'It Is Good to See the Person As a Whole Person and Continue to Improve Our Psychologically Informed Working': A Thematic Analysis of Clinical Psychology Trainee Placements in Homelessness Settings.

OBJECTIVES: The National Framework for Inclusion Health identified the need for collaborative action between the NHS and third sector health to improve access and outcomes for Inclusion Health groups. Clinical psychology trainee placements in homelessness settings could be a valuable pathway to improving access to psychological support for people experiencing homelessness and the provision of clinical services, which is key to developing the workforce and a catalyst for the future recruitment of clinical psychologists in the third sector. METHODS: A qualitative evaluation was conducted using semistructured interviews to explore the perspectives of clinical psychology trainees, supervisors, staff in homelessness settings and a peer mentor. Twenty-two participants were recruited from two universities and six services across the South East, including 11 clinical psychology trainees, six supervisors, four placement staff and one peer mentor. RESULTS: Placement staff described the value of a psychological approach but identified some challenges to be overcome. Induction was identified as the key to success. Supervisors recognised the breadth and depth added to trainees' knowledge and skills alongside significant challenges. Trainees valued the opportunities to work in homelessness settings and develop their understanding of the role. The peer mentor identified collaborative working as especially important. CONCLUSIONS: Clinical psychology trainee placements are a necessary programme to fulfil the NHS vision for Inclusion Health. These placements equip the health and social care workforce to create excellent and sustainable provisions to improve the physical and mental health of people experiencing homelessness whilst also providing much-needed psychological support for staff. PATIENT AND PUBLIC CONTRIBUTION: Psychologically Informed Environments Through Staff Training: Staff training and support within these placements contribute to the development of psychologically informed environments. This not only leads to better outcomes for both staff and clients but also aligns with the objectives of the National Framework for Inclusion Health, fostering sustainable provision for the health needs of people experiencing homelessness (PEH). Enhanced Therapeutic Adaptability: Trainees gain invaluable experience in adapting therapy to meet the diverse needs of clients, benefiting both trainees and clients alike. This adaptability fosters more effective therapeutic relationships and contributes to the improvement of inclusion health provision in the long term. Tailored Therapy for Timely Intervention: Clinical psychology trainee placements in homelessness settings offer therapy that bypasses long waiting times for interventions, crucial for individuals experiencing homelessness. This flexible approach caters to the unpredictable engagement levels of PEH, ensuring timely support aligning with the Health and Care Act 2022 to improve overall health and address health disparities through primary care networks.

A pilot trial investigating the feasibility of a future randomised controlled trial of Individualised Placement and Support for people unemployed with chronic pain recruiting in primary care.

BACKGROUND: We investigated the feasibility of recruiting patients unemployed for more than 3 months with chronic pain using a range of methods in primary care in order to conduct a pilot trial of Individual Placement and Support (IPS) to improve quality of life outcomes for people with chronic pain. METHODS: This research was informed by people with chronic pain. We assessed the feasibility of identification and recruitment of unemployed patients; the training and support needs of employment support workers to integrate with pain services; acceptability of randomisation, retention through follow-up and appropriate outcome measures for a definitive trial. Participants randomised to IPS received integrated support from an employment support worker and a pain occupational therapist to prepare for, and take up, a work placement. Those randomised to Treatment as Usual (TAU) received a bespoke workbook, delivered at an appointment with a research nurse not trained in vocational rehabilitation. RESULTS: Using a range of approaches, recruitment through primary care was difficult and resource-intensive (1028 approached to recruit 37 eligible participants). Supplementing recruitment through pain services, another 13 people were recruited (total n = 50). Randomisation to both arms was acceptable: 22 were allocated to IPS and 28 to TAU. Recruited participants were generally not 'work ready', particularly if recruited through pain services. CONCLUSION: A definitive randomised controlled trial is not currently feasible for recruiting through primary care in the UK. Although a trial recruiting through pain services might be possible, participants could be unrepresentative in levels of disability and associated health complexities. Retention of participants over 12 months proved challenging, and methods for reducing attrition are required. The intervention has been manualised.

