1 St Basils’ Model of PIE Housing Lin West Midlands – 12th January 2017Dr Amanda Skeate Consultant Clinical Psychologist Forward Thinking Birmingham & St Basils © St Basils & University of Birmingham

2 Introduction What is PIE? How does it work? St Basils’ PIE recipeOutcomes and outputs

3 © St Basils & University of BirminghamIn One Year, 4751 young people sought our assistance as homeless* 54% young men, 56% referrals were BME young people 21% aged years; 59% aged years 58% of 16/17 year olds NEET; 74% of 18-21y + 81% of y were unemployed Over 80% of YP cite family conflict as a contributory factor leading to homelessness 1/3 have multiple support needs D/V, complex trauma, ASD, sexual exploitation, self-harm, suicidal ideation; drugs and alcohol, criminal convictions * Figures from 2015/16 © St Basils & University of Birmingham

4 © St Basils & University of BirminghamFair Chance Social Investment Bond Programme 350 young people across 5 LA areas Homeless and NEET -100% Mental Health issues – 83% (Suicide/Self Harm – 35%) Offending background – 65% Learning Disability – 40% Substance Misuse – 55% (problematic) Abuse – 32% (reported) Debt/Eviction – 71% Sexual abuse/Sexual exploitation – 34% (female only) © St Basils & University of Birmingham

5 Housing Barriers Feared:Of all refusals and declines to accommodation projects: 79% of were due to the client being assessed as too high a risk Of these: 77% posed to great a risk for staff/other residents 76% refused due to the client needs being too high Homeless Link Support for single homeless people in England: Annual Review 2015 Feared: “They shouldn’t be here” “They need to be looked after by professionals” Blamed for lacking adaptive relational & practical skills “They should be independent” “rude and aggressive … entitled” “spoilt by the care system” Compared to other reasons e.g. out of area, wrong criteria (age) or no bed spaces Staff need to feel competent and confident to work with complex needs Otherwise people in need end up receiving the least help – don’t fit with either system © St Basils & University of Birmingham

6 © St Basils & University of BirminghamSt Basils’ PIE – A Whole Organisational Approach Psychologically Informed Environments Improve positive outcomes for young people: Harness & build resilience and capability Enable YP to move on, sustain independence in a challenging environment Ensure staff have skills, attitudes, behaviours and resilience to cope, and support positive outcomes for young people resilience © St Basils & University of Birmingham

7 © St Basils & University of BirminghamOur Journey… 2008 Rough Sleeper Strategy 2009 DOH and DCLG Research commissioned Enabling Environments: Rex Haig and Robin Johnson 2011 Launch of St Basils’ PIE programme in partnership with Dr Nick McGuire & NHS 2012 DCLG – PIE for Homeless People: Good Practice Guide 2013 Development of Mental Skills Training4Life™ with University of Birmingham 2015 Created Psychologically Informed Parenting Programme with UoB, NHS and Brap 2016 Further expansions: PIE4Work&Training™; and PIE4Education™; Parenting Young People™ roll out to NHS employees © St Basils & University of Birmingham

8 April 2016 A PIE Organisation Designed to meet the emotional and psychological needs of it’s clients A commitment to putting relationships at the heart of the approach* Meet needs of SU not other logistical and practical concerns such as convenience, H&S concerns, costs *Johnson & Haigh, 2010, 2011 © St Basils & University of Birmingham

9 Psychologically Informed EnvironmentsUtilise evidence-based psychological theories and models Applies scientific research to inform policies, processes, decisions and behaviour Recognises the most valuable tool for facilitating behaviour change is the relationships between people Therapeutic relationship predicts positive outcomes across a settings and problems* Benefits in engagement, adherence, positive behaviour change and recovery Research on the statistical power of the therapeutic relationship now reflects more than 1,000 findings* *Orlinsky et al., (2004) © St Basils & University of Birmingham

