1

Reflective practice in homelessness services:

A CBT approach

20th June, 2014Nick Maguire

University of Southampton

Reflective practice

Staff reflection on:

• Experiences with service users

• Experiences with services

– Emotions related to behaviours

– Enabling change

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Structure

• Training followed by reflective practice

• Training

– Cognitive model

– Complex trauma

– Service issues

• Reflective practice

– Reflection on skills learned

– Learning through experience of others

Kolb’s Learning Cycle

Abstract conceptualisation

Active experimentation

Concrete experience

Reflective observation

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Relating thoughts, feelings and behaviour

Specifics

• Six basic emotions(evolutionaryperspective; Ekman,1992)– Anxiety

– Anger

– Sadness– Happiness (including love)

– Surprise

– Disgust

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4

Random thoughts...

The Cognitive Model

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Identifying Beliefs: The ABC Model(Ellis, 1966)

Antecedent event Belief Consequence

Emotion:

Behaviour:

Metacognition...

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“Is what I’m thinking about what they’re

doing absolutely true?”

“Are they doing it for the reasons that I

think that they’re doing it?”

“If the thought about another’s

behaviour isn’t totally accurate, could

I do something different?”

Choice.

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Maintenance of the problem - cognition

• Selective attention(Posner, 1988)

• Thinking changes with stress levels(Interactive Cognitive Subsystems (ICS);Barnard & Teasdale, 1991)

Thinking and burnoutThoughts

• ‘Nothing’s changing’

• ‘It’s my fault’

• ‘I’m no good at this’

Emotions

• Anxiety, low mood

Behaviours

• Blame

• Disengage

• Leave

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Evidence

Measures

• Maslach Burnout Inventory (MBI; ; Maslach, Jackson & Leiter,1986).– Measure of staff burnout in the helping professions.

• Effective Working with Complex Clients (EWCC; Maguire,2007).– Novel questionnaire designed to assess staff confidence with using

CBT techniques with complex clients.

• Staff Attitudes and Beliefs – 42 (SAB42; Clarke et al, 2005 ).– Novel questionnaire designed to assess negative beliefs about

complex clients.

• CORE-OM (CORE Project Group, 2003).– Services users’ general mental health functioning

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Staff training and reflective practice

• Around 350 staff trained nationally

• St Basils, DePaul, Westminster CC, St James, TwoSaints,Exeter CC

• Pre-post (T1-T2) training improvements in

• Burnout

• Negative beliefs

• Confidence in effecting change

• Reflective practice further increases improvement

• Numbers much lower for T3, still significant

Staff burnout

Maslach Burnout Inventory

40

45

50

55

60

65

70

Time 1 Time 2 Time 3

MB

I S

co

re

Maslach Burnout Inventory

3028

12

p < .05

10

Beliefs about effectiveness of facilitating change

Effective Work With Complex Clients

40

41

42

43

44

45

46

47

48

49

50

Time 1 Time 2 Time 3

Eff

ecti

ve W

ork

ing

Sco

re

Effective Work With

Complex Clients30

285

p<.05

Negative beliefs about the client group

Staff Attitudes and Beliefs

80

90

100

110

120

130

140

Time 1 Time 2 Time 3

SA

B-4

2 S

co

re

Staff Attitudes and Beliefs

30

28

5p < .05

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Mediation analysis

Effective working beliefs

BurnoutNegative

beliefs

-.287*

. 438**

-.382**

* p < .05

** p < .01

• n = 62

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Reflective practice in homelessness services:

A CBT approach

End

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Inclusion Health Continuing Professional Development Day 1

BSMS

20th July 2014

WELCOME!

• Housekeeping

• Tea , coffee, food

• Timetable

• Thanks to Pathway for funding the catering

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Aims of the day

• Theme is excellence

• Multidisciplinary and interdisciplinary education

• Setting and maintaining high standards

• Start of Inclusion Health speciality education

• Meeting like minded people (aka networking)

• Mutual education, mutual support

• Reducing isolation, preventing burnout

• Chance to influence developments

Introductions

• Name

• Role

• Where you are from (service, location)

AND

Either a ‘top tip’ for working in Inclusion Health

OR something you would like to see develop

OR one thing working in IH has taught you

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First steps towards a speciality of Inclusion Health

• Dr Chris Sargeant

• GP Pathway Homeless Team BSUH since 2012

• Senior Clinical Lecturer

• GPwSI Substance Misuse

• Previously GP at BHH Morley St 1998-2008

One thing IH has taught me is that we havemore success when services change to suit people, rather than expecting the opposite.

