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New homelessness book on addressing the causes of trauma, not just the symptoms

In February 2020 St Martins Head of Residential Care Iain Boag published a book exploring how to provide the best, person-centred support for the most marginalized people living in registered care. In it he introduces the Psychologically Informed Environment (PIE) framework as an innovative tool that care workers can use to improve their daily work practice.

Here Iain explains how he came to want to write about our experience at Highwater House using the PIE model.

St Martins has been supporting vulnerable people in Norwich for almost 50 years. From its simple beginnings – an open church door and room on the floor or a camp bed – to the comprehensive collection of services it offers today, the organisation has evolved throughout its history to reflect ever improving understanding of the causes of homelessness, substance use and mental distress. The diversification and specialism of the St Martins family of services has been an organic process, responding to social and scientific research, and is ongoing.

Highwater House is part of this tapestry of provision – a 22-bed residential care home supporting men and women with a dual-diagnosis; that is, both mental health and substance use issues, whose life experiences have led them to need a high level of social support, as well as physical care. They can live at Highwater House for as long as they need, with 24-hour support from the staff team.

Over the almost twenty years that I have worked for St Martins, I have witnessed, and been part of, a seismic shift in how best care is provided for these people with ‘complex needs’. The greatest change has been the movement away from simply providing prosthetic care – propping up the individual in their troubled state – and so only working with the symptoms of their addictions and poor mental health, to providing dynamic recovery-focused care; that is, finding ways to work with the causes of their distress.

I can safely say that in all my years of working in the field of care and homelessness, I have never met a person who, as a child, hoped to grow up to become homeless, mentally distressed and addicted to substances. Something, somewhere, has not worked for them; some actions or events, either personally chosen or pushed upon them, have directed the course of their life, which has led to them becoming disturbed and unsettled, unable to cope, or to find equilibrium. Research over the last decade has shown how early years developmental trauma can negatively impact a person’s whole life, and this knowledge compels us to ask ‘what happened? What led you to our door?’ As a forward-thinking service, we then have a duty to find ways to adapt our delivery of care to suit their needs.

Over the last four years at Highwater House we have been using the Psychologically Informed Environment (PIE) model to develop our care provision for people who have by and large had deeply traumatic episodes in their lives and found themselves unable to cope.

The PIE model, created primarily for use in night shelters and hostels and adapted by the Highwater team to use in a residential care setting, provides workers with a reflective framework through which they can improve their day-to-day work. The core message of the PIE model is that change is best enacted through healthy supportive relationships forged between the service user and worker.

Separated into key ‘elements’ – Psychological Awareness, the Environment, Evidence gathering, Rules and Roles, and Staff Support – we can use the framework to, for example, reflect on whether our environment is supportive or restrictive. When a new resident walks into the building will they feel welcomed or worried? Does the building promote healthy relationships, with space to socialize and relax, or does it feel clinical or institutionalized? How can we use the environment to enhance the residents’ care?

Similarly, we can reflect on how our roles within the service might affect the residents’ wellbeing – can we reduce jargon or medical terms to a minimum and create a language of equality? Will a resident’s past experience of prison affect how they respond to carers, seeing them as a point of coercive authority? Do we place our residents in the role of ‘patient’, ‘ill’, or ‘helpless’ while putting ourselves in the role of ‘helper’, ‘well’ and ‘professional’?

As we use the PIE framework to reflect on our working day, we can see that sometimes even the most well-intentioned or benign services can accidently cause harm to our residents, or reinforce long held feelings of distress. By placing the thoughts, feelings and emotions of the residents at the heart of the service and our actions, we can adapt our service and better answer their needs.

My book uses Highwater House as a case study, giving real-world examples of how the PIE framework can be used to improve care. The PIE model has given the home a clearer narrative, and has helped us to celebrate the shared achievements of the team and residents who work together to find shared ‘sparkling’ moments – of life beyond diagnoses, risk assessments, problems, and worries.

Humans heal through healthy personal connections, and community creates catharsis. If people are deemed too ‘hard to reach’ – simply step closer.

For me, these messages are certainly worth writing about.

‘Psychologically informed Environment Principles in Adult Residential Care’ by Iain Boag is available at and through Amazon.

Click here to download a 20% discount voucher

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