How Compassion Focused Therapy supports staff and patients alike
The use of Compassion Focused Therapy (CFT) in supporting staff with stress management and the ability to better support patients with challenging behaviour through CFT-based psychological formulation is being rolled out across The Disabilities Trust, following a successful pilot project.
Although CFT is most commonly used as a psychological intervention, through The Disabilities Trust’s innovative application of the therapy in supporting staff with stress, feelings and emotions – with the ability to also recognise this in patients – relationships with service users have been strengthened and staff are more confident in their skills and abilities.
As well as happier and more confident staff, examples of patients reducing challenging behaviours by over 50 per cent have also been achieved in some cases, the CFT-informed formulations helping staff to understand the impact of their brain injury and emotional presentations.
The pilot at the Trust’s York House, led over several years by consultant clinical psychologist Dr Miles Rogish – who won a UKABIF Clinician of the Year Award in recognition of his work in this area – has seen such levels of success and engagement that it is now being introduced to care staff across its centres nationally.
It was also trialled in a community setting in York to further gauge impact, which showed similar results with increased staff understanding of service user behaviours and emotional presentations, along with reduced anxiety in staff and staff becoming more likely to engage with service users and less likely to avoid behaviours that challenge.
Dr Rogish used the relatively simple concept of three circles affect regulation system of CFT to create a formulation for staff to express themselves more effectively, to help them understand and manage their stress levels and reactions and protect against burnout, while better supporting patients and understanding their emotional experiences in the process.
“Often within care settings, you can get situations where people want to downplay their own emotional responses, they say ‘I’m not scared, I can cope, I’m fine’, because staff don’t want to show they’re suffering in any way,” says Dr Rogish.
“I tried to discourage that as much as possible, I want staff to communicate their feelings openly, honestly and effectively within an appropriate supervisory context.
“For example, if you were helping someone with personal care and they slapped you when you were trying to help them, it’s understandable to be angry and it’s OK to be scared when that situation occurs.
“But what you have to then do is think about why it occurred, where was the service user in their emotional experience of the situation, and where were my (staff) emotions when that occurred.
“Often you can find that if you can modulate your own emotions, so that you are as stabilising for the service user as possible, the probability of challenging behaviours occurring goes down. You then have a better interaction with the service user, you develop a better relationship and they progress better.
“I’ve had staff come back to me and told me stories of working with service users, they told me that once they understood (through the formulation) that the patient was scared and not angry, they were able to empathise, be less anxious, and be a lot more compassionate and caring towards him.
“And that made him less scared, which made the relationship a million times better. And now they feel safe working with him, and he feels safe working with them.”
Dr Rogish has been working in CFT – a concept devised by Professor Paul Gilbert – since 2000, with its effectiveness in supporting people with treatment-resistant depression being supported by increasing evidence over the years.
But keen to test its application in a wider field, Dr Rogish saw the potential to support care staff through the use of CFT, with high levels of stress and burnout being huge problems within social care.
Through teaching staff a formulation based around the three circles affect regulation model – which comprise systems of threat, drive and soothing. The three circles are typically represented by three different colours – the ability of staff and service users to express themselves became a lot easier.
“You can really boil the three systems model down to quite concrete ideas that a lot of people can really hold on to,” says Dr Rogish, also an associate lecturer at the University of York, whose MA students assisted in the research.
“When you’re working with someone, you can tune into a shared language which can be as simple as ‘What circle are you in right now? Where is your red circle right now?’
“And as well as staff, where appropriate, you can quickly turn it into something that service users, even with some profound cognitive impairment, can get the gist of in a way that helps them understand what might be driving their emotional dysregulation.
“Using the three circle system has been very effective. For example, if someone is very fear-based reactive, they have an overactive threat system. Staff then need to be then very aware of their own threat system, because if you are approaching someone who is very fear reactive, and you are showing fear or anxiety yourself, you will increase their fear.
“You can then activate your soothing system, so that when you are approaching someone who is very threatened, you approach them with a very compassionate, soothing and caring perspective, so that none of your interaction should trigger their fear.
“Through this, staff then understand how they can compensate for the dysregulation in the service user by adapting their own presentation.”
This approach has been central to achieving significant progress in patients, including those with profound difficulties.
“I started using CFT to individually formulate the service users. With psychological formulations, you typically share them with the service users, sometimes you do not, it would depend on the service user and their capacity to understand such things,” says Dr Rogish.
“I used it with a particular service user with profound cognitive impairment and challenging behaviour.
“He would not have had capacity to understand the formulation, or the need for a formulation, but it was really clear to me through my typical applied behavioural analysis-type interventions that most of his challenging behaviours were reactive and fear-based.
“He was reacting from a fear based perspective, typically triggered by staff trying to support him. I formulated him using a CFT perspective, and what staff were able to get from the formulation was just that, that his aggressive behaviours were a fear-based reaction.
“He was not an angry person – he was a scared person. And while that sounds really simple, how you approach an angry person and how you approach a scared person can be very different.
“All it took was for some staff to just understand that ‘He’s not angry at me, he’s scared of me’. And that really changed the whole situation. It allowed them to approach him with a lot more empathy and compassion for his feelings, and within a month, his challenging behaviours had reduced by well over 50 per cent.”
The success of the project will now see staff of all levels across The Disabilities Trust receive basic training in CFT, with Dr Rogish creating online and face-to-face support for staff in its implementation.
“At York House, we have integrated CFT into so many aspects of how we work here, it’s in our inductions, it’s in our psychology training, and it’s in almost all of our formulations,” he says.
“Staff in York House are very CFT-informed, so we are now targeting support workers outside of York House who may not have been exposed to CFT before to see if this training has as much of an impact with people who are naive to the model.
“And I’m also going to be specifically targeting senior management with this training as well, because I’m interested to see the differences in perceptions of training between senior management and the people who are working with service users day-to-day, face to face.
“I’m particularly interested in developing training that is clear, easy and effective for all staff, and through the research projects I hope to provide insight to senior leadership, so that we can understand whether our ideas are translating to everyone within the Disabilities Trust as well as they could.”
