Psychologically Informed Environment Principles in Adult Residential Care

Iain Boag

• Publisher: Taylor & Francis
• Year: 2020
• Print ISBN: 9780367436476
• eBook ISBN: 9781000052657
• Edition: 1
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

As pressure grows on care managers and staff to work with ever more complex needs, this book is a timely account of how introducing the Psychologically Informed Environment (PIE) principles into a care home will improve work practice and outcomes for residents.

The PIE approach enables staff to:

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• Have improved understanding of residents' needs

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• Better understand how to respond effectively to complex behaviour

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• Introduce trauma-informed practice into their work

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• Improve staff support and morale

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• Improve outcomes for even the most hard to reach clients

Reflecting on one care home's journey to becoming a PIE this book shows how low-cost, high-impact interventions delivered on the frontline can have far reaching effects on the wellbeing of residents, staff and wider culture of the care environment. It will be of interest to all professional, academics, policy-makers and students working in the fields of adult social services and health and social care more broadly.

1
Highwater House

Highwater House is a 22-bed residential care home, providing care for men or women aged 18–65 who have a dual diagnosis.

Dual diagnosis is defined as: ‘an individual who presents with co-existing mental health (and/or Personality Disorder) and substance misuse problems (drugs and/or alcohol)’.¹ This definition does not begin to express the devastating social and emotional impact that living with such co-morbidity has on people’s lives.

In 2005 a dual diagnosis strategy was announced in Norfolk to find ways to improve working with this challenging client group, recognising that ‘their behavioural problems and reluctance to engage with services adds to the challenge. Consequently, this group tends to be stigmatised and responsibility passed across agencies.’² Highwater House was part of this strategy.

The service is part of St Martins, the Norwich-based homeless charity, which has been supporting vulnerable people since 1972. Consequently, as an organisation, it has adapted many times to the changing needs of the homeless population, and to improved understanding of the causes of homelessness, and has found ways to address these needs with compassion.

I began working for St Martins in 2003, in a service called St Martins House. At that time, it was being recognised that the traditional night shelter could not provide for the complex needs being seen in some of the users. St Martins House was the response to this – a registered premises housing 33 ‘complex’ characters; in it we cared for the homeless who were mentally unwell, and who were struggling to access the night shelter. Some were isolated and unable to cope after the local large mental health hospital closed its doors in the 1990s in favour of providing care in the community, some were too chaotic to use mainstream services – their anti-social behaviour excluding them from much needed support ‒ still others were the product of the failing care system of the 1980s. The home was a sincere attempt to support some of the most troubled and challenging people in the community – people who would become, by and large, to be known as dually diagnosed.

By 2008 St Martins House had undergone a transformation. The building, deemed unfit for purpose, had been renovated, and was renamed Highwater House – reduced to a 22-bed registered care home and with a specific remit to work with dual diagnosis, and so became the service it is today.

The alterations to the building reflected society’s changing response to homelessness, mental ill-health, and addiction. The dual diagnosis strategy was a recognition that people were falling through cracks in the system and ending up in chronic isolation, on the streets and unsupported.

The dual diagnosis model we used at Highwater House shifted the focus away from working with homelessness and towards working with vulnerability, and away from coping with our residents’ challenges, and towards constructively supporting positive change in them.

This process was not without its difficulties. Workers, skilled in conflict management and used to ‘night shelter behaviour’, found the increasingly caring role a struggle at times. Introducing new models of support asks staff to change and adapt their own behaviour, which is not always an easy task, or welcome. In the main however the challenge to change was met with a positive, if wary, attitude.

The Psychologically Informed Environment approach has been another such stepping stone on Highwater House’s journey, and another leap into the unknown.

The care provided at Highwater House has always mirrored and incorporated changes being enacted across wider society. As part of a relatively small charity it has the ability to be progressive and innovative, being less beholden to statutory mechanisms. With its roots in homelessness it has a ‘can do’ attitude, a willingness to try new ideas out.

As understanding of how to work with trauma and addiction improves, so the service has reflected this in its care delivery. It is somewhat of a magpie service, and, when prompted by commissioners to find innovative ways to improve the care for its in-need residents, has stretched itself to find new, creative responses.

Highwater House is quite a unique residential care home, and therefore is in the vanguard of pushing the traditional role of a care home beyond its usual boundaries. Some of the characters you will meet within this book may seem extreme as their acute needs are met.

But it is through extremes that we find the centre. I hope that the examples throughout the book help to align that centre in favour of the residents – as individuals in need, and as humans that deserve connection.

Notes

1 Sourced from www.dualdiagnosis.co.uk/uploads/documents/originals/Norfolk%20Dual%20Diagnosis%20Strategy.pdf, 11.

2 Sourced from www.dualdiagnosis.co.uk/uploads/documents/originals/Norfolk%20Dual%20Diagnosis%20Strategy.pdf, 4.

2
What is a Psychologically Informed Environment (PIE)?

In this chapter we will:

• Explore PIE as a psychosocial framework designed to support individuals with complex needs and compound trauma
• Discover that building trusting relationships are key to using the PIE framework
• See PIE to be an adaptable framework suitable for use in all human services
• Be introduced to relationships and reflective practice as the core principles of PIE, and to the five key elements of the PIE model

This chapter introduces the PIE principles as a model of support which places emphasis on building strong, trusting connections between carer and resident; this rapport is used as the key tool to enact change in the resident’s life.