10 © St Basils & University of BirminghamApril 2016 PIE – 5 Key Areas Developing a Psychological Framework: Transforming the way a service operates not just an add on; Made explicit to all The physical environment and social spaces - Designing and managing social environments with service user input – Evidence based design Staff training and support - Reflective Practice Managing Relationships – not reacting to the obvious, managing challenging behaviour, at different levels , emphasise on what you can do rather than what they can’t, having difficult conversations with colleagues - splitting Evaluation of Outcomes – at individual level, as well as at team and organisational level © St Basils & University of Birmingham

11 PIE starts with … “The Physical Environment and Social Spaces”People need safe and comfortable places to live that meet their basic needs before being able to consider psychological or higher needs – there needs to be some stability Designing and managing social environments with service user input – Evidence based design Staff test – would you feel ok about your grown-up child to living here? Maslow’s Hierarchy of Needs © St Basils & University of Birmingham

12 St Basil’s PIE – Training & SupportA whole systems approach Explicit framework and expectations Development of a shared language Consistency with other programmes Partnership with Mental Health Services Training & Support PIE Foundation Training PIE Managers & Champions Workshop Reflective Practice Strategy Evaluation to measure outcomes In-house Psychologist Strategic development Case consultation Targeted PIE in areas of higher need De-briefing support following serious incidents

13 St Basils’ Reflective Practice GroupsA key element of PIE Describes the process of recapturing and analysing actions and processes in order to learn from incidents and improve the responsiveness of the service.

14 Emotional Dysregulation Invalidating EnvironmentsThen … “Developing a Psychological Framework” St Basils’ Trauma Informed Environment: Informed by Dialectical Behaviour Therapy* Emotional Dysregulation Invalidating Environments Developing a Psychological Framework: Transforming the way a service operates not just an add on; Made explicit to all *Marsha Linehan © St Basils & University of Birmingham

15 St Basils PIE Foundation Training Day 1April 2016 Core Skills Listening Skills In pairs, discuss a time when you really felt listened to … what was the impact on you … what did it feel like? In practice, good listening is sometimes rare © Dr A Skeate + Dr N Maguire

16 Using PIE to create a Trauma Informed EnvironmentEmotional Dysregulation Invalidating Environments Emotional Dysregulation Feel understood and contained Learn adaptive coping skills Build up positive activities Learn positive relational skills Validating Environments Validate past experience Promote reflection Teach & Reinforce positive learning Provide positive opportunities © St Basils & University of Birmingham

17 © St Basils & University of Birmingham“Managing Relationships” – Attitudes and Skills Empathic Listening Validation & Compassion Exploration & Reflection Formulation & Understanding Motivational & Productive Conversations Doing To Informing Telling Nagging Controlling Doing For Supporting Nurturing Fostering Dependence Disempowering Doing with Empathic Validating Empowering Collaborative © St Basils & University of Birmingham

18 PIE – Because sometimes our instinctive response … is not the helpful oneDean, 19 years old, NEET, Care leaver Very sociable, agreeable, funny Excluded from school at 15 Repeated failed attempts to start training/education programmes Typical impressions: irresponsible, immature, lazy, spoilt by ‘system’ Typical response: irritated, he makes outcomes [me] look bad

19 Vicious Cycle - CBT Course start date Belief: “I will fail”Poor motivation, hopeless-ness/ Anxiety Hangs with friends + cannabis (feels better) Makes excuses when confronted “I’m a failure” PIE – Because sometimes our instinctive response … is not helpful Outcome – Support Worker spent time to identify problem; Referred to Mental Skills Training Vicious Cycle - CBT

