Staff Support at Amberleigh Care: Helping the Helpers – Kevin Gallagher
“The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet… We burn out because we’ve allowed our hearts to become so filled with loss that we have no room left to care” (Naomi Rachel Remen, 1996).
Amberleigh Care is a therapeutic residential care and education intervention service for young males, 11-18, who have displayed harmful sexual behaviour (HSB). We engage in a range of activities to support staff and this article aims to share these with others who may be interested in developing support in this vital area of our work.
Amberleigh Care runs services on 2 sites, each operating as a formal therapeutic community (TC). A TC is a structured approach to group living, making conscious use of relationships, day to day living and learning opportunities (Ward et al, 2003). Structurally, each TC comprises a residential home, an independent school and an in-house clinical team all co-located on site. The service works specifically with looked after young people with a range of early life complexities, trauma and adverse childhood experiences which underpin their behaviour. Children’s Services’ departments are the primary commissioner of individual placements, but pathways in can also be as an alternative to custody, or a step down from secure or welfare referrals, with or without convictions. Placements are on average approximately 24 months and most young people are helped to prepare to live independently or in supported living settings when they move on. Some young people are helped to return to family placements (typically foster care) and a small number with additional learning needs might transition to adult care services when they turn 18.
AIM3 assessments, supplemented by a range of psychometrics and other tools, together with background files and referral information, inform the profiling and specific intervention needs of each young person which are then delivered through the framework of the Good Lives Model (Ward, 2007). They are reviewed every 3 months by the young person and the multi-disciplinary team. This structures interventions and the application of learning in day to day situations by coordinating which part of the system (care, education, 1:1 therapy) will lead on which element of the intervention. This also helps ‘cross fertilize’ the young person’s progress and strength across different aspects of their functioning. The component parts of the system work within NICE Guidance on HSB (2016) and keep abreast of relevant practice development.
Working in Practice
The underpinning principles at Amberleigh are about safeguarding and the positive management of risk in the community, and these are built upon through a whole system approach which is relationship based. This involves working with attachment concepts, maintaining boundaries, promoting open communication, building self-esteem and healthy inter-dependence, developing responsibility, and accountability in relationships with others.
In one sense, the “technology” that staff use to help promote change and growth is themselves – they bring this to the relationships they have with the young people and the other adults, acting as role models. This creates a ‘double edged sword’ (Larson, 1993) in that the very empathy and attunement that makes them effective in their practice are also the potential points of vulnerability. Practitioners can become emotionally overwhelmed by the work. This requires continual monitoring and the principle that ‘all behaviour is communication’, applies as equally to staff as it does to young people.
Staff Support Systems
There are a range of support systems that we have in place for staff – some operational, some about practice and some about wider employee wellbeing. It is well recognized that working in the helping professions can be physically and emotionally demanding. Undertaking direct work with emotionally vulnerable and traumatized young people while also managing risk and their specific behaviours (previous or current), in the context of a residential community makes the work particularly complex and demanding. Our practice is informed by the applied work of Teater and Ludgate (2014) who write about compassion fatigue (the negative psychological state resulting from helping people over a period of time; feeling hopeless, detached, tired, resentful and demoralized), and secondary traumatic stress (an acute reaction caused by indirect exposure to another person’s trauma experiences) (See also Perry (2014).
As a residential childrens home and school governed by external regulations, there are structured approaches to induction, internal staff training and line management supervision. These are adapted specifically to the therapeutic community operating environment and also the theoretical models that underpin intervention and day to day practice. These help staff to understand the concepts of boundaries, communication, use of self, defensive projections and group dynamics. This is continually reinforced as applying to all members of the TC, whether you are an adult or a young person.
The Context of Therapeutic Communities
TCs draw on psychodynamic principles, thus the service needs to have a system in place with protected time for reflection in each of the different groups, to consider the dynamics at play. For example, there are groups for specific teams, groups that involve the whole community (including boys), for adults from different teams (education/ care/ therapy) and care leadership (managers, deputies and team leaders). Some of these are very regular, others more sporadic or called to explore tensions or for thoughtful planning. In these reflective spaces, a number of themes may be explored including parallel processes between young people and staff teams; avoidant or defensive mechanisms which may be being deployed and, how we can harness positive relationships, especially between peers, to promote healthy, pro-social behavior. This process requires staff to be highly reflective about their own behaviour and open to challenge day to day, perhaps from a young person as well as a colleague. Ideally, we are trying to role model healthy, undefended adult functioning – in fun activities, when people are upset, or when boundaries have been broken.
This is demanding and somewhat exposing for staff. As adults we have developed our individual ways of thinking and functioning over time and so it can be uncomfortable to have this open for exploration as an explicit component of the work with our young people. Additionally, whilst we want as flattened a hierarchy as possible, there is the reality of differences in power with the adults remaining ultimately responsible for children in their roles as parents, carers and educators, as much as in their regulatory role.
Therapists are a very visible part of the team. As well as overseeing initial assessments and delivering 1:1 therapy from a variety of modalities, therapists informally consult staff on a day to day basis in a variety of ways. These include attending team meetings, assisting in specific debrief work, delivering face to face staff training and tailored child specific workshop training dependent on a child’s individual developmental and learning needs. Each site has a lead therapist, and a team of 4 work across both sites so that the service can be responsive and draw on a wide range of specialist knowledge. This includes, but is not limited to forensic psychology, cognitive behavioural therapy, psychotherapy, eye movement desensitization reprocessing (EMDR), life-story work, schema focused therapy and drama and movement therapy.
