‘Working in a psychologically informed way on the ‘frontline’ supporting homeless young people during COVID-19’.

20.03.2020: It has now been almost a year since I left the National Health Service (NHS) in the UK after almost two decades of service, to take up my current post as the Centrepoint Lead for Psychologically Informed Environments (PIE). The world today seems quite different from a year ago, but I still have many friends and ex-colleagues working in the NHS right now on the ‘frontline’ of dealing with the current COVID-10 pandemic. Therefore, it was lovely that the UK last night honoured these amazing staff by coming out of their homes briefly to clap and cheer (whilst hopefully remaining 2m apart from each other!) for our NHS and care workers (https://www.bbc.co.uk/news/uk-52058013). It was a powerful act of solidarity, appreciation and community, that was quite moving to witness and reminded me of the great human capacity for resilience and strength when we come together. However, it did get me thinking that the ‘frontline’ is wider than the NHS and social care right now, and consists of many other ‘keyworkers’; who whilst most of us are staying at home, are still going to work to look after the most vulnerable in our society or keeping vital services and food and medicine available.

Specifically, I thought of Centrepoint’s own ‘frontline’ teams, in Housing and Support (and Health), who are continuing to work directly on the frontline in almost 60 services nationally providing care and support to homeless young people. Over the past year, I have met many of these staff during the scoping exercise for our PIE strategy and framework, as well as more recently setting up the staff PIE training and reflective practice groups. Our staff are truly amazing and are dealing with huge challenges in services right now. Not least managing government guidance on physical distancing (tricky in services that aren’t designed with large spaces or wide corridors!), supporting young people showing COVID-19 symptoms and self-isolating in less than ideal conditions in hostel accommodation (e.g. ensuring they have basic supplies and ways to cope with self-isolation), all whilst ‘fire-fighting’ the usual challenges relating to mental health and running a homeless hostel with diminishing staff numbers. Their spirits and morale, and ‘willingness to go above and beyond’ during these difficult and challenging times are truly inspiring and I have huge admiration and gratitude for the important work that they are undertaking (c.f. https://twitter.com/centrepointuk/status/1243211151359475720?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Etweet).

Consequently, to support our ‘frontline’ services moving forward, I have this week been involved in Centrepoint’s staff redeployment training. Those who usually work in other roles within the charity (e.g. educational, training and engagement services) are preparing to cover housing shifts, to ensure that that we can prioritise keeping our homeless services open in the coming weeks and months as our ‘frontline’ staff become unwell or unable to work due to health guidance around self-isolation. I have been extremely impressed with the degree to which other staff in the organisation are willing to support our vital ‘frontline’ housing staff and the homeless young people. However, supporting the homeless during the COVID-10 pandemic is a particular challenge, highlighted by our CEO Seyi Obakin this week (c.f. https://www.manchestereveningnews.co.uk/news/greater-manchester-news/homelessness-charities-warn-boris-johnson-17956590) and we urgently need resources and funds to continue our vital work. If you can donate to support this, please do so here: https://www.justgiving.com/campaign/Centrepoint-Emergency-Coronavirus-Appeal.

Our small PIE team is also offering support to ‘frontline’ staff, albeit remotely at present, particularly in supporting the inevitable psychological stress that they are experiencing. Whilst helping those in need can be rewarding, it is also a challenge (personally and professionally), now more so than ever. Consequently, it is natural and expected that our staff will be feeling fear of their own risk of infection, grief and sadness about the current situation, frustration and anger with the challenges of working with limited equipment and resources, and exhaustion with the surge in demands for support / care. Whilst the priority must be to care for physical health needs, and reduce the risk of further COVID-10 transmission, the psychological and social needs of our homeless young people (and staff) also need to be considered and would be arguably under a PIE, be considered as important in the longer term. Luckily, there is lots of good evidence based advice and guidance now being produced that can offer some pointers (e.g. https://www.mhinnovation.net/sites/default/files/downloads/resource/IASC%20Interim%20Briefing%20Note%20on%20COVID-19%20Outbreak%20Readiness%20and%20Response%20Operations%20-%20MHPSS.pdf).

