Leading with Psychologically Informed Environments: A framework for relationally inclusive leadership

Psychologically Informed Environments (PIE) and trauma informed approaches seek to understand why as humans working in health and social care services, we behave, think, and feel the way we do, within the context of the fundamental drivers for any change: our relationships. Key principles (Keats et al., 2012) enable this understanding and aim to guide the development and design of inclusive services for those who are often excluded due to the psychological and social consequences of compound trauma (Cockersell, 2018a; Johnson, 2017; Maguire et al., 2009), thereby enabling them to make positive changes to their lives through the reparative quality of positive relationships.

There is a growing practice based literature demonstrating the effectiveness of PIE's in delivering trauma informed care (TIC) (Cockersell, 2016; National Lottery/ Fulfilling Lives, 2020; Revolving Doors Agency, 2019; Williamson, 2018: Cockersell, 2018b). So, what is it that enables organisations to create PIEs that thrive and achieve longevity and what are the challenges that prevent this process? Which factors either enable or disable leaders' and organisations' ability to introduce and embed effective trauma informed PIEs? 

To reach beneath the surface of what is seen in the here and now and begin to understand the conscious and often unconscious processes that inform the experience of leaders and organisations, here we will consider common themes in relation to the key principles of PIE within the context of organisational change. 

This exploration is designed as an introduction and invitation to begin to think about how leaders and organisations affect the shape and journey of PIEs. Informing this invitation are two ideas. Firstly, that relationships drive change for all of us: they are as central to successful and sustainable change in health and social care services as they are in life. Secondly, using the key areas of PIE as guiding principles for leadership approach and organisational development can drive the use of psychologically and trauma informed approaches, and thereby support the creation and delivery of effective PIEs and TIC. 

The context 

The development of a PIE doesn't happen in isolation: it occurs within the context of an existing organisation, which sits within the societal norms and values of the wider system. The introduction of a PIE represents change for an organisation. This can vary depending on the degree to which existing policy and practices are informed by psychological approaches and ways of working. At minimum, it might mean a review of existing practices and at most it could represent a significant shift in the way services are run and in an organisation's culture. 

The nature of change

Change is about a future not yet conceived: moving towards it can require working with limited knowledge and control (Krantz and Trainor, 2019). Our response to inhabiting these liminal spaces as individuals and systems is often characterised by anxiety and can be understood as a defence against the ambiguity, ambivalence and uncertainty they represent (Kupers, 2011). A sense of loss and a grieving for what has once been often sits alongside a palpable sense of foreboding about what the future might hold (Grace, 2016). 

When introducing PIE organisations will, to varying extents, lose one way of being and sit within a liminal space before arriving at another way of being. Part of a leader's and organisation's ability to hold and contain therefore lies in the capacity to sit with and tolerate this ambiguity and uncertainty, to manage anxieties and, in doing so, to model this to other parts of the system. This in turn relies on the ability to reflect on experience before acting (Krantz and Trainor, 2019), to sit with uncomfortable exchanges rather than rush to know the answer or find a solution.

Layers of change

Working with the emotional response to the work, as required by PIE or TIC, means moving towards a more relational way of working which may, for some organisations, represent a significant cultural change in terms of the values, beliefs and assumptions of the organisation. This cultural change can be understood as fundamental in either enabling or disabling the longevity of effective PIEs and TIC (Fallot and Harris, 2009) as without it both technical (policies and practices) and behavioural (people's response to the technical) layers of organisational change are likely to revert to original ways of being (Clark, 2020). Without adopting a relational approach throughout, policy and related practices may not change and despite the intention to create a more psychologically informed service, will continue, as outlined above, to be designed to meet the needs of the system rather than the people it serves. 

In operationalising these changes, a shared understanding of what being psychologically informed might look and sound like when working with different individuals in front line services, in the management of these services, in the senior management team, and in the board room is also needed.

Managing relationships

As humans, we are relational beings. We all grow and develop within the context of relationships and are shaped by the extent to which they hold and contain us (Winnicott, 1960). Throughout our lives, our physical and emotional wellbeing is dependent on the relationships, the type of attachments, we have with others (Holt-Lunstad, 2021; Mate, 2019; Siegal, 202; Van der Kolk, 2014). We therefore make sense of the world through our relationships. 

Those relationships sit in the context of our individual life experience starting in our mothers' wombs, as well as the different systems we are both included within and excluded from along the way. So, thinking systemically, an organisation's wellbeing as a whole is dependent on the quality of relationships within it. In this way, the relationships between service users, front line staff, service managers, senior managers, and board members inform both the well-being of those individuals and of the system as a whole. Sitting alongside this knowledge, an expansive body of leadership literature offers up many different perspectives on what makes an effective leader but limited evidence about which approach is most effective: it does however agree, regardless of approach, that effective leadership involves relationships (Monaghan and Thorley, 2022).

Managing relationships is at the heart of what makes a PIE distinct from other approaches. In this sense, relationships are seen as the fundamental driver for change, with every interaction between staff and clients being an opportunity for learning (Keats et al., 2012), for developing and managing repair, and they are, or should be, prioritised above the organisational pressures of the economic system. In other words, enabling healing, recovery-oriented environments or services is not done by imposing management or leadership models taken from industrial production or finance-driven 'market forces': it is done by managing and leading in a way that is itself psychologically or trauma informed – it is fundamentally relational rather than transactional.

Trauma, relationships and systems

If an organisation, system or service takes actions to implement service changes in all of the domains under [the] principles [of PIE], then they will deliver effective trauma informed care and will experience a set of positive outcomes for their staff and for their beneficiaries. There is evidence for this throughout our book as the various chapter authors – psychologists, psychiatrists, chief executives, middle and senior managers, consultants and commissioners – describe the processes they enabled in their organisations and the impact they had and the outcomes they produced.