Individualised placement and support programme for people unemployed because of chronic pain: a feasibility study and the InSTEP pilot RCT.

BACKGROUND: Chronic pain is a common cause of health-related incapacity for work among people in the UK. Individualised placement and support is a systematic approach to rehabilitation, with emphasis on early supported work placement. It is effective in helping people with severe mental illness to gain employment, but has not been tested for chronic pain. OBJECTIVE: To inform the design of a definitive randomised controlled trial to assess the clinical effectiveness of individualised placement and support for people unemployed because of chronic pain. METHODS: A mixed-methods feasibility study comprising qualitative interviews and focus groups with key stakeholders, alongside a pilot trial. STUDY PARTICIPANTS: Primary care-based health-care professionals, employment support workers, employers, clients who participated in an individualised placement and support programme, and individuals aged 18-64 years with chronic pain who were unemployed for at least 3 months. INTERVENTION: An individualised placement and support programme integrated with a personalised, responsive pain management plan, backed up by communication with a general practitioner and rapid access to community-based pain services. OUTCOMES: Outcomes included stakeholder views about a trial and methods of recruitment; the feasibility and acceptability of the individualised placement and support intervention; study processes (including methods to recruit participants from primary care, training and support needs of the employment support workers to integrate with pain services, acceptability of randomisation and the treatment-as-usual comparator); and scoping of outcome measures for a definitive trial. RESULTS: All stakeholders viewed a trial as feasible and important, and saw the relevance of employment interventions in this group. Using all suggested methods, recruitment was feasible through primary care, but it was slow and resource intensive. Recruitment through pain services was more efficient. Fifty people with chronic pain were recruited (37 from primary care and 13 from pain services). Randomisation was acceptable, and 22 participants were allocated to individualised placement and support, and 28 participants were allocated to treatment as usual. Treatment as usual was found acceptable. Retention of treatment-as-usual participants was acceptable throughout the 12 months. However, follow-up of individualised placement and support recipients using postal questionnaires proved challenging, especially when the participant started paid work, and new approaches would be needed for a trial. Clients, employment support workers, primary care-based health-care professionals and employers contributed to manualisation of the intervention. No adverse events were reported. CONCLUSION: Unless accurate and up-to-date employment status information can be collected in primary care health records, or linkage can be established with employment records, research such as this relating to employment will be impracticable in primary care. The trial may be possible through pain services; however, clients may differ. Retention of participants proved challenging and methods for achieving this would need to be developed. The intervention has been manualised. TRIAL REGISTRATION: Current Controlled Trials ISRCTN30094062. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 5. See the NIHR Journals Library website for further project information.

Chronic pain is a common cause of disability and unemployment. Individualised placement and support is a package of care that aims to rehabilitate people and get them back into paid employment. It is effective for people with severe mental health conditions, but no one knows if it works for patients with chronic pain. This research aimed to determine the feasibility of a future randomised trial to test if individualised placement and support improves quality of life or other health outcomes in this group. We conducted in-depth interviews with patients, doctors, nurses, employment support workers and employers, as well as a small-scale pilot trial. All of the groups interviewed supported the value of the intervention and the pilot trial. The Patient Advisory Group helped review trial documentation and produced a standardised treatment-as-usual booklet for comparison with individualised placement and support. However, despite experimenting with a range of methods, recruiting patients proved challenging, particularly from general practices, where employment status is not recorded systematically. More efficient recruitment was achieved through pain services. Overall, we recruited and randomised 50 participants, 22 of whom received individualised placement and support and 28 of whom received treatment as usual. There were no adverse events and both groups found their 'intervention' acceptable. Returned questionnaires were completed well by all participants; however, we experienced significant levels of non-returns, particularly among those receiving the individualised placement and support, possibly related to starting work. Overall, we believe that a trial would not be feasible if recruiting through general practices, but may be feasible via pain services. Challenges would be complex clients, retention over 12 months in both arms, integrating individualised placement and support with pain services and ensuring that the intervention was delivered as intended across multiple sites. The full report comments on how such challenges might be addressed.

