PICT in 5 minutes
The Psychologically-Informed Consultation & Training (PICT) approach is primarily a staff-facing intervention rather than direct working with the service user. I support the existing workforce who have regular face- to-face contact with service users presenting with multiple and complex mental health and challenging behaviours. Equipping the workforce not only enhances the quality of case management delivery, but it is relatively quick and inexpensive to set up and the benefits achieved are sustainable beyond the PICT input.
This approach is predicated on the following principles:
The care and management pathway for individuals with complex needs should eventually lead to integration and inclusion into mainstream society.
Frontline practitioners need to be upskilled to work with this population or they will struggle to support effective recovery and community functioning, leaving service users making little progress at increasing human and economic cost.
The vast majority of such service users will never enter formal treatment/therapy services for a variety of reasons. The majority are managed and cared for in more mainstream services, eg., primary and secondary care, probation, prison, housing organisations, local authority drug services.
No single organisation or service can meet the long term needs of this population across the whole recovery pathway, but an intervention aimed at practitioners can support a coherent and effective interagency approach.
PICT in 10 minutes
Life Blueprint
Like the body's immune system, our psychological functioning develops from birth. It develops within the context of continuous interactions with the environment. With a combination of a resilient enough biological disposition and exposure to optimal environmental conditions our psychological development flourishes and becomes a helpful blueprint for how to respond appropriately to others and life's demands. However, if born with a particular biological vulnerability and then exposed to adverse (childhood) experiences we are more likely over time to develop a pattern of distorted and unhelpful ways of relating, for example, to support services.
It is unsurprising that many individuals with such problems end up in a revolving door pattern with community, residential and inpatient/custodial services. For some, their life's blueprint (eg., seeing others as a threat) means they will relate to and behave towards self and others in unhelpful ways, including harming self/others in some cases. Understandably, engaging such service users can often elicit strong negative emotions in practitioners (eg., anxiety, fear, frustration, confusion) and the way in which the practitioner reacts to such negative emotions (eg., to reject, panic, punish, criticise or avoid) can reinforce the blueprint, thus inadvertently perpetuating the problem. The result is that such service users make little improvement whilst continuing to place high demands on human services.
The PICT approach is focused on upskilling and supporting practitioners to understand and work more effectively with such complex and challenging behaviours that arise from the service user’s life blueprint. I do this mainly through providing consultation and training to practitioners. I also undertake joint caseworking with the holding case manager to model a way of engaging and to understand the work of the practitioner. Another focus I take is to map whole systems pathways for such service users in order to make more effective use of inter-disciplinary and inter-agency resources.
Understanding behaviour
The premise is that both unhelpful behaviour and poor engagement with services are behavioural and relational phenomena. Psychology can contribute to the understanding of both, ie., what's going on beneath the surface behaviour. Once frontline practitioners understand the underlying needs of the service user rather than just respond to the surface behaviours, they can improve engagement and case manage in a more targeted, proportionate, objective and effective way.
Not replicating early relationship patterns
Working with service users presenting complex needs and challenging behaviours evokes very strong emotional reactions in the practitioner. This emotional reaction then invites the practitioner to engage in an unhelpful relationship pattern between them and the service user that replicates earlier life relationship patterns. For example, the hostile and paranoid service user might feel that people in authority are hurtful them and cannot be trusted. However, their hostility and secrecy can invite the practitioner to either adopt a defensive or punitive approach. This reinforces the service user's pre-existing view of others as hurtful and untrustworthy.
Another example might be that the service user's adverse childhood experience has left them with a life blueprint that they are worthless and cannot cope on their own. They have found early in life that when they enter into a crisis others respond immediately and consistently. In the absence of a stable personal support network, the blueprint is confirmed by human services in adulthood. Services, in a well-meaning way, increase their input and support to the person in crisis but not when (s)he is coping well, thus confirming the idea "I cannot cope on my own". Alternatively, if practitioners respond in an unempathic way, they may confirm the service user's sense that (s)he is worthless.
Focusing my intervention on practitioners is designed to help the practitioner understand these emotional reactions and how these relate to relationship patterns rooted in early developmental experiences of the service user. This understanding helps the practitioner to begin to respond in a more informed and strategic way that is both effective and healthier for the practitioner and the service user.
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