As a psychologist, I am mindful of the important but basic strategies that benefit us all, not least our ‘frontline’ staff in maintaining our mental health and well-being. Firstly, as Maslow (1943) outlined in his now famous ‘Hierarchy of Needs’, we should ensure we care for our ‘Physiological Needs’. Although this can be a challenge on a long shift, ensuring we have sufficient food, water and rest is critical — being ‘biologically deprived’ makes us less able to care for others and we also risk our physical health. The importance of taking regular, even if brief (!), breaks throughout the day, is key as after all this current situation may best be described as a ‘marathon not a sprint’. In order to ‘keep going’ we must ensure we have sufficient resources (physically and mentally) to avoid ‘hitting the wall’ that long distance runners are so familiar with.

Secondly, Maslow notes that we need to ensure we have ‘Safety and Security’. It is therefore key to adhere to the latest guidance from the UK government (e.g. handwashing, minimising our travel and movements etc.) in order to ensure our safety during a pandemic and ‘flatten the curve’ with regard to the prevalence of cases requiring hospital admission thereby reducing the chances of overwhelming our NHS. However, our psychological safety and security will also be key at this time. Within Centrepoint’s staff PIE training, we have focused on the importance of creating a ‘secure base’ for our homeless young people within the context of ‘Attachment Theory’ (c.f. Bowlby, 1988). Our services, and the relationships that our ‘frontline’ staff have with our young people within them, are these ‘secure bases’ in these uncertain times.

Consequently, as also highlighted on the PIE training, utilising our pre-existing person centred (e.g. Rogers, 1966) counselling skills such as active listening, empathy, non-judgement and unconditional positive regard, creates ‘spaces’ to support and hear our young people when they express their natural anxieties, fears and worries about COVID-19. Many of our homeless young people have pre-existing mental health conditions and will therefore continue to be offered support for these from our Health team and statutory partners when possible. However, all of us remain vulnerable to psychological distress in the current situation and it will be important to normalise these understandable emotional reactions to the current situation as well as offering a message of hope and community. Therefore, as much as we can, let us create the spaces to listen to ‘little things’ as and when needed from our homeless young people and our colleagues. This will ensure that we ‘nip issues in the bud early’ (e.g. the challenges of living in close proximity to others, self-isolation or having our freedom curtailed), hopefully reducing the chance of bigger or longer term issues developing. Specifically, there is some great advice written by psychologists, about how to have conversations with young people about COVID-19 available here: https://emergingminds.org.uk/wp-content/uploads/2020/03/COVID19_advice-for-parents-and-carers_20.3_.pdf, including how to open conversations and manage the associated emotional responses, as well as age appropriate resources and information about COVID-19.

It will also be key to adapt to the current threat by trying not to dwell on wider threats we cannot control. For our ‘frontline’ staff working directly with homeless young people in our hostel services, our focus will need to be on the getting the ‘basics’ right before we worry about ‘additional’ targets or challenges. This has been a time for us all to revaluate our priorities, including whom society defines as critical or a ‘keyworker’! Staying in the present (e.g. perhaps using Mindfulness meditation techniques — see You Tube for lots of Mindfulness videos and audios) and focusing on the most important, achievable and immediate tasks can also reduce our attention on future worries, which may be overwhelming. Knowing that it is perfectly normal to have ‘good days and bad days’ is reassuring. For example, my daughter is currently keeping a diary of her experience of being at home (she recently studied the plague at school and was inspired by the historical journal writing of the time!), using pictures and words to process her experience. This might be something (whether on paper or by audio / video) that can help us (or the homeless young people we support) create a sense of order in the current chaos (Pennebaker, 1997). Interestingly, it has already highlighted to her that she may experience many emotions (especially missing her friends and getting cross with her sister!), and that whilst some days are easier than others, overall she can, and is, coping with her school being closed and her usual social and educational activities curtailed.

Coming from a forensic background, wherein many of my clients were ‘locked down’ for months and years on end, and looking at the research literature from scientists or explorers used to extreme isolation, one of the biggest challenges over the coming weeks will be managing boredom. This can be helped by establishing new routines (e.g. Smith et al, 2017; Solcova et al, 2016), which can facilitate a sense of control and reduce uncertainty. In addition, both the PIE Team and the Health Team in Centrepoint have been distributing resources (e.g. free online activities and support) that our homeless young people can access within services. Allowing space for creative activities for homeless young people to express their feelings as well as providing appropriate information is also helpful, as is providing basic resources for reading, listening to music, playing card or board games, cooking sessions or exercise opportunities. I recall many different ideas were generated by the residents of our forensic services (e.g. ‘A Pub Quiz without a Pub’ / Play Station 4 ‘Gaming Knockout’ / Courtyard exercise challenges) within the confines of a four walls. Moreover, we often diffused potential situations on our longer stay wards by creating opportunities or ‘small projects’ for others to be ‘helpful and support’ others within the service (e.g. clearing up outside space/gardens, offering peer support to others, daily jobs or ‘roles’). Such activities can provide a sense of achievement and value for those who take part, as well as creating a sense of community and reduce challenging behaviours resulting from frustrations towards others.