The Role of Debt in the Maintenance of Homelessness.

Debt is highly prevalent within the homeless population. This narrative review makes use of a varied literature to explore the relationship between debt and homelessness, focussing particularly on organisational (systemic) and individual factors and formulating the relationship between the two. A number of forms of debt and the causes of that debt are explored, in terms of individual factors such as motivation and organisational factors such as inflexible rent protocols. These factors are considered within the context of the cash economy operated by people who are homeless, together with the survival behaviours that drive such a way of operating. Conclusions are drawn about the nature of interventions and how individual psychological approaches to motivation need to be taken into account.

Individualised placement support as an employment intervention for individuals with chronic pain: a qualitative exploration of stakeholder views.

BACKGROUND: Individualised Placement and Support (IPS) is a tailored, client-centred employment intervention for people with chronic health conditions. It involves the integration of vocational advisers within health teams to optimise return-to-work strategies. The intervention aims to get clients into employment by complementing traditional job searching skills with placements, and one-to-one mentoring alongside a work-focused health intervention. AIM: To explore the concept of IPS for individuals with chronic pain. DESIGN & SETTING: A multi-method qualitative study was designed to explore stakeholder views of IPS for individuals with chronic pain in southern England. METHOD: Fourteen semi-structured interviews and three focus groups were conducted with current recipients of IPS (clients), employment support workers (ESWs), and healthcare professionals (HCPs). All data were audio-recorded, transcribed, and analysed using thematic analysis. RESULTS: In total, 11 HCPs, five ESWs, and nine clients participated in the study. The analysis identified four themes. The situations of chronic pain patients were discussed, including their complex needs, multifaceted relationship with work, support from HCPs, and existing programmes that were failing to meet their needs. The intervention input was highlighted, including the recruitment procedures and role of ESWs. Programme activities and outcomes were also identified. CONCLUSION: This study identified the complex needs and relationship with work of individuals with chronic pain. It showed that ESWs need to understand the unpredictability of symptoms for individuals with chronic pain and that clients may need additional support before a placement. The findings highlighted several activities for future IPS interventions and potential outcomes for future evaluation.

Exploring the views of stakeholders about the feasibility of carrying out a randomised controlled trial of Individual Placement and Support for people unemployed with chronic pain based in primary care (the InSTEP study).

BACKGROUND: Individual Placement and Support (IPS) is a model of vocational rehabilitation originally developed to help people with severe mental illness obtain and maintain employment. Work disability is common amongst people with chronic pain conditions, yet few effective interventions exist. As part of mixed-methods feasibility research and as a forerunner to a pilot trial (In STEP), we investigated the barriers and facilitators to carrying out a future randomised controlled trial of IPS set in primary care amongst people unemployed with chronic pain. METHODS: Semi-structured interviews and focus groups were conducted with: unemployed people with health conditions receiving IPS (clients), Employment Support Workers (ESWs) delivering IPS for people with chronic health conditions and primary healthcare professionals. Interviews and focus groups were transcribed verbatim and analysed with field notes using thematic analysis. RESULTS: All stakeholders generally viewed a future trial of IPS positively and deemed both the intervention and treatment as usual acceptable. Themes that emerged regarding potential barriers were recruitment, the importance of recruiting people voluntarily who wanted to return to work and were motivated to do so and giving them agency in the process; a need for additional training and support of the ESWs; and a risk of over-burdening participants with paperwork. Regarding facilitators however, the themes were offering the intervention early after unemployment, the importance of relationship and continuity with the ESWs and that an employment intervention could bring a range of health benefits. CONCLUSIONS: All stakeholders thought that a randomised trial was potentially feasible and highlighted some potential advantages of participation. TRIAL REGISTRATION: Study no ISRCTN30094062.