20 © St Basils & University of BirminghamYouth Engagement - Strategic Priority 3: YP fully Involved in shaping service and setting standards St Basils Youth Council engaging Resident Reps Scrutiny Panels 2 Ex-Residents full members on Board of Directors Youth Voice National Youth Reference Group Youth Homeless Parliament Scrutiny Panels – Young people are able to look at different areas of St Basils and discuss issues with a panel of St Basils staff on areas that matter to young people such Like Support, Safeguarding, Security Co-opts Board Members – 2 X Ex Residents on NYRG are fully fledged members of the Board of Directors directly engaging in the governance of St Basils. Youth Voice National Youth Reference Group / Youth Homeless Parliament funded by DCLG NYRG - Young people are trained and supported to be able to share their lived experience to bring about change both projects are creative and engaging putting young people at the focus of the group They take part in consultations and offer workshops and training on how best to involve other young people in reviewing services in order to improve those services. In the past 8 years they have worked with local governments, universities, hospital trusts and housing and youth charities and organisations. YHP - One Hundred young people from across the country, supported by our 9 partner agencies attended West Minster to advise Ministers of their views regarding proposed Government Policy, which will affect young homeless people Young people are trained and supported to be able to share their lived experience to bring about change both projects are creative and engaging putting young people at the focus of the group © St Basils & University of Birmingham

21 Training Example – PIE Tools The ABC ModelActivating Event Beliefs Consequences Dean doesn’t attend his induction for a placement Dean, 19 years old, NEET, Care leaver

22 Training Example – PIE Tools The ABC ModelActivating Event Beliefs Consequences Dean doesn’t attend his induction for a placement Staff: What will staff think about Dean? Dean: what beliefs will Dean have? Emotional Staff: How will staff feel? Dean: what about Dean? Behavioural Staff: How will the staff react? Dean: How will Dean manage his feelings?

23 Training Example – PIE Tools The ABC ModelActivating Event Beliefs Consequences Dean doesn’t attend his induction for a placement Staff: I have been let down Dean is lazy & ungrateful Dean: I fail at everything, there’s no point in trying, I’ll get grief from the staff – I’ve let him down (he was alright) Emotional Staff: Angry, irritated, let down Dean: Embarrassed, defensive, irritable Behavioural Staff: dismissive, prioritise others Dean: Avoid staff, smoke cannabis to chill out

24 Training Example – PIE Tools The ABC ModelActivating Event Beliefs Consequences Dean doesn’t attend his induction for a placement Staff: I have been let down Dean is lazy & ungrateful Dean: I fail at everything, there’s no point in trying, I’ll get grief from the staff – I’ve let him down (he was alright) Emotional Staff: Angry, irritated, let down Dean: Embarrassed, defensive, irritable Behavioural Staff: dismissive, prioritise others Dean: Avoid staff, smoke cannabis to chill out

25 Training Example – PIE Tools The ABC Model – An alternative responseActivating Event Beliefs Consequences Dean doesn’t attend his induction for a placement Staff: This is a pattern of behaviour Dean has good interpersonal skills, so there is a problem, we don’t understand Dean: I fail at everything, there’s no point in trying, I might as well Emotional Staff: Curious, interested, determined Dean: Embarrassed, defensive, irritable Behavioural Staff: makes an effort to make contact Is clear that Dean is not in trouble Dean: ???

26 © St Basils & University of BirminghamSt Basils Outcomes Last but certainly not least … “Evaluation of outcomes” Out of 4751 young people sought our assistance as homeless* 84% of young people were prevented from being homeless Of 1273 young people lived with us during the year 87% achieve positive outcomes and leave in a planned positive way 77% of young people who were NEET re-engaged with education, training and employment. Figures from 2015/16 © St Basils & University of Birmingham

27 Naz’s Story… Street Homeless “… Fair Chance has changed my life and they actually care … “ “I felt like I was just a job to them Video directed by the National Youth Reference Group © St Basils & University of Birmingham

