 2023; p.17), which we need to remain mindful of in our interactions with them. There is also an important reminder that ‘endings are just as important as beginnings’ (Wells et al, 2023; p.20), so that we can support a homeless young person to move on without any feelings of rejection.
Some other points noted is that staff should ‘consider screening for cognitive and neurological problems’ (Wells et al, 2023; p.16) as these can impact on presentation and longer term prognosis. If supported accommodation staff in Centrepoint are therefore concerned about these issues in the homeless young person they are supporting, then do speak to one of the PIE psychologists to discuss further in terms of assessment options and recommendations for adapted ways of working. Other points in the guidance also reflect a psychological way of working, and are included in both our PIE offers of staff training and reflective practice. For example, ‘formulation is key’ (Wells et al, 2023; p.18), ‘make use of integrated models of psychology, paying attention to attachment and theories of motivation’ (Wells et al, 2023; p.18), ‘consider what model fits the person, and how to adapt it based on their current circumstances’ (Wells et al, 2023; p.19) and the importance of applying the ‘frameworks of trauma informed practice and psychologically informed environments (PIEs)’ (Wells et al, 2023; p.19). The latter point is critical to ensure that we are connecting with and empowering the homeless young people we support, and we are being alert to the impact of past trauma and avoiding any re-traumatisation in their time with us.
The guidance then considers some important points for multi-agency working. In this sector, especially within a homeless charity like Centrepoint, we are always working in partnerships with others both statutory (e.g. mental health services, social services, criminal justice systems) and non-statutory such as other charities. It is therefore advised that we ‘think carefully about what your role should be with this person’ (Wells et al, 2023; p.10). In other words, within the network of professionals around the homeless young person, who has what role, who is best placed to undertake a particular task (either because of their relationship with the individual or the service that they work in) and what boundaries need to be maintained (i.e. we do not take on everything!).
When working with other agencies, it is advised that we also maintain ‘clear communication, within the boundaries of consent, … with everybody’ (Wells et al, 2023; p.10) and ‘promote good multi-agency working across professionals especially when working with complexity and risk’ (Wells et al, 2023; p.12). This means information sharing, especially about risk, and ensuring regular professionals meetings so that the homeless young person is getting all the support they need at any one particular time. Of note, the guidance also highlights ‘when possible, be co-located and embedded within the multi-disciplinary team’ (Wells et al, 2023; p.12), further suggesting the importance of a ‘team around the person’ to best manage their often complex needs.
The final part of the guidance related to indirect work or to put it another way, working with other staff. Of course, as you would expect with psychologically informed guidance, this also starts with the importance of relationships! Therefore, the foundation of our work with others (wherever we work in the organisation; frontline or support) ‘has to be based on spending time to build relationships … and partnerships… with staff who are key to much of what we do’ (Wells et al, 2023; p.21). We therefore need to ‘think about your language and how you explain things to staff in a way that is accessible’ (Wells et al, 2023; p.22). Of course, it goes without saying that we should always ‘be mindful of the stress and pressures that staff … are under and how challenging their day-to-day work can be’ (Wells et al, 2023; p.22). Therefore, just as we have empathy for the homeless young people we support, we need to have empathy with our colleagues! This involves (whether we are managers or psychologists) ‘providing a space for validating workers’ emotional reactions/toll of the work and understanding behaviour’ because ‘… to buffer again burnout and vicarious trauma and the challenges of working in complex systems, a range of staff support systems are essential’ (Wells et al, 2023; p.23). Psychologists working in the homeless sector can be particularly aware and able to provide an ‘understanding of what is happening within teams or organisations’ (Wells et al, 2023; p.24) but all of use need to consider thinking about what we are doing and why we are doing it.