Psychological factors associated with financial hardship and mental health: A systematic review.

A review of the literature investigating the role of psychological factors in the relationship between financial hardship and mental health was completed. The review sought to identify which factors have been most consistently and reliably indicated, and the mechanisms by which these factors are proposed to contribute to the association between hardship and mental health. Although the review identified that a broad variety of factors have been investigated, skills related to personal agency, self-esteem and coping were most frequently and reliably associated with the relationship between financial hardship and mental health outcomes. Just over half of the studies reviewed concluded that the psychological factor investigated was either eroded by financial hardship, increasing vulnerability to mental health difficulties, or protected mental health by remaining intact despite the effects of financial hardship. The remaining studies found no such effect or did not analyse their data in a manner in which a mechanism of action could be identified. The methodological quality of the research included in the review was variable. The valid and reliable measurement of financial hardship, and conclusions regarding causation due to the use of predominantly cross-sectional design were areas of particular weakness.

Do Locus of Control, Self-esteem, Hope and Shame Mediate the Relationship Between Financial Hardship and Mental Health?

In a longitudinal study of 104 participants, the psychological factors of economic locus of control, self-esteem, hope and shame were explored for their impact on the relationship between financial hardship and mental health. Participants completed measures of financial hardship, the psychological factors and measures of mental health three times at three-monthly intervals. A hierarchical regression analyses indicated that subjective financial hardship, hope and shame significantly predicted mental health outcomes. Mediation analyses demonstrated that hope mediated the relationship between subjective financial hardship and depression, stress and wellbeing; that shame mediated the relationship between subjective financial hardship and anxiety; and that neither shame nor hope mediated the relationship between subjective financial hardship and suicide ideation.

The ACE Index: mapping childhood adversity in England.

BACKGROUND: Studies of adults show that adverse childhood experiences (ACEs) are associated with health and social problems and are more common among people living in deprived areas. However, there is limited information about the geographical pattern of contemporary ACEs. METHODS: We used data from the police, social services, schools and vital statistics in England to calculate population rates of events that represent childhood adversity. We constructed an 'ACE Index' that summarizes the relative frequency of ACEs at local authority level, informed by the methods of the Index of Multiple Deprivation. We explored associations between the ACE Index and local characteristics in cross-sectional ecological analysis. RESULTS: The ACE Index was strongly associated with the proportion of children that live in income-deprived households (child poverty). In addition, the ACE Index was independently associated with higher population density and was higher in certain regions, particularly the north-east. CONCLUSIONS: The association between ACEs and child poverty provides evidence of a process in which deprivation increases the risk of adverse experiences in childhood. The ACE Index can inform allocation of resources for prevention and mitigation of ACEs.

Values-Based Interventions in Patient Engagement for Those with Complex Needs.

The objective was to evaluate a novel intervention that integrates a psychological, values-based approach with coordinated care management. This paper describes an integrated comprehensive health record system to enhance engagement with a subset of those with complex needs; those who are high-needs, high-cost (HNHC). Patients are selected after conducting data analysis on the most costly and complex patients of a payer system that works with HNHC patients. Specifically, the Patient Care Intervention Center in Houston TX, applies the values-based intervention to HNHC patients. This pilot study reports data from 18 HNHC patients over 6 months; specifically, outcomes related to daily functioning, depression, working alliance, stages of change, and overall well-being. Additionally, this paper reports preliminary findings from qualitative monitoring of provider experiences implementing the values-based approach and integrated evaluation. HNHC patients improved their daily functioning over 4 months but no other significant changes were found over time. Patients self-reported mild depression, strong working alliances with their provider, being in the contemplation phase of change, and moderate well-being. There also was variation when patients completed the assessments and data points were collected. Although this is a small sample and short time frame, preliminary results suggest that the intervention has a positive impact on HNHC patient daily functioning. Provider accounts of the implementation describe using the evaluation items to inform their interactions with patients, and also suggest that patient literacy level impacts when data can be collected. Other changes to the approach are suggested.

