Presentation on theme: "Psychologically Informed Environments"— Presentation transcript:
1Psychologically Informed Environments Peter CockersellSt Mungo’s
2Tackling homelessness and exclusion- understanding complex lives The report looked at 4 research programmes commissioned as part of the Multiple Exclusion Homelessness (MEH) Research Programme, which ran form Feb 2009 to Sept 2011.Fitzpatrick et al., Heriot-Watt UniversityCornes et al., King’s College LondonDwyer et al., University of Salford and Nottingham Trent UniversityBrown et al., University of Salford and University of Lincoln
3The main findingsNearly half of services users reported experiences of institutional care, substance misuse and street activities such as begging as well as homelessness.Using hostels or making homelessness applications commonly happened after contact with non-housing agencies such as mental health services, the criminal justice system and social services.Traumatic childhood experiences and later self harm and suicide attempts in adulthood were a commonly reported factor.Housing and hostel staff often take the primary responsibility for supporting people with multiple and complex needs, often without support.
4These tell us three important things Some clients using non-housing services will go on to rough sleep and staff in these services need to be able to recognise those at risk, and know where and how to make appropriate referrals.The impact of early childhood trauma must be explicitly acknowledged by both housing and non-housing service providers and included in the assessment process.Housing and hostel/floating support/day centre staff should be trained and supported to work with clients with multiple and complex needs.
5St Mungo’sAbout 2000 beds: hostels to self-contained flats, including registered careSpecialised drug, alcohol, mental health, dual diagnosis; older, women’s, and sexworkers’ projectsStreet outreach, 2 day centres, employment, training, substance use, health, and psychotherapyLondon, Reading, Oxford, Bath and Bristol
6St Mungo’s clients 61% substance dependency/ies 69% mental health problems46% substance dependency and mental health problems34% substance dependency, mental health and physical health problems(Client survey 2009)
7St Mungo’s clients’ childhoods 47% experience of neglect/emotional abuse34% early loss of parents through abandonment, separation or divorce31% early loss of parents through death (including murder and suicide)27% sexual abuseHigh levels of parental alcoholism, drug use, and domestic violence
8Impact of TraumaHomelessGeneralPersonality disorders: 60-70% (So’ton University, 2009; Oxford University, 2008)Psychotic illnesses: 31% (SLaM, 1989; CHAIN, 2010)Anxiety/depression: 50-80% (Oxford University, 2008)Personality disorders: 5-13% (DH, Recognising Complexity, 2009)Psychotic illnesses: 0.4% (NHS Information Centre, 2008)Anxiety/depression: 17.6% (NHS Information Centre, 2008)
9Behaviours associated with Complex Trauma Self-harmUncontrolled drug or alcohol useImpulsive, careless of the consequencesWithdrawn, reluctant to engageAnti-socialIsolatedAggressiveLacking daily structure or routineInability to sustain work or educationBullying, or being a victimOffendingUnstable relationships
10Catalysing Change: Theory Negative internal working models (Bowlby)Insecure attachment paradigms (Bowlby)Damaged affect regulation (Schore)‘Frozen’ cognitive responses and coping strategies (Siegel)
11Catalysing Change: Practice Recovery approach – positive regard and positive aspirationsRespect and intensive engagementIndividualised approach to problem-solving – Outcomes StarMultiple optionsPsychologically informed environmentPsychotherapy
12Origin of PIEsRobin Johnson and Rex Haigh developed ‘enabling environments’PIPEs developed in criminal justice systemPIEs developed in communityHelen Keats (DCLG), Nick Maguire (Southampton Uni), Robin Johnson (RJA Consultancy), Peter Cockersell (St Mungo’s and Homeless Healthcare CIC)
13What is a PIE?Hostels and day centres are highly managed and reactive environments focusing on risk assessment and crisis management. This has an impact on client outcomes.PIEs will identify, adapt and consciously use the managed environment to focus on the psychological and emotional needs and capacities of clients in a positive wayPIEs use a therapeutic framework to develop clear and consistent responses to clientsPIEs are not simply about containing challenging behaviour, but changing it; they create an empowering and calming environment where people can feel emotionally as well as physically safe, and can gain an understanding of their behaviour and an ability to take responsibility for themselvesReflective practice, and effective supervision, are essentialPsychologically aware housing services are not a replacement for clinical services; health commissioners should be involved to ensure that people with complex trauma, and including those with dual diagnoses, have accessible and appropriate clinical services