The guidance also reminds us all of the importance of ‘doing with’ not ‘doing to’ (as per a PIE), noting ‘where possible and appropriate, work should be led by service user involvement and feedback’ (Wells et al, 2023; p.25), whether that it through focus groups, surveys or other feedback mechanisms. However, this needs to be meaningful. There is a difference between consultation or ‘lip service’ (wherein you have decided what you want to do already and then are seeking validation for this) versus ‘co-production’ (wherein you involve stakeholders in the actual decision making). The latter creating a positive working culture, whilst the former risking alienation and frustration from staff who do not feel heard. Our indirect work with others is also highlighted to need to be ‘meaningful to the people and services we are working with’ (Wells et al, 2023; p.26) recognising the ‘service context in which they work, recognising and acknowledging the skills beliefs and ways of working already in the system’ (Wells et al, 2023; p.26). Just like with the homeless young people we support, working with our colleagues is about building on existing strengths in others to collaborate more effectively, share knowledge and discuss ideas in psychologically safe spaces that ‘give people a sense of control and foster a psychologically and trauma informed environment’ (Wells et al, 2023; p.27).
Sometimes the guidance notes that this might mean that we need to ‘model and reinforce the skills that we want to develop within systems and staff groups’ (Wells et al, 2023; p.27) and utilise multiple approaches such as case studies and telling ‘stories … as these can motivate people to work together’ (Wells et al, 2023; p.28). Moreover, it is noted that when we talk about ‘staff’ in a PIE, we mean that we need to work ‘collaboratively with all staff, including those working on shifts or domestic workers’ (Wells et al, 2023; p.28). We should be working respectfully with others are all levels of the organisation — as we are all important pieces of the puzzle in the battle to #EndYouthHomelessness.
Finally, the guidance focuses the importance of systems change. This I believe links with our Centrepoint strategy to end youth homelessness by 2037. In order to meet this aim in the longer term, as well as become more PIE on our journey to this point, we need to ‘think about the system the work is happening in … the organisations we are working with, the wider societal context and communities’ (Wells et al, 2023; p.31). For example, sometimes we need to be bold and ambitious (e.g. our Centrepoint Independent Living Scheme), whereas sometimes we need to perhaps enhance something existing or address a current challenge because ‘it is not always about seeking to create an entirely new initiative which has minimal chance of survival’ (Wells et al, 2023; p.32). Consequently, ‘joined up, systemic working is essential. Work closely with other agencies’ (Wells et al, 2023; p.32) because we can’t solve everything by ourselves. PIE is argued to be ‘in prime place to influence and develop services including mental health and the wider homeless service sector’ (Wells et al, 2023; p.33).
It is noted that ‘setting up specialist services for homeless people is not sufficient’ (Wells et al, 2023; p.34). Rather we need to promote inclusively within existing systems; ‘working to bring different services together and to proactively support the needs of people with multiple complex needs, bridging the gaps between services that service users can fall between, helping to address service exclusion’ (Wells et al, 2023; p.34) including developing ‘ideas nationally about psychological approaches to homelessness’ (Wells et al, 2023; p.35). Of course, in order to do this we need to know ‘what works’ in the homeless sector so the guidance concludes with noting that we ‘should allocate time to research and evaluation’ (Wells et al, 2023; p.36), which are then shared ‘more widely in the organisation and the research community’ (Wells et al, 2023; p.36). This research work, key in a PIE, is important as it will also help to influence policy and practice, address inequalities and even promote a more helpful and positive narrative around homelessness, something that at Centrepoint we believe is important to reduce the stigma that homeless young people can sometimes face.
In conclusion, this new guidance, which should also be read in conjunction with the National Institute of Clinical Excellence (NICE) Guidance on Working in Homelessness (c.f. https://www.nice.org.uk/guidance/ng214) for me marks an important consolidation of best practice and ways of working, not just for psychologists but also for anyone who is working in the homeless sector to practice in a more psychologically informed manner. I hope it has been useful to outline the guidance in this PIE blog, but as noted at the start, I would recommend taking a moment to read the full guidance and considering how you can apply it in your own practice wherever you work. I am grateful to my colleagues in the Network of Psychologists working in Homelessness and in particular, the authors of the guidance for articulating so well what makes practice in this area ‘psychologically informed’ or ‘PIE’. I look forward to applying this further in my own work, and supporting both by psychology and non-psychology colleagues in Centrepoint to do similar — we now know ‘how’ — so let us all ‘do’…