28 Outcomes for Young peoplePIE leads to better engagement by: Breaking down typical barriers to support “Well I’ve had quite a few young people that have said, that have been in the system since they were babies and they say well people don’t usually understand me, why do you understand me? And I think that that is down to PIE … “ Project Support Worker “What PIE enables us to do is help them work through, over a period of time, the issues that have prevented them from moving on and being successful in their own lives.” St Basils Manager Year 1 KPIs: 13% reduction in serious incidents 31% reduction in NTQs for behavioural issues 19% reduction in unplanned departures Quote from staff: Outcomes of formulating: Well I’ve had quite a few young people that have said, that have been in the system since they were babies … because we’ve been trained to look at a pattern of behaviour and break it down and go through the really basic things, then actually you can look at something and say, I think you’re maybe feeling this way or behaving in this way because of a, b, c and then they’re like no way, that is what I’m doing and it irritates me that you know that, how do you know that. But using it themselves and being able to see that people understand them rather than just seeing them as a naughty child or an attention seeker or whatever, being able to understand them a bit deeper, then they open up more and they realise I can’t hide or play you like they have done in the past, then that bit works. in regards to people with authority and its about breaking that barrier down a little bit and actually kind of making sure that you’re not the person to be seen to be letting them down, you seem to be very inviting in regards to engagement with them and you seem to kind of be able to listen and kind of react in regards to their needs positively. So it means that they are more likely to engage with us rather than us telling them what to do, asking them what it is they want from us and hopefully being able to try and provide that. Developing YP’s self-regulation skills: I’ve had another young person who now it’s great, he has done it himself with a friend, so he copies what he’s been shown. So now he’s using it because he saw that it worked and where he felt like in a bit of a rut and had been on antidepressants because he didn’t know how else to deal with it, his antidepressants ran out, which was a bit naughty because he didn’t go back to the doctors, anyway, but he hasn’t needed to go back to the doctors because he uses it and honestly, this is the truth, he used it and it worked better and now he uses it with his friend, which is amazing. Increasing understanding of own patterns of behaviours © St Basils & University of Birmingham

29 Outcomes for Young people“I’ve had another young person who now it’s great, he has done it himself … he copies what he’s been shown. … he saw that it worked … [he] had been on antidepressants because he didn’t know how else to deal with it, … his antidepressants ran out … but he hasn’t needed to go back to the doctors … and now he uses it with his friend, which is amazing” PIE leads to better engagement by: Applying tools to manage own emotions and behaviours Moving forward (stop revolving doors/ vicious cycles) To stop spirals of deterioration into multiple complex needs - revolving door of homelessness/substance misuse/criminality/MH - YP helped to get back into EET/learn better relationships with support staff, teachers, employers Project Support Worker © St Basils & University of Birmingham

30 © St Basils & University of BirminghamOutcomes for staff A PIE workplace associated with: ↑ Job satisfaction ↑ Job engagement (vigour & dedication) Confidence to work in a PIE associated with: ↓ Job burnout (emotional exhaustion & depersonalization) “PIE … enables the worker to have some more of an understanding of the issues that young people are going through, so it depersonalises a lot of situations. Staff are, in some situations, less stressed because they have these tools to work with.” St Basils Manager Year 1 KPIs: 26% reduction in sickness absence 7% reduction in grievance and disciplinary actions PIE Message: improving the mental health and well-being is not just the job of MH "experts“ Staff are in demanding roles, pressures - the same techniques knowledge can help them - positive feedback about this - reduction in burn-out everyone can have a positive impact on someone's vulnerable MH Improve confidence in staff + Focus on what you can do to help - rather than refer on to "someone/something" else Research - better valued and positive staff will provide better support and care to yp To have a more validating environment for everyone Data from St Basils 2016 staff survey (N = 121) © St Basils & University of Birmingham

31 Expansions of St Basils’ PIEPIE4 Work& Training™ Mental Skills Training4Life™ NHS? Social Care? What Else? Parenting Young People™ PIE4 Education™ Two pilot workshops at different sites 11 parents © St Basils & University of Birmingham

32 The Mental Skills Training for Life™ ProgrammeMST VIDEO: https://www.youtube.com/watch?v=OfJDW9GFACc&feature=youtu.be @drjenncumming © St Basils & University of Birmingham

33 St Basils Foundation Training Day 3 SlidesApril 2016 Acknowledgements Jean Templeton – CEO, St Basils Dr Jennifer Cumming -MST4Life, University of Birmingham Lucy Clarke – PIE Programme Administrator, St Basils Thank You For Listening Dr Amanda Skeate - © St Basils & University of Birmingham © Dr A Skeate & Dr N Maguire