The value of PIE

As an expert by experience, working at a strategic level, I often work alongside current and former architects of the ‘system’ as well as governmental influencers.

When I started out, it quickly became evident that the system was broken. It took a subtle shift to think positively: What are we doing in our service to generate emotional recovery? What is it? How do we do it? What are the blockages and how do we overcome them? And how do we make coming to work an enjoyable experience instead one of dread?

I understand that mental health is not a disease but a condition; a negative reaction to a world which is in denial. Wellbeing is complex and subsequently we have developed a complex system of containment towards people experiencing mental distress. We often fail to take into consideration people’s cultural and religious beliefs, which can undeniably play an important role in one’s recovery.

Unlike having a broken bone or cancer, a mental health condition cannot be definitively diagnosed through a scan or a test. As a result, mental health conditions do not satisfy the ‘Virchow Test’ to categorially define a lack of wellbeing as a disease. A psychiatrist, the late Thomas Szasz, shared this train of thought and refused to define mental health conditions as diseases but as ‘problems in living’.

Now one problem in living is the clinical diagnosis which hangs a label around the ‘patient’. He or she could see three different psychiatrists and end up with three different diagnoses. Any mental health professional or service user may have witnessed this by in a mental health tribunal battling the nature of a diagnosis.

Normally, in healthcare, patients expect clear pathways and outcomes in their treatment. It’s a different story when it comes to mental health everything merges into a ‘grey area’ regarding ‘outcomes’.

Like a diagnosis, outcomes appear subjective and vary from mental health team or professional. Although these ‘goals’ are supposed to be co-produced, the reality is that they are often medically driven. In response, a recovery-oriented model challenges this old system of diagnosis and compliance to one of outcomes based on building strengths and empowerment.

Currently, any outcome journey is left to clinical judgement, and when I ask about recovery or the effectiveness of the status quo within mental healthcare I am told, ‘Well… it depends’. At this point the conversation drifts towards definitions and ceasing of disturbances.  In the end it is about providing individualised care.

When looking for a model to assist a paradigm shift towards offering individualised care across the board, I struggled. From counselling in the community to supported accommodation and high-secure forensic mental health care, it seemed impossible to find an overarching model. It was at this point that I came across psychologically informed environments (PIE).

Psychologically informed environments is about viewing recovery not just as functioning to get a job on a DWP programme. It’s about being someone who regains their emotional sense of being to actualise themselves within the world, which means having a sustainable vision rather than just a set of cognitive goals and milestones. PIE can include one’s personal, cultural and religious beliefs to adapt the model to their individual needs. This was evident with some of the case histories I viewed as part of producing this piece.

Dr Dean Whittington created PIE after working for 16 years to develop an innovate service for people using substance use services in Deptford, South East London. An area immortalised in the acclaimed film Nil by Mouth and the former home of Millwall Football Club. Later, Dr Whittington worked in a hostel near London Bridge delivering psychotherapy for six years to men written off by various treatment services. Men who were apparently too ‘difficult’ to work with, or just viewed as ‘hard work’.

During this time the model he formulated supported the emotional recovery of individuals failed by a broken system. Through reading his case histories I saw what he was grasping at – that emotional recovery should be the aim of treatment services.  Practitioners mingled with ‘patients’ and talked to them as equals. Through mingling, the basis is to build rapport and trust. Through building trust, the ‘service users’ reveal what is normally concealed: their life stories.

Through engaging with people’s strengths and building recovery capital by looking at what they have formerly succeeded in, a secure base is built.  The basis of recovery also entails bringing to the fore those narratives infused with overcoming brutal negative experiences. This requires practitioners not flinching from the intensity and not being scared of the cultural and/or religious differences they may have with the people they are caring for.

By providing people with a space to be heard and having the skills and patience to listen, the focus centres on practitioners becoming ‘enlightened witnesses’; people who validate these life stories. The aim is to bring each person into the present so they can rest upon their secure base, providing a breather as they begin their recovery journey. The practitioner builds the scaffolding for this in a co-production.

Now this is not the task of one member of the team. It requires everyone to believe that recovery can and will occur. It requires having a team vision and the team being supported to keep hold of their vision despite the negativity they face as people filled with despair become soothed. This is called grounding. From being grounded, the person can reveal their past, including the positive and negative experiences, and then work towards sustaining their vision.

Initially, as Dr Whittington showed, this is painstaking work is “like putting an ancient vase together”. But as each practitioner working as a team has put together one, there is confidence that the skills do exist which provides hope to everyone trapped in the system. Confidence that recovery is possible because everyone needs hope.

PIE is about doing an audit of existing practices to see what is creating the blockages which allows you to think about how to build recovery capital. The next step is generating a vision within a team, which includes incorporating actualising the vision of those who enter ‘treatment’. From this recovery pathways emerge, and the individual is supported along their journey to overcome institutional blockages.

More importantly PIE puts the person accessing care back at the centre of everyone’s thinking and creates an opportunity for people to take back control of their lives ‘doing with’ as being ‘done to’.

To find out more about psychologically informed environments read this piece by Dr Dean Whittington.


About the Author

Rafik Hamaizia is the expert by experience lead for Cygnet Healthcare. Rafik, aged 25, has been a service user in a variety of mental health settings. His role within the Cygnet Healthcare is to work alongside the Executive Board of Directors to shape and improve service user involvement, co-production and patient experience structures on both strategic and local levels. In 2017 he was given the Cygnet Healthcare Special Recognition Award by Universal Health Services. He has participated in over 100 Care Quality Commission inspections and develops guidance with the National Institute for Health and Care Excellence (NICE). He is currently studying for an MSc in Mental Health Recovery and Social Inclusion at the University of Hertfordshire. Rafik is also the founding member of the Joint Thinking Initiative, a not-for-profit, service user led organisation, focusing on improving mental health care through co-production.

You can follow Rafik and his work on Twitter: @Raf_Hamaizia.