‘’Supporting the challenging’ — A psychologically informed approach to managing our emotional responses to those we work with’
24.09.2021: As I sit down to write this week’s PIE blog, as the lead for Psychologically Informed Environments (PIE), at the national youth homeless charity; Centrepoint, I have been reflecting on some reflective practice sessions with staff over recent weeks. These sessions have involved not just a discussion of recent incidents or case formulations, but also some of the more difficult or challenging feelings that have been associated with the homeless young people that they are supporting. As noted in previous blogs (e.g. https://drhelenmiles.medium.com/creating-spaces-for-ourselves-and-each-other-the-value-of-reflection-and-connection-5e8d9e71deaa) and Keats et al (2012) PIE Good Practice Guide (c.f.
https://eprints.soton.ac.uk/340022/1/Good%2520practice%2520guide%2520-%2520%2520Psychologically%2520informed%2520services%2520for%2520homeless%2520people%2520.pdf, reflective practice is a key part of any PIE. It serves many functions, but one important one is to allow a safe psychological space for staff to discuss the emotional consequences of the work they undertake with often very complex and challenging homeless young people. Therefore, the exploration of our feelings is both normal and encouraged in these sessions.
As Keats et al (2012) specifically note, reflective practice ‘gives staff a perspective on the emotional challenges of their work’ (p.6) because ‘key-working clients with complex trauma can be challenging and exhausting’ (p.21). Reflective practice can however ‘enable staff to learn from experiences and thereby improve the way they respond when something similar happens again’ (p.21) and can serve ‘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’ (p.21). This emotional processing is in addition to the role of reflective practice to ‘develop learning cycles and skills development’ (p.6) but as a result ‘can significantly reduce staff burn out’ (p.21).
It is important to highlight that in a PIE, having an emotional response when undertaking the type of support work that many of our frontline staff engage in with the homeless young people, is something to be expected rather than ignored or feared as an indication that you aren’t ‘good at your job’. Reflective practice (as well as 1:1 supervision) in a PIE is therefore the place to articulate and process these responses so that they do not negatively affect us either personally or professionally, within the workplace. Many of the young people in Centrepoint can present with challenging or difficult behaviours, often arising from their earlier experiences of trauma and abuse, which can trigger strong or negative emotional responses in us. We can feel angry with or sad for them, we might be anxious about them or even feel disgusted or rejected by them. Equally, we can feel inspired by or hopeful for them. As with any human in a ‘relationship’ (albeit in this case a therapeutic rather than personal), we can feel a wide range of emotions towards and about them. This is ‘normal’ and as I often remark to staff, who may be wary initially of disclosing their emotional responses to a young person, I would be more worried if they did not have an emotional response to something they have heard or experienced from a young person because this would be a ‘red flag’ suggesting compassion fatigue and/or burnout (c.f. previous blog here: https://drhelenmiles.medium.com/running-on-empty-dealing-with-compassion-fatigue-in-a-psychologically-informed-environment-8af533f15013).
Other than a lack of any emotional response, I think one of the most difficult emotional responses to process, is the acknowledgement that we might not ‘like’ or we may struggle with a particular young person’s behaviours towards us (or others). Reflective practice can be helpful in this situation to air these thoughts and feelings, hear from others in a team who may struggle with similar experiences as well as hear from others about how they manage this. Consequently, we can gain some perspective upon these feelings that enable us to move to a position of ‘not taking things personally’ and/or being able to hold the young person and their challenging behaviour as ‘separate’ in order that we can find some way of forming a positive therapeutic alliance with them. Sometimes this can be particularly difficult when the young person’s behaviour is extremely anti-social or even criminal. I can recall many occasions in my career as clinical and forensic psychologist wherein I have had to manage contrasting and conflicting positions or feelings at the same time, and without support from colleagues the management of my ‘ambivalence’ would have been very difficult. For example, whilst I may have been able to hold a positive empathic or sympathetic response to a young person because of their understanding of their Adverse Childhood Experiences or ACE’s (e.g. trauma, abuse or neglect), I have also had to hold the knowledge that they have committed a serious or appalling act or crime and process my associated response to this.