Frontline carers are the face of any human service and the gateway through which service users access support; they have more contact – formal and informal – with service users than anyone else; they provide physical care and are often the primary ear; and they provide friendship, guidance, and support throughout the service users’ stay at the home.

The importance of this role cannot be overstated. Carers play the role of parent, friend, and advocate; of guardian, nurse, rule-enforcer, and supporter. They are figures of trust and safety as well as of authority. A carer’s typical day involves meeting multiple needs in the complex worlds of the residents; the caring role – sometimes official, sometimes benign – is always purposeful. ‘There is artistry in human relationships’,¹ and carers embody this.

Negotiating this array of roles can be as demanding as it is rewarding, and when working with people with a wealth of mental health and substance use issues, and a lifetime of painful memories, this can be especially so. The innate drive to nurture and to protect, inherent in the carer, can be subsumed by the realities of working with issues of such enormity, of such human catastrophe. Carers need as many tools as possible at their disposal to help them keep their residents, themselves, and fellow workers safe. The PIE framework helps to do so.

Defining a PIE

• Psychologically – ‘in a way that affects the mind or relates to the emotional state of a person’
• Informed – ‘having or showing knowledge of a subject or situation’
• Environment – ‘the surroundings or conditions in which a person, animal, or plant lives or operates’²

The many definitions of PIE to be found all agree on a basic tenet: PIE is a humanistic psychosocial model of support which places building relationships between worker and client as the core goal and as the key tool to enact change.

2012 saw the publication of Psychologically Informed Services for Homeless People – Good Practice Guide – it is readily available to view and download online, and is a key document in the evolution of the PIE model. In it a PIE is defined as: ‘[a service] that takes into account the psychological make-up – the thinking, emotions, personalities and past experience – of its participants in the way that it operates’.³

This definition challenges human services to place the client at the heart of their care experience. Despite the Good Practice Guide being created to improve support in homeless provisions, the sentiment will resonate throughout any service providing for vulnerable or marginalised people, as residential care homes do.

Inferred in this definition is that services, despite their best intentions, might be primarily answering the needs of the system, staff, or inspectors – with an accidental bias towards the service succeeding rather than the people it is serving. The PIE model, then, aims to redress this systemic bias – another definition of PIE is:

if asked why the unit is run in such and such a way, the staff would give an answer couched in terms of the emotional and psychological needs of the service users, rather than giving some more logistical or practical rationale, such as convenience, costs, or Health And Safety regulations.⁴

Throughout the book I argue that systems and services created to support vulnerable people can be unintentionally harmful, especially to those who have experienced traumatic events in their lives such as childhood abuse, being sectioned under the Mental Health Act, or who have become socially rootless. The seemingly benign structure of the care home can unwittingly compound previous trauma, notably for those who have spent time in the psychiatric system (as all of our residents at Highwater House have).

However, if workers use the environment mindfully, it is a unique opportunity to enact positive change. The care environment is not passive, nor are carers’ actions within it – how workers behave affects the residents either positively or negatively. Using PIE principles can help undo the abrasive damage that constant contact with the care system can inflict on a person. The framework helps workers to put the ‘human’ before the ‘service’ in human services.

Another definition of a PIE, provided in Social Exclusion, Compound Trauma and Recovery, is: ‘a framework for designing “frontline” services that can react as a benign, reflective, complex adaptive system and therefore deal creatively and effectively with complex problems and the complex people experiencing them’.⁵

Working with complex needs can be a frustrating experience. As workers try to support a dual diagnosis client to access other helping services, they can be met with a bewildering set of inclusion criteria – one aspect of the residents’ health needs excluding them from accessing help to address another, equally urgent, health-need. At Highwater House our residents have been told time and again: to access counselling you must be sober; to access drug and alcohol services you mustn’t be too mentally ill; and to access mental health services you mustn’t have a crippling addiction. So, a drug and alcohol service’s inclusion criteria might involve a client taking part in group work, but if they suffer from intense social anxiety, born from years of trauma, how will they cope? By self-medicating using alcohol to numb the worst effect of their anxiety. They are then deemed ‘not ready to engage’ and ejected from the system. Thus, they are placed in a chronic anxiety-making state, the most in need of help unable to access it, caught in a cruel, self-perpetuating cycle.

Our remit at Highwater House has always been to work with such ‘unreachable’ clients. Historically our primar...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• Acknowledgements
• Introduction
• 1 Highwater House
• 2 What is a Psychologically Informed Environment (PIE)?
• 3 Trauma-Informed Care
• 4 Relationships
• 5 Reflective practice
• 6 Elastic tolerance
• 7 Psychological awareness
• 8 Environment
• 9 Evidence
• 10 Rules, roles, and responsiveness (the 3 Rs)
• 11 Staff support and training
• Conclusion
• Index