’Managing psychological complexity in a PIE — small steps or 90 cups of tea!’
28.02.2020: After a wonderful half-term break last week (relaxing and recharging with family/ friends), I returned to work at Centrepoint as the Lead for Psychologically Informed Environments (PIE) ready to continue with the rollout of our PIE Staff Training Day 1 in our London region, as well as the commencement of several team Reflective Practice sessions in Manchester and London. It has been a busy week, and my occasional feelings of being ‘overwhelmed’ juggling all the competing demands of my current role, has been a feeling echoed even more significantly by some staff within these training and reflective practice sessions.
Reflecting on these feelings at the end of this week, I have been struck by how much they originate in a sense of feeling ‘powerless’ or ‘hopeless’ within the wider health and social care system. Many of our staff have talked about “going above and beyond” within our organisation, but then facing barriers and challenges when operating in systems outside Centrepoint (e.g. statutory services), leading to frustration and a sense of being ‘overwhelmed by the scale of change needed’ or ‘lack of resources’. Related to this is that this week a significant report was published noting a fall in life expectancies for the first time since records began, particularly for women, with the conclusion that the past decade of austerity / cuts to services is the main driver of such a result and the associated health inequalities (c.f. Marmot Review: 10 years on — http://www.instituteofhealthequity.org/resources-reports/marmot-review-10-years-on/marmot-review-10-years-on-full-report.pdf). Psychologists have also been arguing for some time that there is a negative impact of austerity policies not just on physical health but also on the mental well-being of the population (c.f. https://psychagainstausterity.files.wordpress.com/2015/03/paa-briefing-paper.pdf). Within this wider landscape, it can sometimes feel like we are just one voice and that therefore we have no chance to #changethestory for the homeless young people referred to Centrepoint. Therefore, it can feel very stressful or pressured, whether working frontline or in our support teams. However, when I have these thoughts, I have found it helpful to hold in mind this quote from the famous anthropologist Margaret Mead; “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has”.
As well as the system creating feelings of being ‘overwhelmed’, staff also spoke about the complexity of the homeless young people that they are working with causing these feelings. Consequently, one ‘psychological tool’ taught in training sessions and used in reflective practice sessions this week that has proved useful, has been to support staff to use the ‘5 P’s Formulation’ breaking down complex issues into (1) Presenting Problems, (2) Predisposing or Background Factors, (3) Precipitating or Trigger Factors, (4) Perpetuating Factors, and (5) Protective Factors. This process helps staff to reflect upon the complexity of an issue by breaking it down into its specific parts and therefore generating actions or ideas to manage (1) by decreasing (3) and (4) and increasing (5). I noted when engaging in this process with staff teams that they often were able to generate ideas to move forward and manage complexity when given the time and space to reflect upon it. This was not only in terms of practical and /or tangible actions, but also in terms of their increased ability to manage their emotional responses to the issue through the processes of collective self-care operating in the team discussion. For example, it was particularly powerful when staff validated each other’s feelings and acknowledged each other’s challenges.
Moreover, the psychological concept of ‘projection’ (c.f. Psychoanalysis: Freud) is relevant here and can be helpful to explain why staff can feel overwhelmed or experience ‘vicarious trauma’ or ‘distress caused by hearing about others distress’. Essentially, all projection means is that the feelings that the homeless young person is feeling (e.g. overwhelmed by their situation, feeling threatened, confused, anxious and/or hopeless) are ‘projected’ or transferred on to the staff member listening to them, who then comes away from the interaction feeling what the young person was feeling. As a therapeutic tool, it can actually be very helpful. For example, answering the question; ‘How am I feeling after that interaction; could this reflect how the other person was also feeling?’ can lead to the identification of the feelings of the other person, particularly if they were unable or unwilling to communicate these to you clearly. However, it is also important to ensure we manage our ‘transferred feelings’ through self-care, supervision, and support in order to mitigate the impact upon us. Centrepoint exists to #changethestory for homeless young people in the UK, and our staff are the critical ingredient in the PIE recipe to do this. I am therefore looking forward to also working with the organisation on co-producing the new ‘People Strategy’ with staff, particularly the focus on staff health and well-being. I would encourage all Centrepoint staff to contribute as possible to the forthcoming focus groups and feedback sessions, to ensure that the strategy meets and reflects their needs.
Another related theme in the sessions has been staff’s own expectations of themselves and what they can achieve. Human beings are very complex, and any work that utilises the relationship with another as a therapeutic tool for change is therefore going to be challenging at times and can take time. It can therefore be helpful to remember the value of ‘small steps’ and the value of ‘informal contact’ and ‘building positive relationships’ when working with complexity. For example, I will always remember working with one individual in my previous NHS role who had a 20-year history of street homelessness, substance use, mental health issues and offending behaviours. He had always refused to engage in any kind of ‘talking’ or psychological therapy and made no secret that he continued to hold this view when I offered him psychology sessions! However, he was willing to meet me each week for a ‘cup of tea and a chat’ (as long as I made the tea of course!). Slowly over time, he began to share his story over these cups of tea, and after 3 years and over 90 cups of tea later (!), he had made such significant progress he ready to be discharged from the psychiatric hospital and to maintain a housing tenancy in the community for the first time in decades.
I particularly remember at the final clinical team discharge meeting, the Consultant Psychiatrist noting that he had done very well completing his psychological therapy with ‘Dr Miles’. At which point he commented, “Who’s that? …. Oh her, she made some great tea and was a really good listener … she actually helped me’. After 3 years of me wondering whether I was having any impact upon him, it was amazing to hear that his perception of our work was positive and helpful! It reminded me that sometimes we don’t even know at the time, how our support or connection to that other person is landing as well as the value of ‘informal contacts’. As Professor Nick Maguire (PIE expert, Consultant Clinical Psychologist & Professor of Clinical Psychology at the University of Southampton) has noted, sometimes our success in this work is to “receive one less f**k off than usual!” If the homeless young person continues to return to us for support, whatever that support looks like, we must be doing something right!
Therefore, just like our PIE journey takes time, so does working with the complexity of the homeless young people referred to Centrepoint. It might take 90 cups of tea, or something else that we can bring to that interaction with the other person, but working with such complexity within the systems as they currently exist, means that as also highlighted this week ‘we can only do what we can do’. Or as put another way in the famous Serenity Prayer: ‘’God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference’…
