Innovative approach to hostels shows promise

A project aimed at encouraging homeless people to engage in psychological treatment and support, and maintain accommodation, has reported very promising outcomes after a £1.3 million expansion. Clinical lead of the Psychology in Hostels Project, Dr Emma Williamson (pictured on couch), spoke to The Psychologist about the project's successes and potential for further growth.

The Psychology in Hostels Project was originally commissioned four years ago after the London Borough of Lambeth's (LBL) adult directorate approached the South London and Maudsley NHS Foundation Trust (SLaM) and homeless charity Thames Reach to change the approach used in hostels for the homeless. Clinical psychologist Dr Williamson and an assistant psychologist from SLaM, worked in partnership with Thames Reach Waterloo Project hostel team to develop this innovative pilot service redesign.

There is a group of homeless people, Williamson said, who have difficulty maintaining accommodation. Some struggle with a 'claustro-agoraphobic' dilemma. Those with early histories of trauma or disruption can struggle to find an area where they are not so close they feel trapped, intruded upon or threatened but also do not feel isolated or abandoned. She added: 'This group can find it very hard to find a comfortable place to exist, and bounce in and out of services, struggling to settle and make use of support. It is knowledge of this experience and an understanding of the high levels of complex trauma and unmet mental health need that led LBL to consider trialling development of a psychologically informed environment (PIE) hostel in south London.'

At the hostel Williamson looked into work by Johnson and Haigh on psychologically informed environments: 'It is recommended that a coherent shared psychological understanding within an environment is the best way to facilitate growth, recovery and enablement. Together the psychologists and hostel staff designed an onsite psychologically informed environment service aimed at helping residents sustain accommodation and promoting access to services which would enable inclusion and engagement in opportunities.' This was seen as an environment where everything could potentially be informed by the psychological needs of the client group.   

Williamson and her assistant psychologist worked full-time within the hostel environment itself and were available for informal engagement work and involved with the day-to-day goings-on in the hostel. The clients themselves could approach the psychologists on their terms and when more comfortable could have more formal treatment including mentalisation-based treatment (MBT) on an individual or group basis and take part in the MBT-informed art group and other hostel activities. Another key aspect of the onsite approach was that psychologists and hostel staff were able to work jointly in supporting clients, as well as receiving regular reflective practice, consultation and training.

The outcomes from this initial work, Williamson said, were 'outstanding'. She added: 'We saw great outcomes in terms of mental health improvement and a reduction in drug and alcohol use, emergency service use, a 51 per cent reduction in all types of criminal justice contact in a one year sample and crucially people stabilising and sustaining accommodation where they had had trouble before.'

Based on this the partnership applied to the Guy's and St Thomas' Charity to expand the project, with the aim of working towards mainstream commissioning. They were awarded £1.3 million in funding starting in January 2015; this expansion included a larger clinical team working across a variety of sites in three hostel settings. They continued work in the original 19-bed hostel in Waterloo but expanded to include a 69-bed facility in Vauxhall and a five-bed supported housing complex with female-only clients.

She explained: 'We were finding certain subgroups of the population continued to be harder to engage with direct psychological support, including females and those with poly-substance misuse (drugs and alcohol).' The original hostel had recently undergone a renovation at the start of the pilot, and was a mixed-gender service, and so the team were keen to explore applications of their PIE model in female-only settings, larger hostels, supported accommodation settings and those that had not had large capital investment in the building.

The expansion saw Williamson continue in the clinical lead role while two specialist clinical psychologists, two assistant psychologists and an administrator were also taken on. They also introduced one session of psychiatry to be available each week to the clients with the aim of increasing accessibility of timely psychiatric input and referrals into mainstream services. They are now developing a peer mentoring service for clients to hear the experiences of others who had been in their shoes and who will deliver psychologically informed support, training and advocacy.

The service has also developed a transition arm helping individuals to make the move into different accommodation and offering support and training to other accommodation providers working with those clients. They have bought in two evaluation teams – Southampton University to carry out a clinical evaluation, and Resolving Chaos for an economic evaluation to complement in-house evaluation.

The early outcomes from the external and internal evaluations, Williamson said, had been 'really positive'. She added: 'We've continued to build on the great outcomes seen in the initial pilot. Our in-house evaluations have seen a clinically significant reduction in psychological distress. Early indicators from the Southampton University assessment show there have been improvements in emotion regulation among clients as well as a reduction in incidents of aggression and alcohol use. Theoretically this would make sense with people better able to regulate their emotions and therefore less distressed, less aggressive and relying less on alcohol, which in itself feeds into cycles of distress and aggression.'

Of the future, Williamson spoke about the ongoing work needed in developing the evidence base for meeting the complex needs of homeless people and highlighting the gaps in current service provision which PIE approaches can answer. 'We are gathering further health-economic data demonstrating the impact of our integrated service approach and finding promising early indications of savings across the system. This group have for so long struggled to access appropriate support and have provision of services that will meet them where they are at – we are addressing that and we feel that outcomes speak for themselves'.