Wells, Jennifer
(2021)
Consensus based good practice guidelines for clinical psychologists working in and with homelessness: a Delphi study.
DClinPsy thesis, University of Nottingham.
Abstract
The number of those considered homeless – including the hidden homeless - has been increasing since 2010 (Fransham, 2018). Legislation, such as the Homelessness Reduction Act (2017), has been introduced to tackle rising numbers. This is the first piece of legislation to acknowledge the complexity and prevalence of mental health difficulties in the homeless population, repeatedly highlighted in the literature. Despite increasing numbers, complexity, links to mental health difficulties and backgrounds characterised by trauma, Clinical Psychologists (CPs) currently have no guidelines to support their direct work with this population, nor the organisations and staff they work with. Furthermore, this lack of guidance means commissioners have no way of knowing the resources required for CPs to work effectively with this population. Despite the absence of an empirical evidence base, CPs have been working in homelessness services, meaning they will have generated practice-based evidence. This research sought to harness this practice-based evidence and create consensus-based good practice guidelines.
The Delphi Method was used to elicit and synthesise this practice-based evidence to support the creation of good-practice consensus-based guidelines for CPs working within homelessness. The Delphi was conducted over three Rounds. Prior to Round One, a panel of Expert Citizens were consulted, and asked to discuss their experiences of homelessness and mental health. The information generated from this consultation group was provided to all the CPs – called panel members - for information prior to Round One. The first Round consisted of an initial semi-structured interview with the 12 panel members recruited whom had with experience working in homelessness. This explored their experiences of working with this population. Each panel member was asked to provide six potential guidelines: three for direct work and three for indirect work. All guidelines – 36 direct and 36 indirect – were collated into a survey for Round Two. This survey was sent to all panel members, who were asked to rate each guideline using a Likert scale to denote its importance for inclusion. Using the data generated from Round Two, Round Three included all collated panel member feedback, detailed amendments to the guidelines and provided panel members with the opportunity to provide more feedback. Required consensus levels for a guideline to be considered important or essential were set apriori at ≥80% guided by existing Delphi literature. Percentages were calculated using the number of panel members who had responded to the Round. Following Round Three, all endorsed guidelines were supplemented with two clinical vignettes taken from the practice-based examples provided by panel members in Round One. All guidelines and vignettes were distributed to panel members in Round Four for member checking, and to provide additional vignettes where a guideline had <2.
The panel endorsed 23 direct and 26 indirect working guidelines. The research team grouped these under similar categories. Direct guidelines fell under the following three categories: “Approach”, “Multi-agency working” and “Individual Therapy”, and indirect guidelines under four: “Relationships with and support for staff”, “Supporting staff to support service users, including building therapeutic skills”, “Approaching systems change” and “Contributing to the evidence base”.
Limitations include the guidelines having limited international applicability outside of the United Kingdom, the homogeneity of the sample, and lack of external corroboration of the panel members reported experiences of good practice with staff, service users and organisations.
This research provides both guidance to CPs and commissioners in an area where this was previously lacking, and also highlights the lack of empirical evidence base in homelessness. Endorsed guidelines echo the importance of CPs working in homelessness to contribute to the evidence-base, reducing the research-practice gap.
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