Psychologically Informed
Environments
Peter Cockersell
St Mungo’s
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Tackling homelessness and exclusionunderstanding 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 University
• Cornes et al., King’s College London
• Dwyer et al., University of Salford and Nottingham Trent University
• Brown et al., University of Salford and University of Lincoln
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The main findings
• Nearly 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.
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These tell us three important things
1. 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.
2. The impact of early childhood trauma must be explicitly
acknowledged by both housing and non-housing service providers
and included in the assessment process.
3. Housing and hostel/floating support/day centre staff should be
trained and supported to work with clients with multiple and
complex needs.
St Mungo’s
• About 2000 beds: hostels to self-contained flats,
including registered care
• Specialised drug, alcohol, mental health, dual
diagnosis; older, women’s, and sexworkers’
projects
• Street outreach, 2 day centres, employment,
training, substance use, health, and
psychotherapy
• London, Reading, Oxford, Bath and Bristol
St Mungo’s clients
• 61% substance dependency/ies
• 69% mental health problems
• 46% substance dependency and mental health
problems
• 34% substance dependency, mental health and
physical health problems
(Client survey 2009)
St Mungo’s clients’ childhoods
• 47% experience of neglect/emotional abuse
• 34% early loss of parents through abandonment,
separation or divorce
• 31% early loss of parents through death
(including murder and suicide)
• 27% sexual abuse
• High levels of parental alcoholism, drug use, and
domestic violence
Impact of Trauma
Homeless
General
• Personality disorders: 60-70%
(So’ton University, 2009;
Oxford University, 2008)
• Personality disorders: 5-13%
(DH, Recognising Complexity,
2009)
• Psychotic illnesses: 31%
(SLaM, 1989; CHAIN, 2010)
• Psychotic illnesses: 0.4% (NHS
Information Centre, 2008)
• Anxiety/depression: 50-80%
(Oxford University, 2008)
• Anxiety/depression: 17.6%
(NHS Information Centre,
2008)
Behaviours associated with Complex
Trauma
• Self-harm
• Uncontrolled drug or alcohol
use
• Impulsive, careless of the
consequences
• Withdrawn, reluctant to
engage
• Anti-social
• Isolated
• Aggressive
• Lacking daily structure or
routine
• Inability to sustain work or
education
• Bullying, or being a victim
• Offending
• Unstable relationships
Catalysing Change: Theory
• Negative internal working models (Bowlby)
• Insecure attachment paradigms (Bowlby)
• Damaged affect regulation (Schore)
• ‘Frozen’ cognitive responses and coping
strategies (Siegel)
Catalysing Change: Practice
• Recovery approach – positive regard and
positive aspirations
• Respect and intensive engagement
• Individualised approach to problem-solving –
Outcomes Star
• Multiple options
• Psychologically informed environment
• Psychotherapy
Origin of PIEs
• Robin Johnson and Rex Haigh developed ‘enabling
environments’
• PIPEs developed in criminal justice system
• PIEs developed in community
• Helen Keats (DCLG), Nick Maguire (Southampton Uni),
Robin Johnson (RJA Consultancy), Peter Cockersell (St
Mungo’s and Homeless Healthcare CIC)
What 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 way
• PIEs use a therapeutic framework to develop clear and consistent
responses to clients
• PIEs 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 themselves
• Reflective practice, and effective supervision, are essential
• Psychologically 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
Key Ingredients
A Psychological Framework
Social Spaces
Staff Training and Support
Managing Relationships
Evaluation of Outcomes
Key Ingredients
Psychological
Framework
• Cognitive
Social Spaces
• Remodelling is not
essential!
• Psychodynamic
• Welcoming and noninstitutional
• Eclectic
• Encourage interaction
• Safe movement, and safe
meeting spaces
Key Ingredients
•
•
•
•
•
Staff Training and Support
Reflective practice
Good supervision
Client involvement
Ongoing evaluation
Corporate theoretical
framework and approach
•
•
•
•
•
Managing Relationships
Consistent boundaries,
sanctions and rewards
Pro-social modelling
Awareness of power
Positive regard
Psychological and emotional
awareness
PIE Pilots
Old and Crusty
Just Baking
• Mental Health projects
• Brent Dual Diagnosis
• Rolling shelter
• Access hostel
• Lifeworks Psychotherapy
Service
• Women’s project
• London and Bath
Psychological Framework
Psychodynamic (Shedler)
Attachment
Cognitive
Recovery
Staff support and training
•
•
•
•
Clinical supervision
Client access to psychotherapy
Reflective practice
Training:
Attachment, etc: psychological perspectives
Motivational interviewing, etc: psychological techniques
The Escape Plan: client perspectives
Recovery
Leadership & Performance Management
• Corporate Commitment and Framework
Managing Relationships
• Complex trauma arises from abusive
relationships
• Healing relationships need to be managed, and
take care, and time
• Relationships have an impact on both/all parties
• Group dynamics affect individual group
members’ relationships
• Setting up PIEs is also about managing
relationships
Brent Dual Diagnosis and Lifeworks
Brent DD
• Psychotherapist and specialist SU
Worker as part of team
• Clients discharged from hospital with
severe and enduring mental illness
and substance dependency
Lifeworks
• Individual psychodynamic
psychotherapy
• Statutory and voluntary sector
referrals at 8 sites; ‘chronically
excluded adults’
• Reflective practice
• 67% engagement (4+ sessions) (IAPT,
38%); 75% positive outcomes MWIA
measure (IAPT, PHQ9, 44%)
• Groups, 1-1’s, individual therapy
• 100% increased positive outcomes on
Outcome Star
• No rehospitalisations
• 3X more likely to go from precontemplative to active
• 17 of 18 positive moves to less
supported housing
• 42% employment/training placements
Client Testimony 1
• I 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.
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Client Testimony 2
• I 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.
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More reading
• Cockersell 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), 88-98
• Cockersell P (2011b), More for Less? Using PIEs and Recovery to Improve Efficiency
in Supported Housing, Housing, Care and Support Journal, 14(2), 45-51
• Maguire NJ, Johnson R, Vostanis P, Keats H, and Remington RE, (2009)
Homelessness and Complex Trauma: A review of the literature. Southampton: eprints.soton.ac.uk
• Johnson 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
Further Information
• Operational Guidance will be published in the
new year by Homeless Healthcare CIC,
Southampton University, RJA Consultancy
• There is a PIE group on LinkedIn
• Contact me:
peter.cockersell@mungos.org