The earlier roots and wider context of the PIE concept
New thinking almost never springs from nowhere; and generally, any new paradigm has its roots in the limitations, contradictions or fragmentations of earlier account.
We have described in a full length article the immediate origins of the PIE framework in earlier work done with the UK Royal College of Psychiatrists. This aimed to build on their earlier work on developing a more contemporary description of therapeutic communities, to identify features of healthy or ‘enabling’ environments that can be seen as aspects of public or community mental health.
The paper that first launched the term PIE was the first in a trilogy, whose overall title was: "Social psychiatry and social policy for the 21st Century". So for those with an interest in social policy, here we can briefly mention just a few of the wider contexts, in social policy and practice, in which this idea arose and developed.
The social model of disability and social epidemiology
The social model of disability, and the rise of social epidemiology, are parallel approaches to understanding the ways that disadvantage, stigma and exclusion can become disease vectors of poor mental health and morbidity in a population. These two rather abstract strands of thought then began to cohere in practice in informing social inclusion policies of successive governments.
This new thinking can be seen in areas such as the UK DCLG’s approach to homelessness, which began to adopt an approach that we might now identify by the term ‘recovery’; and the DoH’s creation of the NSIP, which was tasked with identifying areas where society’s institutions might be persuaded to operate differently, to anticipate mental health problems and develop more constructive responses.
With growing recognition around that time of the high concentration of poor mental health in the homelessness population (UK, US, France), combined with attempts to introduce quality standards in housing support services, homelessness provision slowly began to be seen not simply as ‘holding pens’ for those with problems the health services might be able to sort out, but instead as the frontline for a new kind of community mental health work.
"Complex trauma" and the Personality Disorder pilots.
The post-War therapeutic community can be seen as a very early precursor of the need for institutions to change, to adapt their working to meet therapeutic aims; and the 'TC' had long been one of the few effective ways of working with those we would now describe as having a personality disorder (PD). For many years TCs were out of favour, eclipsed by the apparent promise of medications for psychiatric problems. But another important strand in this history of ideas was the re-think within mental health services around the millennium, on the role of trauma, and on the nature of personality disorder.
Personality disorder is a mental health condition which is highly stigmatised, even by mental health standards, and even within healthcare was previously dismissed with what the UK Department of Health (DoH) termed ‘therapeutic nihilism’. Yet a growing understanding from neuroscience and psychology of the lasting effects of severe and 'complex' trauma was giving more ‘scientific’ corroboration for the clinical observations and theories of attachment theory, for example, over the importance of early life experience, and the growing realisation that relationships can harm, and can heal.
With the publication of a seminal document, “Personality Disorder - No longer a diagnosis of exclusion”, the UK Dept of Health signalled a major change of direction; and the launch of 11 PD pilot services to encourage innovative approaches, and learn lessons from them. One of the more striking results of the 11 pilots was how far these new, creative and more user-responsive services were finding ways of working and wider lessons that echoed what was happening in homelessness services.
This remained, however, a specialist area, and even in the UK, other government departments were largely unaware of this development. It was only the chance meeting of NSIP staff with DCLG staff, brought together over a quite different policy initiative – the short-lived ‘PSA 16’ - that led to the discussions on how to meet the needs of those NOT constructively engaged in mental health care; and from this came the first guidance document, known as the complex trauma guidance.
New Public Management and the new provider culture
Still less well recognised, however, is the significance of one further strand in the intellectual culture of our times – the managerial/political philosophy known to insiders as the New Public management, or 'NPM'. NPM is a term dreamed up, not even by social policy wonks and government advisers, but by the academics who study them – as many steps removed from frontline learning as it is possible to get. Yet NPM is to date the only real description of a change so radical, so widespread, that we hardly even see it at all. This is the term for the culture change, by which local authority staff, health staff and voluntary sector providers no longer simply did the best they could, with the resources they had.
NPM is the philosophy of the ‘purchaser/provider split’, aka the ‘contract culture’; the centrality of local ‘needs analysis’ and the commissioning of services – the shift from trusting staff to do what they could, to telling them what the state was prepared to ‘purchase’ from them; and the contracted in-puts and outcomes measures by which all services, henceforth, were to be judged. For those skeptical of the idea that quite abstract ideas can have any real sway over ordinary, hand-on, practicalities, the concept of NPM should give pause for thought.
NPM combined with a radically “hands off” version of localism adopted by the in-coming Coalition government in 2010. Henceforth, national government shied away from giving ‘top down’ national policy direction; all commissioning was to be devolved to local level, both in local government and in the health service. Regional intermediary structures, and a range of QUANGOs (including NSIP and its successor, NMHDU) were simply dissolved.
What this also meant, however, was that - notwithstanding the efforts of the remaining voluntary sector national organisations, such as SITRA, HomelessLink, hact, and the PIElink itself, to disseminate and promote innovative practice - all learning about what was effective was happening at local level, and in the full complexity of local context.
In consequence, in the field of homelessness, where the PIEs concept first started to come together, a much more ‘bottom up’ approach arose to identifying creativity, relatively free from centralised direction, and premature endorsements of ‘good practice’. This was therefore, fortuitously, able to build on the vestiges of a culture of needs-led responsiveness that had been encouraged, and was in many areas now quite effectively bedded, in during the Supporting People era.
In other countries, of course, there were other policy drivers and programmes; and we attempt here to identify them, and their impact on services, and service philosophies, wherever possible. But this is why the UK developments took the form of expression they did, after the official publication of the ‘complex trauma‘ guidance – more properly known as "guidance on meeting the psychological and emotional needs of people who are homeless", which was actually one of the last pieces of central government endorsement of practice under the new Coalition government .
In the following section we describe the original account of a PIE, as outlined first in an article by Johnson & Haigh, and then adopted and developed for the 'complex trauma' guidance.
Understanding Homelessness and Mental Health DCLG & CSIP, 2008
The 'complex trauma' guidance DCLG & NMHDU 2010