Expert viewpoints of peer support for people experiencing homelessness: A Q sort study.

Peers have shared experiences of phenomena such as mental illness, addiction, and homelessness. Homelessness services are increasingly utilizing peers in their models to support people experiencing homelessness. While there is extensive literature on peer support in general, few studies focus on the potential change mechanisms that might underpin this intervention, particularly regarding homelessness. This study aims to utilize expert opinions to identify common viewpoints on components involved in effective peer support. Forty-three statements were developed from previous literature that broadly describes elements involved in peer support. Forty experts (20 peers and 20 professionals) ranked the statements into a hierarchy. Q methodology is a rigorous method to objectively research participants' subjective viewpoints, using a by-person rather than by-variable approach to factor analysis. The study was done in three stages: first-order analysis to identify shared viewpoints within (a) the peer participant group, (b) the professional participant group, and (c) a second-order analysis of Stage 1 and 2 results to identify common viewpoints held across participant groups. Stage 3 analysis resulted in three differing viewpoints; the dominant viewpoint asserts that effective peer support is rooted in experiential knowledge, where peers build unique, trusting relationships to provide clients with a different level of support. The results highlighted different types of peer support and defined a new one: a unidirectional, mentorship type of intentional peer support. Strengths and limitations are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Paranoia and maladaptive behaviours in homelessness: The mediating role of emotion regulation.

OBJECTIVES: Current research has implicated a role for cognitive and emotional processes in the pathways to becoming homeless. Evidence implicates three risk factors, which are often associated with an increased incidence of homelessness: paranoid thinking, emotion regulation, and engaging in maladaptive behaviours. Maladaptive behaviours include deliberate self-harm, substance misuse, and high-risk sexual practices. Currently, no studies have investigated the specific psychological mechanisms, such as difficulty regulating emotions, which underpin the association between paranoia and maladaptive behaviours. DESIGN: A mediational design was employed in a group of homeless individuals. METHOD: Participants (N = 40), who were homeless at the time of the study, completed a single-session assessment of paranoia, emotion regulation, and maladaptive behaviours. RESULTS: Mediation analyses indicated that individuals scoring high on paranoia were more likely to engage in maladaptive behaviours, particularly substance misuse and aggression, when they had difficulty regulating their emotions. These results demonstrate a novel finding relating to the effect of emotion regulation in maintaining psychopathology and behaviours in vulnerable individuals, which may in turn sustain periods of homelessness. CONCLUSIONS: Emotion regulation may therefore be one particular psychological mechanism through which severe mental illness affects engagement in self-destructive behaviours in homelessness. These findings have valuable clinical implications for targeted therapeutic interventions, in this often difficult to treat homeless population. PRACTITIONER POINTS: Psychosis is over-represented in the homeless population; the cycle of homelessness may be attenuated by addressing psychotic symptomology. Homeless individuals engage in drug abuse, self-harm, aggression, and high-risk sexual practices due to an inability to regulate distressing emotions effectively. Therapeutic interventions, such as MBT and DBT, which target emotion regulation difficulties, may be useful in reducing maladaptive behaviours and preventing homelessness, by providing emotion regulation strategies to cope when homeless persons become distressed.

What works in inclusion health: overview of effective interventions for marginalised and excluded populations.

Inclusion health is a service, research, and policy agenda that aims to prevent and redress health and social inequities among the most vulnerable and excluded populations. We did an evidence synthesis of health and social interventions for inclusion health target populations, including people with experiences of homelessness, drug use, imprisonment, and sex work. These populations often have multiple overlapping risk factors and extreme levels of morbidity and mortality. We identified numerous interventions to improve physical and mental health, and substance use; however, evidence is scarce for structural interventions, including housing, employment, and legal support that can prevent exclusion and promote recovery. Dedicated resources and better collaboration with the affected populations are needed to realise the benefits of existing interventions. Research must inform the benefits of early intervention and implementation of policies to address the upstream causes of exclusion, such as adverse childhood experiences and poverty.

