This chapter provides an introduction to psychodynamic theory as applied to settings outwith the specialist psychotherapy clinic, paving the way for the chapters that follow in Part 4. An individual’s internal world affects how they relate to others. Others may be unconsciously invited into playing old roles that are familiar to the individual (such as rejecting, not listening, criticising), even though these roles bring difficulty and distress to both sides. This chapter explores how these powerful but sometimes ‘invisible’ interpersonal dynamics may play out between service users and staff in settings where the human relationship is at the fore (such as schools, social service agencies, and hospitals). We also discuss splitting within a clinical team and other system dynamics. In circumstances where services and professionals can sustain a good-enough therapeutic environment in the face of unconscious invitations to repeat a problematic relationship, trust may develop between service user and service and many people are able to discover new ways of forming relationships. This depends partly on the capacities and current state of the person using a service, but also, crucially, on the capacity of the professionals and services to observe and be reflective about both sides of the relationship.

This chapter provides a brief introduction to the relational dynamics underlying ‘multiple exclusion homelessness’ and an approach to working in this area. Adults experiencing multiple exclusion homelessness have often, during their developmental years, experienced multiple homes, disrupted attachments, un-forecasted endings, multiple and short-lived figures of support – all experiences that can lead a person to develop an understandable anxiety about trusting anyone to remain stable in their life. These dynamics may inadvertently be recreated in the person’s adult life through the impermanency of different organisations they are involved with. Multiple exclusion homelessness can be understood as a late emerging symptom of underlying difficulties in someone’s relationships with care. A psychologically informed approach for staff working in the homeless sector is outlined. The staff-service user relationship, while often viewed as important within mainstream services, is commonly seen as a vehicle through which treatments can be completed rather than as the treatment itself. By contrast, a psychologically informed service for people experiencing multiple exclusion homelessness understands that the reverse is often more accurate: that the tasks and activities are really just the vehicle through which a relationship can develop that carries the possibility of developing a sense of safety, trust, and continuity.

Staff in the caring professions often have to contain troubling and unpredictable communications (projections) from those they work with. It is usual and expected for staff to have feelings in response to these communications – this is part of the process of emotional containment. If reflected on, the professional’s feelings and inner responses (countertransference) can be a vital source of information about the relational dynamics the service user carries with them and how the staff member is responding to these. However, if staff members do not reflect on and process their countertransference, there is the potential for increased stress for the staff member, and to inadvertently re-enact the patient’s relational difficulties rather than provide containment for them. A reflective practice (RP) group brings a whole clinical team together with the primary task being to reflect on and process staff-patient, teamm and organisational dynamics, to sustain caring relationships with patients and reduce the stresses of the work for staff. This chapter offers an introduction to psychodynamic RP groups, aimed at both participants and group facilitators. We discuss the theory of RP groups and their intended purpose, outline a process of starting a group, and consider what is expected for both participants and facilitators.