A PIE perspective suggests that when working with a young person with challenging behaviours, we should try to ‘understand or explain’ a behaviour even if we are of course not ‘excusing it’. For example, we know from research on young offenders with significant anti-social behaviour and criminality that many of them have experienced ACE’s including abuse, neglect, domestic violence and family criminality. One of the most famous of these is the Cambridge Delinquency Study (e.g. Farrington et al, 1997), which for forty years has followed a cohort of over 400 young males born in South London. Those that ended up committing serious offences had significant ACE’s in their early life. Boswell (1998) also looked at the backgrounds of 200 of the most serious young offenders in the UK criminal justice system, defined as those who had committed significant offences such as murder, arson or rape. Nearly all of these young offenders had experienced severe loss, neglect or abuse in their early life. Knowing this evidence of the impact of these predisposing factors upon later presentations can offer us a way to understanding those young people who display the most significant challenging behaviours and who are likely to trigger the most significant negative emotional responses in us. However, ‘knowing’ this is one thing. Translating this into an appropriate emotional response that enables us to work positively with them can take a bit more effort!
It is therefore critical that any PIE organisation recognises the impact of this emotional response to support work, and does not just focus on a performance management or target driven culture (Whitehead, 2010). Key to this is to create a culture that is not only PIE informed but also encourages the development of emotional intelligence and emotional literacy through self-awareness, self-regulation, empathy and social competence. We need to be ‘authentic’ in our work, as young people are extremely good at seeing through superficiality(!), in order that we can build positive therapeutic relationships that create the conditions for change. Using the core skills of positive regard and respect, empathy, and offering a non-judgemental and consistent trauma informed approach is key. However, this means we need to be able to accept and process the difficult negative feelings we may feel about a young person outside of our therapeutic contact with them (i.e. in reflective practice and supervision) so that they do not enter the room with the young person and effect our engagement with or support of them. For example, research on staff working with offenders in probation settings (where arguably the ‘ambivalent’ feelings are often very high) has shown that discussion and debriefing with colleagues though reflective supervision is critical to achieve this and avoid burnout (Knight at al, 2016).
Aside from reflective practice and supervision, it is also important that we ensure that there is a focus on staff well-being and self-care in this sector. We are all different and have different ways of coping, but it is critical, especially when holding ‘ambivalent’ or conflicting feelings about those we work with, that we find ways to physically or mentally disconnect from our work. This may be through having time away from work (e.g. annual leave), connecting or socialising with others outside of work, and/or engaging in non-work related activities (e.g. exercise, hobbies, relaxation). It can also be helpful to ensure that we are accessing regular psychologically informed training to work with this client group and reminding ourselves of our successes in work (to motivate us to ‘keep going’) rather than just focusing on the challenges.
Moreover, it is important that we keep realistic expectations about ourselves, those we work with and the outcomes we can expect to achieve. Although Centrepoint has very high positive outcomes for many of the homeless young people that we work with, our population is some of the most vulnerable and complex in the UK. Therefore, ‘progress’ may be slow or full of steps backwards as well as forwards and we may not be able to help everyone all the time. However, even if we feel our work has not been ‘successful’, it is important to try to do all we can and to remember that any of our work won’t be wasted. Sometimes we may be ‘laying the foundations’ that other services (e.g. statutory agencies or other charities) can take forward positively in the future with a particular individual. We may think we have ‘failed’ if a young persons’ challenging behaviour results in them leaving our services or entering the criminal justice system. However, if we have tried to form a positive supportive relationship with them, they will carry that experience forward into their future engagement with other professionals that can lead to positive change in the future when they are perhaps more receptive to it.
Working with homeless young people can stir up many feelings within us. They can present with very challenging behaviours and ‘push our buttons’ or trigger us in a myriad of ways. Recognising and processing these emotions in reflective practice and/or supervision is very important both personally and professionally. Holding either positive or negative feelings (or even both) about those we are working with is both normal and expected. It only becomes an issue if we deny or ignore those feelings because we fear that we will be labelled as weak or incompetent. This acceptance of our emotional responses can take emotional courage and effort on our part (Knight et al, 2016) but it is critical if we are to operate in a truly psychologically informed manner in our practice and work most successfully with the often vulnerable and complex young people we see in Centrepoint. After all, as the quote in the picture at the start of this blog correctly notes ‘the kids who need the most love will ask for it in the most unloving of ways’…