Finally, to meet our psychological needs, Maslow argues that we need ‘Belongingness and Connection’ to others, a challenge with self-isolation and the advice to ‘stay at home’. Consequently, regularly connecting (whether two metres apart in services, or remotely / virtually via telephone, e-mail, connectivity apps, and/or social media) with our homeless young people (as well as our colleagues) will be critical for our mental wellbeing over the next few weeks and months, as I highlighted in my blog last week. Trying to ensure that our communication is ‘constructive and optimistic’ as far as possible, whilst sharing our frustrations and solutions with each other, and remembering to compliment and support each other when we can on a ‘job well done’, can provide effective mutual support to deal with the daily challenges we are currently facing. Moreover, our social support networks, supervision and team meetings will create other opportunities to connect with others both professionally and personally, in order to manage our well-being. And whilst it is helpful to stay updated, we must remain mindful of not overloading ourselves (or the homeless young people we work with) with too much news, which can be overwhelming and increase our anxiety. Psychologists suggest that it is important to try to remember remain ‘balanced’ in our daily lives to cope with the inevitable anxiety of the current situation. This means ensuring that our day-to-day activities give us a mixture of a sense of ‘achievement’, help us feel ‘close and connected’ with others’ and provide ‘pleasure’ (c.f. https://www.psychologytools.com/assets/covid-19/guide_to_living_with_worry_and_anxiety_amidst_global_uncertainty_en-gb.pdf).

I have also been reflecting this week that sometimes things do not go the way we may have originally planned it, and this is never more so than currently! Therefore, flexibility will also be critical in the coming weeks and months. For example, one of our key PIE objectives for the organisation was to set up reflective practice groups across all services this year. However, although we have had to put formal reflective practice sessions on hold for the time being due to restrictions on physical distancing and travel as well as the lack of staff (and time) to ensure regular attendance, I have been thinking about how we can continue to utilise reflective practice concepts on the ‘frontline’. Reflective practice reduces staff stress and burnout, and promotes well-being (e.g. Homeless Link, 2017), and as highlighted in our staff PIE training, can be done ‘anywhere and anytime’.

Talking to ex-colleagues working on the NHS medical frontline, they have reported that it is been helpful when they have spend a whole shift ‘running about’ dealing with crises to at least ensure ‘handover’ space(s) at the start and end of their shifts. This reflective space (whether in person or virtually) can be used to positively reinforce successes to colleagues, share fears and worries, ensure good communication between shifts about any issues and to allow staff to ‘let go of work’ before they leave the hospital to go home. This is not a formal ‘debrief’, which wouldn’t be appropriate, but rather a space to re-connect with colleagues and just ‘process the shift’. There is a great short video (c.f. https://www.communitycare.co.uk/2018/05/15/tools-help-students-reflective-practice-using-theory/), that summarises some key reflective questions that can be helpful to consider when short of time and thinking space. Positively, even brief reflective spaces can be helpful to ensure that we continue to have open and honest conversations with our colleagues and resolve any issues before they lead to further tension, stress or arguments (Smith et al, 2017).

Whatever the immediate future holds, the good news is that psychologists have plenty of evidence that human beings can adapt to changes in their situation, and often show surprising levels of resilience and coping resources as well as tolerance towards others. These may be ‘tough times’ but I know that our ‘frontline’ teams in Centrepoint are ‘tough together’ and we will weather this storm. It may take time but I remain optimistic that the changes to our society resulting from the COVID-10 pandemic, may force us all to re-evaluate our perception of what is truly important or ‘frontline’ in our lives. Whilst walking my dog yesterday evening, I noticed many rainbow pictures in the windows of houses locally to me, drawn by children as part of an art challenge to show other children they are not alone when they are not at school. I wondered if seeing all these rainbows is a metaphor for hope, because rainbows appear after the storm and rain has gone, and the sun has come out. For now, each and everyone one of us; ‘frontline’ or otherwise, can only focus on what we can do in each moment, support the members of our teams and social networks, and wait for the storm to pass, the rain to stop and for those rainbows to appear…