Introductions 1

• Name

• Role

• Where you are from (service, location)

Either a ‘top tip’ for working in Inclusion Health

OR something you would like to see develop

OR one thing working in IH has taught you

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Inclusion Health Where Did we Come From?

Primary Care

• Doing a ‘bit extra’- e.g.covering a hostel

• Part of generalist role

• Working in day centres

• Urgent care

• Being in ‘right’ place

• Special funding

• One off/special interest e.g.Christmas

Specialist Services

• Disease specific e.g.TB/mental health/sexualhealth

• Voluntary / faith basedservices

• Street outreach services

• Mainly large cities

• Local funded initiatives

Who is included in Inclusion Health?

• Hard to reach/easy to ignore groups

• Those poorly/not served bymainstream/traditional services

• Homeless People

• People with addictions

• Asylum seekers

• Gypsies and travellers

• Sex workers

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Legislation in late 1990s

• Allowed PMS services and salaried GPs

• PCTs, Trusts, other GPs could employ deliverPrimary Care services (GMS/PMS)

• More specialist services started for those notserved by mainstream

• Developed along different lines depending onlocal focus, funding, needs

Which services do we need to help educate and include

• Emergency Services

• E.D.

• Primary care

• OOH Primary Care

• Ambulance Services

• Mainstream Services

• In-patient facilities

• Out-patients

• In-reach to hostel/daycentres

• Outreach to street

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Introductions 2

• Name

• Role

• Where you are from (service, location)

Either a ‘top tip’ for working in Inclusion Health

OR something you would like to see develop

OR one thing working in IH has taught you

Where are we now?

• Faculty of Homeless and Inclusion HealthLondon based with North,South,East Hubs and West

coming• Increasing number of services developing-Pathway

services and others• Faculty Standards published• Pathway trial of in-patient intervention to be published

soon• Discussions with RCP re specialty accreditation (more

later!)• CCGs tasked with reducing health inequalities

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Where are we now ? cont

Specialist education programme for IH under development

To include:

On-line/distance learning modules

Stand alone educational modules

Full MSc programme for IH

Continuing Professional Development (started!)

What do we do?

• Support and enable (patients and each other)

• Educate each other

• Fill in the gaps

• Influence to change attitudes

• Get the best from other services for ourpatients

• Stick with people

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What do we do that is different?

• Truly multidisciplinary• Making services work

better together• Filling the gaps• Pushing boundaries• Staying with patient• Increasing support• Acting for patient• Bottom up and top down

and influencing themiddle!

• MDT meetings• Bringing in social care

earlier• Outreach /in-reach• Advocating for rehab• Community teams• New services in TA• Representation/advocacy• CEOs, administrative staff,

managers

Introductions 3

• Name

• Role

• Where you are from (service, location)

Either a ‘top tip’ for working in Inclusion Health

OR something you would like to see develop

OR one thing working in IH has taught you

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Where do we want to go?

• Recognised as specialty within our professions

• Fully networked and connected to each other

• Supporting each other

• Educational programme and trainingprogramme for out/ in-reach workers, socialworkers, nurses, doctors and medical students

• Maintaining agreed standards of excellence

• Growing services (and influence)

Local example in Brighton

• NowPathway Plus Team in hospital

Follow up for patients discharged to TA or street homeless

Hostels team of nursing+OT, plus nurse and outreach worker for discharged patients

Weekly Pathway MDT and hostel MDT

Education programme for medical students

Medical student homeless society

• Future

Bid to scale up above programme-increaseoutreach to hostels/TA and street

Plans for Homeless Hub for all services

Plans for purpose built premises

Pre-1998

Session of GP and 3 sessions of DN in local day centre

Post 1998

Specialist NP and GP services

Specialist primary care care, gradual additions of substance misuse, mental health, midwife services,alcoholservices.

Shared MDT with MH Homeless Team

Outreach to street and day centres

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The end

• Questions and discussion