Resilients, overcontrollers and undercontrollers: A systematic review of the utility of a personality typology method in understanding adult mental health problems.

The person-centred typological approach to personality makes the distinction between overcontrolled and undercontrolled personality types. This review systematically searched for research on the utility of these personality types in adult mental health. A total of 43 papers were included, which were divided broadly into cross-sectional studies, longitudinal studies and studies with clinical populations. Three personality types have been largely replicated in both normal and clinical populations: resilients, overcontrollers and undercontrollers. These types show utility in predicting long-term functioning and mental health, understanding heterogeneous personalities within clinical subgroups and have implications for treatment. Some disagreement on the number of personality types deemed replicable across samples and differing methodologies do exist, with some finding a dimensional approach to personality to have greater predictive utility. These personality types have been shown to be important in a number of mental health problems such as eating disorders, which may prove helpful in developing new psychological interventions. These studies point to the importance of overcontrolled personality types as well as undercontrolled in mental health. More research is needed with a greater range of clinical populations.

Experts by Experience: Peer Support and its Use with the Homeless.

The homeless population has complex needs. Peers with experience of homelessness offer unique perspectives in supporting those experiencing homelessness. Peer support fostered and developed by professional organisations, termed intentional peer support (IPS), formalises this process. This review aims to assess the effectiveness of IPS as an intervention with young adults and adult homeless persons (including streetdwelling and those within services). PyscINFO, Web of Science, MEDLINE, and CINAHL were searched, resulting in ten studies, involving 1,829 participants. Peer support has significant impacts on quality of life, drug/alcohol use, and social support. Common elements of peer support are identified, suggesting possible processes that underlie effective peer support. Shared experiences, role modelling, and social support are suggested to be vital aspects of peer support and moderate changes in homeless clients. One study was deemed to have moderate/high quality; the remaining studies had low and moderate quality. Limitations of each are discussed.

What is the Lived Experience of Being Discharged From a Psychiatric Inpatient Stay?

Psychiatric patients encounter many difficulties post-discharge reflected by quantitative data such as high suicide rates within the first 3 months. However, little is known about why discharge is so difficult. This article aimed to understand the lived experience of being discharged from a psychiatric unit. Eight participants were interviewed to explore their experiences of discharge. Interpretative phenomenological analysis was used to analyse data. Four superordinate themes emerged: leaving hospital; the outside world; the journey to health; and self-identity/beliefs. Clinical implications and suggestions for further research are discussed.

An evaluation of the choices for well-being project.

The relationship between mental health, self-esteem and unemployment is well established. Emerging research suggests that interventions such as Cognitive Behavioural Therapy (CBT) can counter the negative effects of unemployment and may improve re-employment. This study evaluated the effectiveness of a manual-based programme, which combines CBT with job skills training, in improving the psychological health and job- seeking skills of unemployed individuals within the UK. One hundred and nine unemployed individuals, suffering mild to moderate mental health problems, were referred to the programme. Of these, 47 completed the programme and 32 attended follow-up. The impact of the manualised course was evaluated using a randomised control trial with a waiting list control. On completion of the programme, participants showed improvements in mental health, self- esteem and job-search self-efficacy as well as a reduction in the occurrence of negative automatic thoughts. Twenty participants gained employment and improvements persisted at follow-up. Considering the initial levels of psychological distress and mental health problems among the unemployed sample, the need for adequate service provision for the unemployed is recommended.

Personal experiences of home haemodialysis: patients' and carers' experiences.

The discussions from a patient-led session at a national home haemodialysis conference are described. A number of discussion themes are described, together with patients' views on technical and social aspects of home dialysis. Issues highlighted included the preparation for home systems and the role of intrinsic motivation to change regimens and practice. A number of conclusions are drawn from the discussion, highlighting the role of patient beliefs about conducting haemodialysis at home.