14Key IngredientsA Psychological Framework Social Spaces Staff Training and Support Managing Relationships Evaluation of Outcomes
15Key Ingredients Psychological Framework Cognitive Psychodynamic EclecticSocial SpacesRemodelling is not essential!Welcoming and non- institutionalEncourage interactionSafe movement, and safe meeting spaces
16Managing Relationships Key IngredientsStaff Training and SupportReflective practiceGood supervisionClient involvementOngoing evaluationCorporate theoretical framework and approachManaging RelationshipsConsistent boundaries, sanctions and rewardsPro-social modellingAwareness of powerPositive regardPsychological and emotional awareness
17PIE Pilots Old and Crusty Brent Dual Diagnosis Lifeworks Psychotherapy ServiceJust BakingMental Health projectsRolling shelterAccess hostelWomen’s projectLondon and Bath
19Staff support and training Clinical supervisionClient access to psychotherapyReflective practiceTraining:Attachment, etc: psychological perspectivesMotivational interviewing, etc: psychological techniquesThe Escape Plan: client perspectivesRecoveryLeadership & Performance ManagementCorporate Commitment and Framework
20Managing Relationships Complex trauma arises from abusive relationshipsHealing relationships need to be managed, and take care, and timeRelationships have an impact on both/all partiesGroup dynamics affect individual group members’ relationshipsSetting up PIEs is also about managing relationships
21Brent Dual Diagnosis and Lifeworks Brent DDPsychotherapist and specialist SU Worker as part of teamClients discharged from hospital with severe and enduring mental illness and substance dependencyReflective practiceGroups, 1-1’s, individual therapyNo rehospitalisations17 of 18 positive moves to less supported housingLifeworksIndividual psychodynamic psychotherapyStatutory and voluntary sector referrals at 8 sites; ‘chronically excluded adults’67% engagement (4+ sessions) (IAPT, 38%); 75% positive outcomes MWIA measure (IAPT, PHQ9, 44%)100% increased positive outcomes on Outcome Star3X more likely to go from pre- contemplative to active42% employment/training placements
22Client Testimony 1I was drinking and using drugs for a long time, I used to work in the music business but lost it and ended up sleeping rough. I had a lot of family problems and for a long time, thought it was all my fault. Through my work with Life Works I now know it wasn’t just me, it was all of us, none of us are perfect. May be if my parents had used this service things may have turned out different. I think it could have helped them. I now realise that the drink, the drugs, (losing) the flat, the family, it’s all linked. I think I need more (therapy), I wish I was still there (Life Works). If it wasn’t for them I’d be dead by now, no word of a lie.
23Client Testimony 2I didn’t want to go initially, thought I didn’t need to see a shrink. I gave it a go and the first few sessions were very informal, unthreatening. I grew to trust her, told her things I haven’t told anyone else. A lot of tears were shed, she didn’t drag it out of me, she listened. I got shit out of my system that I’d been carrying around a long time. There was an underlying burden in my heart that she knew what to do with. Everything I said wasn’t written down and I loved that. It was properly confidential. It was a hard one but it was a good one and if it wasn’t for her I’d be floating down the Thames now.
24More readingCockersell P (2011a) Homelessness and mental health: adding clinical mental health interventions to existing social ones can greatly enhance positive outcomes, in Journal of Public Mental Health, 10(2), 88-98Cockersell P (2011b), More for Less? Using PIEs and Recovery to Improve Efficiency in Supported Housing, Housing, Care and Support Journal, 14(2), 45-51Maguire NJ, Johnson R, Vostanis P, Keats H, and Remington RE, (2009) Homelessness and Complex Trauma: A review of the literature. Southampton: e- prints.soton.ac.ukJohnson R and Haigh R (2011), Social Psychiatry and Social Policy in the 21st Century: new concepts for new needs – the ‘Enabling Environments’ initiative, Mental Health and Social Inclusion, 15(1) 17-23
25Further InformationOperational Guidance will be published in the new year by Homeless Healthcare CIC, Southampton University, RJA ConsultancyThere is a PIE group on LinkedInContact me: