‘Reflecting on Reflective Practice in a Psychologically Informed Environment…’

01.07.2022: As I write this week’s PIE blog, as the lead for Psychologically Informed Environments (PIE), at the national youth homeless charity — Centrepoint, I am reflecting again on one of the key delivery streams of work that our PIE team regularly undertake across our ‘frontline’ teams, and ad-hoc currently across our ‘support’ teams. That is; ‘Reflective Practice (RP) sessions’. We have now been running these spaces, primarily face to face although also remotely for over 2 years now, and an audit of these last year (in submission for publication) indicated that they were very well attended (nearly 80% uptake even during the COVID-19 pandemic) and highly valued by attendees. For example, around three quarters of staff respondents (n=140) said they were very satisfied or satisfied with sessions (74.6%), and found them helpful or very helpful (77.5%). However, I wanted to use this PIE blog to reflect on these spaces from the perspective of a ‘facilitator’ as well as an attendee, noting where my perspective on RP may be mirrored in some ways by the participants to create a shared understanding of the purpose and benefit of these valuable spaces.

Reflective practice is one of the key ‘ingredients’ of a psychologically informed environment or PIE, and is something that I have written about in previous PIE blogs (e.g. see here: https://drhelenmiles.medium.com/reflections-on-ensuring-that-reflective-practice-in-a-psychologically-informed-environment-pie-308d92baf371 and here: https://drhelenmiles.medium.com/creating-spaces-for-ourselves-and-each-other-the-value-of-reflection-and-connection-5e8d9e71deaa) although not for some time, hence this week’s focus. In the PIE Good Practice Guide (c.f. Keats et al, 2012: https://eprints.soton.ac.uk/340022/1/Good%2520practice%2520guide%2520-%2520%2520Psychologically%2520informed%2520services%2520for%2520homeless%2520people%2520.pdf), RP is described as ‘the process of continuous learning from professional experiences, which encourages problem solving and critical thinking skills’ (p.21). This guide also rightly highlights that key working homeless young people with complex trauma can be ‘challenging and exhausting, but adopting a reflective approach, especially after difficult incidents, can enable staff to learn from experiences and thereby improve the way they respond when something similar happens again’ (Keats et al, 2012; p.21). Moreover that RP ‘serves to enable the staff member to make their internal experiences (thoughts and emotions) explicit, thereby facilitating the possibility of reducing the intensity of difficult emotions and possibly altering behaviours’ (Keats et al, 2012; p.21) as well as enabling ‘learning cycles’ and reducing staff burnout / attrition.

However, RP is not just unique to a PIE approach, having been around for decades in healthcare and education settings, and as Kurtz (2020) notes, in many ways drawing on ‘ancient wisdom and common sense’ (p.1). Specifically, in that RP is about creating spaces to ‘stop and think’ in our busy working lives, to move from just a work culture of ‘do…do…do’ to ‘do…think…do’. This might seem like an unaffordable luxury when we are all so busy, often managing crises, and moreover, requires an organisation to invest in resources (in Centrepoint’s case; the qualified psychologists in the PIE team). However, as Kurtz (2020) argues ‘the cost of not doing so, certainly in the long-term, is immeasurably higher’ (p.2). Why? Because ‘high levels of clinical activity without sufficient space to consider actions, process responses and draw on the support and encouragement of colleagues, will result in a sense of isolation amongst staff, burnout and poor or at least much than optimal clinical practice’ (p.2). We are not robots; we are human so the messy complex issues that many of our frontline staff are dealing with on a daily basis in our supported accommodation services can have an impact upon us. RP can create the space not just for the answers to questions such as what can we do in this situation, but it can also give space for the human and relational aspects of the work, the how do we ‘feel’ about the work (Kurtz, 2020). This all sounds great then; but is it always that easy?

One of the biggest challenges our team has found in facilitating RP on the ‘frontline’, has been the practical — how can we create the RP spaces in the first place? This often takes considerable planning and liaison with managers and staff to ensure that as many staff as possible are on shift and can access the session as well as a high level of diary management from the PIE team to fit everyone in! Of course, the ideal is that all staff are present and the session is held in a private confidential space. This is not always possible though, so whilst we prioritise face-to-face delivery of RP, we have now developed hybrid versions of RP when needed. For example, being flexible with technology (e.g. video / Teams / zoom sessions or use of a telephone on loudspeaker) when staff are working from multiple sites or from home if they want to join when they are not on shift. As facilitators, we know sessions like this can be challenging for the staff to engage with, just as they are significantly more challenging for us to facilitate to ensure that we enable everyone to have the opportunity to speak and be heard, and for everyone to be able to contribute equally should they wish too.

Consequently, we often travel around different sites to give all staff the chance to be face to face at least one session every 3 months with hybrid online sessions in the interim as well. However our resources currently limit us from being able to offer as many sessions as we would like face to face or that staff ask for (e.g. managers regional sessions / night staff drop-ins, more frequent than monthly for ‘frontline’ and ad hoc for ‘support’ teams). These are areas we are currently looking at developing in the future should we be able to source more resources in the PIE team. This can be challenging for both staff attendees and us in the PIE team, as we are not able to give as much time as we would like particularly when a team is dealing with a high caseload of complex homeless young people, whose presenting needs or challenges are significant. Although RP sessions are scheduled for 90 minutes, it can therefore be common for these sessions to over run at times, which if we can facilitate then we will.

Of course, delivery of RP in ‘frontline’ services can also be challenging not just because of not being able to reach all staff due to other pressures, staff leave or rotas, or geographical lay out of some services being spread across different smaller sites. Even within a staff team are all located in one service, it is rare to have a dedicated confidential space for RP sessions in the building. Often they have to be held in a staff office, or other communal space that means that sessions can be disturbed as the homeless young people in the supported accommodation service may be ‘knocking on the door’ to get their needs met. This can mean that sessions can be a bit ‘stop-start’ at times, meaning the facilitator (and the staff) have to work hard to hold on to the discussion topic between interruptions. I can remember doing my clinical training as a therapist and being taught what the ‘ideal therapeutic space’ in which to offer sessions should be. Of course, once I then worked in the NHS hospital and community settings, prisons and hostels throughout my psychology career, I soon realised that these spaces rarely existed! Rather therapy was undertaken in any room we could find that tried to minimise interruptions or sometimes even outdoors whilst going for a walk with a client! Being adaptable when creating RP spaces is therefore key in the ‘real world’ of delivery, both for the facilitators and the staff attending the session.

Another challenge of RP to a facilitator, and arguably also to an attendee is perhaps the lack of ‘structure’ or an agenda in a session. We are all used to attending meetings where we know what is going to happen and what we need to contribute or prepare beforehand. Whilst, I do start with a reminder of our universal basic group rules (e.g. confidential and respectful space) and a ‘check-in’ of the emotional temperature of the staff since the last session, as a facilitator I don’t bring the topics for discussion. This can sometimes lead to what I describe as ‘the tumble weed moment’ where no one wants to be the first to speak. Thankfully, during my training as a therapist I learnt to ‘sit in silence’, even though it does not actually come naturally to me (as anyone who knows me personally rather than professionally will attest to!). Nevertheless, when you create this space for silence, in my experience it will be filled. It is not my role to fill it however. I want to create the space for the staff to bring up what they need to. Interestingly, I often facilitate RP sessions where initially staff say they have nothing to talk about, however when given the space to ‘stop and think’, actually issues, worries, concerns about their practice or the homeless young people they support quickly rise to the surface. The result of this is that sometimes teams have incredibly productive learning discussions and/or develop detailed case formulations when they initially did not think they had anything to discuss! However, for those that are attending RP, perhaps before your next session, you can take a few moments to think through your current work load and consider what you might like to bring (e.g. case, process etc.) if you found that ‘tumble weed moment’ quite uncomfortable.

In the interests of reflective honesty, I will admit that creating open RP spaces can also be very anxiety provoking as a facilitator. We literally have no idea from one session to the next when we walk into a supported accommodation service or log on to our computers for a remote session what the team we are meeting will bring to discuss. For example, what incidents have happened with the homeless young people or within the team or the wider system from the last month? Sometimes, these are quite serious or significant challenges that require us as facilitators to be ‘on top of our game’ and therefore we try not to facilitate more than two sessions across one day (to allow us to process / travel between sessions). For example, in just the last month or so from our frontline topics have included dealing with the consequences of sexual assault, murder, modern slavery, serious youth violence and gang involvement, domestic violence, failures in wider social systems, staff personal health issues, team changes and challenges with their physical environment. No one day is the same as another, and whilst I enjoy the variety, and after two decades of frontline work, hope I have something useful to bring to these discussions, it does mean I experience a degree of anticipatory anxiety (and a bit of self-doubt!) before a session!

Of course, therefore this might also be how participants feel before a session. It might feel easier to just avoid the session and get on with some paperwork or some other task instead, rather than be willing to be open to sitting in a room with your colleagues discussing recent challenges. Perhaps you want to just forget about them / move on and deal with something else? This is understandable, but of course I would argue that RP creates a space to ‘process’ these challenges, rather than ‘bottle them up’ where they can impact on you later, perhaps even outside of work. Moreover, we hope the RP spaces we create are primarily supportive. They are not a ‘serious incident review’ and whilst the aim is to explore issues and develop action plans for the future, they are not about unnecessary criticism of current practice. None of us is perfect, we can all build on what works and learn new things. RP can create this space for learning in a non-judgemental way especially when we are reflecting together as a team and sharing our ideas. I often learn a lot from my colleagues in RP sessions, as of course I am not there as the ‘sole expert’ but as a ‘facilitator’ of the expertise in the room and part of the team, so let us learn together!

RP can also feel ‘scary’ because it is sometimes wrongly viewed as ‘personal therapy’. It is not. Whilst RP does help us all with our emotional responses to events, improving our ability to ‘reflect in action’ (Kurtz, 2020), it is not about telling each other all our personal ‘stuff’. We can disclose as little or as much as we feel comfortable with in a session. Many new staff attending RP often like to ‘observe’ initially, and whilst I would always encourage every team member to feel able to contribute to discussions and have their own voice, I understand that it can take time to trust the space just as it takes time for us to build relationships with our colleagues and the homeless young people we support. RP is really for connecting with the emotional consequences of our professional practice not to talk in detail about our personal lives. Of course, sometimes these worlds collide and disclosure is helpful, and our PIE team also offer 1:1 staff support / signposting sessions outside RP, if staff do need some additional support or want to talk though any personal triggers resulting from their professional practice. Luckily, in Centrepoint we also have our Employee Assistance Programme (EAP) that offers a confidential telephone counselling service. Therefore, RP is not ‘group therapy’ and you will not be expected to talk in detail about your personal life if you attend!

Sometimes, RP can also be frustrating for us as facilitators, and for staff attending, because when discussing a particular issue we can realise that much of any resolution to any issues raised may be out of our control. Centrepoint operates within a wider health and social care system, in partnership with many other statutory and non-statutory agencies. RP sessions will not stop under resourcing, a lack of information sharing between agencies, or suddenly create services where we identify gaps (Kurtz, 2020). However, we can use RP to think about how we manage this challenge, what support we can offer, and how we can process the natural feelings of frustration or anger towards the wider system. Sometimes in sessions as a facilitator, I am genuinely shocked at the stories staff recant about failures in the wider system, a recognition that does not change the issue but discussion can validate and show empathy towards the staff operating within that system. As an old supervisor once remarked to my younger idealist self, we cannot always change the wider world / other people (i.e. the external) but we can change how we respond to it (i.e. the internal).

Finally, I hope most of all that the RP sessions that the whole PIE team facilitate across the organisation hold at least one key thing in common despite our team’s individual differences and styles or approach. Although we are all trying to create spaces that encourage thinking / reflection, a shared understanding and increased collaboration in teams, and we try and underpin these with the theoretical model outlined as a ‘Reflective Cycle’ by Gibbs (1988), most importantly they are underpinned by Rogers (1951) person centred approach. In particular, we place significant emphasis on bring ‘empathy’ to the room, rather than a rigid formulaic or agenda driven approach to sessions. As the psychologist Brené Brown is quoted as saying; ‘Empathy has no script. There is no right way or wrong way to do it, it’s simply listening, holding space, withholding judgement, emotionally connecting, and communicating that incredibly healing message of “You’re not alone”’. This central tenet of empathy is the underlying ethos that I know that all our PIE team psychologists primarily bring to RP sessions, and I hope that this is something that staff attending can also be part of creating for each other. There is no one RP space, each session is different and we all get out what we put in. So if you have never been to an RP sessions in your team or haven’t had the best experience in the past, maybe give the next scheduled one a go or talk the PIE team about arranging a session or obtaining more information / reassurance about what’s involved. We are all on this PIE journey together in Centrepoint, and RP is a significant part of the process of becoming a psychologically informed organisation…