Therapeutic communities have a highly structured timetable to coordinate the living-learning opportunities. This is used to consciously consider a therapeutic approach to the more ‘ordinary’ aspects of running a very busy home and school such as homework, chores, family contacts, clubs and activities, hobbies and interests. Open communication, involvement, empowerment and having roles and responsibilities are essential features of TCs. One of the main methods of undertaking planning, decision-making, problem solving, reflection and holding boundaries is through daily Community Meetings. Community Meetings are chaired by the young people, are minuted and involve all community members, both adults and young people.
As conscious exploration of the multiple dynamics (between staff, between departments, between boys and staff, between peers) in this complex system are active elements of the work, regulatory line management supervision is not sufficient to underpin this. To support the staff in maintaining an open and authentic engagement with the young people, whilst being open to parallel processes in the organisational dynamic, requires a deeper and broader approach, consistent with NICE recommendations for psychodynamic approaches to residential provision. Consequently, more attention is placed on staff support, development and welfare which is automatically consistent with the TC approach.
Each month, the team are provided with two structured group supervision spaces. These are facilitated by the Therapy Manager working across both communities (to allow the lead therapist from each community to be included as part of the team). They are included in staff contracted hours, structured to follow alternate weekly team meetings and each has a defined task:
- Staff Dynamics/Sensitivity Group – Focusing on the dynamics between the adults
Without a forum to talk together, a team cannot experience a sense of identity. In this case, several processes which work against good team functioning are likely to develop. These are akin to Bion’s (1961) ‘basic assumptions’ and reflect primitive mental functioning, where the environment is made safe by using defensive actions to avoid psychic pain. The psychic pain may be inherent in the work (such as dealing with great human misery) or arise from relational tensions (such as preferring the comfort of a collusive denial to exposure to anger and conflict). Examples are splitting, subgrouping, secrets, scapegoating, dependence and isolation. Put simply, without an effective staff group, things can go underground and are not understood in a productive way. An ‘us and them’ mentality can dominate.
A team where members are open with each other in their relationships – allowing and discussing conflict, for example – is likely to be a positive environment which makes for easier negotiation of stress and difficulty, reduces blocks to creative thinking and increases productivity. Important issues in teams are power, authority and leadership.
- Group Supervision – Focusing on the issues brought up in working with the specific young people in placement
The dynamic in the group of young people in each TC is unique and constantly changing. This is likely a result of the changes in emotional presentation of individual boys through the normal ebb and flow of daily living, combined with progress (and periods of stuckness) in their placement, changes external to the service (e.g. family contact issues) and also the inevitable changes when boys move on and new boys are admitted. The subtle (and sometimes less subtle) changes in these dynamics provide material for the staff team to work with. They may focus on a positive peer friendship between two boys triggering jealousy and rivalry in others, or perhaps an older boy preparing for greater independence with associated anxieties that begin to show themselves in regressive behaviours. These processes often get played out in parallel ways in staff teams and it is therefore essential to have a space to reflect on this.
Staff are supported in working through the realities that they are not going to like every young person they work with and they will have stronger attachments to some young people. Their own maternal/paternal instincts will be triggered to different degrees and if these are not noted, they can create fissures, fault lines and splits in the service, impacting on effective teamwork, or creating divisions and disagreements between departments.
Clinical Supervision and Whole Worker Support
From a specific employee welfare perspective, the service has developed several strands of additional support for staff. In 2017, the service introduced clinical supervision as an option for all staff by self or line manager referral. This might be used as part of a debrief if a staff member has been involved in a difficult incident, perhaps a complex dynamic with a young person or perhaps there is a ‘peak’ of complex personal/ family issues outside of work that are affecting the staff member’s emotional resilience. In order not to blur the roles of our therapy team, if further counselling is required staff will be signposted to their GP or other external sources of support.
In recognition of the demanding context in which staff work, the service is introducing an additional welfare and support package for 2020. All staff now have access to an external, confidential employee assistance programme with access to confidential counselling, financial/ debt management advice, legal advice and other areas of support that think about the ‘whole employee’ and not just relating to the task with the young people. Employees are able to access this support independently and can do this without any reference back to the organisation but is another source of support for line managers to signpost.
Human beings are social creatures that need interaction and inter-dependence. TCs harness this importance of being in relationship with others, and support both individuals and groups to develop and maintain this capacity through a highly structured system. This is happening in an ever changing dynamic and as such this is a process requiring continual attention and thought. This is where the culture of leadership and the attention to management of boundaries, process and people plays a vital role in staff support. Menzies-Lyth (1979) drew our attention to this suggesting that it is possible to have management without therapy, but it is not possible to have therapy without managementThis is not a task that we can complete and cross off our list, but rather a living activity which is linked to how a culture of practice and of relatedness is experienced and felt.
Kevin Gallagher, Managing Director, Amberleigh Care, Organisational and Therapeutic Consultant
Bion, W.R “Experiences in Groups and other Papers”, Routledge, London, 1961
Larson, D.G, “The Helpers Journey: Working with People facing Grief, Loss and Life”, www.calhospice.org,1993
Menzies-Lyth, I, “”Staff Support Systems: Task and Anti-Task in Adolescent Institutions (1979) ” in Containing Anxiety in Institutions, Free Association Books, London, 1988
Perry, B. D, “The Cost of Caring – Secondary Traumatic Stress and the Impact of
Working with High-Risk Children and Families”, www.childtrauma.org, 2014
Teater, M. & Ludgate, J. “Overcoming Compassion Fatigue: A Practical Resilience Workbook”, PESI Publishing and Media, 2014
Ward, A., Kasinski, K., Pooley, J. & Worthington, A. “Therapeutic Communities for Children and Young People, Jessica Kingsley Publishers, London 2003
NICE Guidance on Young People who Display Harmful Sexual Behaviours https://www.nice.org.uk/guidance/ng55