The reason for this can be thought about in terms of nature of the dynamics between trauma, relationships and the systems within which these experiences take place, and how these are a mirroring of human psychological processes. We have evolved our 'minds', in the broad sense that Siegel defines them as 'an emergent, self-organizing, embodied and relational process that regulates the flow of energy and information both within and between' (Siegel, 2017, p37), to regulate our relationships with our social and physical environment and our own internal biological and meaning systems (Panksepp and Biven, 2012). We do this emotionally, through the claustro-agoraphobic, seeking/panic or exploratory/shame system (depending on your author of choice: Finkelstein and Weiss, 2023; Panksepp, 2004; Schore, 2012), and through the attachment system (Bowlby, 1960; Cozolino, 2014).

For services to provide trauma informed care to those who most need it they have to learn to work with the behaviours associated with often deeply and acutely insecure attachment styles including disorganised attachments. For this to happen requires the staff and leadership to not only understand the processes of trauma itself, but also the processes of attachment, and in both cases how they affect the interpersonal behaviours of their clients and their staff. For this reason, it is not enough simply to have training on trauma and its effects; staff and management also need training on attachment and its effects, and on the interplay between attachment and trauma in the development of personality and the dynamics of interpersonal relationships and organisations. If a team, service or organisation does not understand these dynamics then they are more likely to enact processes that repeat the trauma experiences of the clients they are trying to serve and they are likely to induce trauma experiences in the staff who they expect to support those clients (creating, for example, the high levels of burn-out experienced by staff in many 'caring' organisations) (Sweeney et al, 2016). If an organisation adopts PIE principles then it will take on a psychological framework and significantly increase its potential to deliver effective trauma informed care and reduce the likelihood of inducing re-traumatisation in its clients or trauma experiences in its staff.

The role of attachment in managing relationships

Attachment is a primary biological drive or instinct and fundamental to all human relationships (Bowlby, 1990; Lahousen et al., 2019). In recovering from trauma we are also repairing the capacity for relationships and creating what are called 'learned' secure attachment styles; these two pieces of work go hand in hand psychologically (Fonagy and Allison, 2014)'. This is as true for organisations and systems as it is for individuals because organisations and systems are made up of complex interactions between multiple individuals, and are subject to the experiences of group dynamics (Obholzer and Zagier Roberts, 2019).

Because attachment is learned through the experience of relationship with another human, and damaged relationships and attachments are major determinants of whether a person recovers easily from a trauma experience or not because of resilience, then relationships are central to recovery. This is something that survivors almost always highlight and that all the major modalities of psychology, psychodynamic, cognitive, behavioural or humanistic, agree on. Central among the principles of PIE is 'managing relationships' and, to put it straightforwardly, an organisation that takes active steps to implement processes and training for the management of relationships will deliver better trauma informed care than one that does not.

Managing relationships is not simply about having relationships: we have those whether we like it or not, and they can be good, bad or indifferent. What a PIE does is stress the need to use relationships and to invest thought and care into managing relationships so that they are more likely to deliver a positive, progressive, healing or resolving outcome. We cannot control the outcome, but we can influence the probability of the outcome, by using our relationships to positive effect as far as is possible. This means all relationships, not just between staff and client: it also means between staff and staff, staff and managers, managers and middle managers and senior managers, members of the senior team, between the senior staff, board members and commissioners, politicians etc and so on. The biggest tool we all have to deliver trauma informed services is through the management of relationships.

This thesis is borne out by the experiences and conclusions of the many contributing chapter authors who describe the experience of managing, guiding, advising or commissioning services working in a psychologically informed way with people experiencing the impacts of trauma and damaging attachments in the fields of mental health, domestic abuse, and youthwork, in local authorities, voluntary sector agencies and the NHS. 

Staff support and client involvement

Critical to the successful management of relationships are two other principles of PIE: staff support/reflective practice and client involvement. One of the key things for a staff team to be able to deliver trauma informed care is that it should not be traumatised itself, and that it should not feel 'done to', attacked, as with job or pay cuts for example, or neglected, as with lack of recognition of skill or good work. These damage the staff's attachment to the organisation and to its work, just as hostile or negligent parenting damages children's attachments, and they reduce staff resilience. 

Staff support, on the other hand – good training, regular reflective supervision (not just performance supervision), reasonable conditions and reflective groups – enables staff to feel more attached, and so more committed to the organisation and its work. Crucially it also makes them more resilient and so more able to deal effectively and creatively with the complex task of working with people who have experienced compound trauma and the risks of vicarious trauma that come with the work.

Conclusion

In summary, the concept of organisations being a particular collection or grouping of people is central to the argument of our book. Working with people who have experienced high levels of trauma often over long periods of time, within a system of health and social care that itself has a history of trauma over a long period of time, means that organisations have to take into account the psychological processes not only of their clients/patients/customers/users, but also of their staff, managers, and commissioners, and colleagues in other organisations they work with, and manage their relationships with all these stakeholders in such a way as to enable resilience. Resilience is enabled through activation and sustainment of positive attachment relations; to feel safe, people need to feel contained, and containment is achieved relationally. To be effective in service delivery, and to support and enable their staff to work effectively, organisations therefore need to adopt not just trauma informed but psychologically informed relational leadership practices. 

To find out more about leading with psychosocially informed environments click here

The above includes edited extracts from Psychologically Informed Environments and Trauma Informed Care : Leadership Perspectives, edited by Peter Cockersell and Sione Marshall, and published by Routledge.

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