A recent article caught my eye: ‘HCPC suspends social worker with mental and physical exhaustion over failure to manage own health.’1 Over the next fortnight, three more articles all relating to the impact that working in social care and health is having on the physical and mental health of its workforce, jumped out at me, with the following headlines:
‘BASW helps to launch multi-professional initiative to protect care workers’ mental health’2
‘Cuts causing stress and long-term sickness, social workers tell survey’3
‘Social worker distress not taken seriously enough by employers’.4
Worryingly, such headlines have become normal, leaving me to reflect on why it is that those professionals on the frontline looking after the most vulnerable in our society, are so impacted and overlooked. My professional interest stems from my experience during my counselling training, when I worked full time, managing a front-line domestic violence service which included working with social work students on placement. I was genuinely puzzled by the different levels of organisational support and supervision that these professions were offered, and became committed to passing on what we know from the therapy profession, to support others in their work with people.
This article outlines how I support social workers and frontline workers who are impacted by their exposure to trauma, both in the counselling room and in a training environment. It draws on my research from my MSc in Counselling Psychology, and my conversations with practitioners to find a way to better support those who carry out such demanding work with constant pressure on budgets.
A harsh climate
According to the 2016 Labour Force Survey,5 those who are working in health and social care have the highest incidence of sickness due to stress, out of all occupations recorded. Approximately 186,000 health and social care workers in Great Britain were suffering from an illness which they believe was caused or made worse by their work, with around 85,000 being cases of stress, depression or anxiety.5 Out of the 186,000 cases, 107,000 were workers in ‘human health activities’, 37,000 were workers in ‘residential care’ activities, and 42,000 were in ‘social work’.5
This has obvious consequences for retention rates, and the National Audit Office (NAO) suggests a 27.8 per cent turnover of staff and a 6.6 per cent vacancy rate within social care.6 It is not acceptable that we are losing talented, highly trained and committed professionals in human services because we are not encouraging them to look after themselves, and each other.
In June last year, The British Association of Social Workers (BASW) set out its position statement with regard to austerity, highlighting the economic and social policies in the UK, which are continuing to cut deeper for those working on the frontline, impacting on the task of social work and on the wellbeing of social workers.7 BASW highlights how austerity is affecting social workers due to a reduction in preventative services and an increase in caseload. In addition, a reduction of staffing levels, contrasting with an increase in risk to the service user, is leading to increased stress and consequent ill health. BASW also stresses the powerful ethical and professional dilemmas social workers are facing, while trying to provide basic support with less resources. When toilet breaks and lunch away from the desk (if hot desking hasn’t deprived you of a desk) are a luxury in the office, we have some very basic human needs to consider.
Social worker burnout
Working as an affiliate counsellor with EAPs, I regularly see clients who are social workers, who have been referred due to stress, burnout and the consequences of working with other human beings and a lack of resource. I witness at first hand the damage, pain and frustrations that these truly passionate and dedicated practitioners are holding. It’s not good enough that those whose role it is to support others, are not supported as a matter of course, in order to do their work safely, effectively and in good health.
Earlier this year, an article published in Community Care outlined an Ofsted Report that reported East Sussex Children’s Services as outstanding, highlighting that the social workers received ‘regular supervision, and caseloads that enabled them to build trusting relationships with children.’8 It’s frustrating to me that these two basic elements of success have to be highlighted, as in reality, they should be an accepted part of regular safe practice. I find it difficult to witness the ways in which the needs of social workers are neglected when I know, having researched this area, that there are models and strategies to support such professionals and to keep them in roles which they are dedicated to.
My MSc research project focused on practitioners, counsellors, social workers and specialist domestic violence workers who are listening to trauma on a daily basis. ‘Looking through a lens of terribleness’ was the title of my small, qualitative research paper, asking: ‘How do specialist domestic violence practitioners, social workers and counsellors experience trauma and fatigue when working with survivors of domestic abuse?’
Listening to my participants and hearing their stories, I simply wanted to know what helps them and what makes a difference to how supported they feel, whether in training or in practice. Is it possible to help those who are exposed to traumatised service users to have a buffer against the impact of trauma and fatigue? Is there a correlation between the support that counsellors, social workers and domestic violence (DV) workers would like? Given the austerity agenda and the dwindling resources in health and social care, I also wanted to know if my participants had found cost-efficient ideas that could be easily reproduced and cascaded, that had worked for them.
Professional trauma and fatigue
I use the term ‘professional trauma and fatigue’, to describe the risks that can be associated with working with other human beings who are in need of support and potentially affected by trauma. Stress, compassion fatigue, secondary trauma, burnout and vicarious trauma are all terms also used to describe this impact.
While counsellors and psychotherapists may be familiar with professional trauma and fatigue, I was interested that the counsellors in my research felt that these concepts were under-emphasised in their training. For example, they recalled one or two lectures during their course, but did not feel that they were prepared for the reality and potential impact, let alone encouraged to find support strategies to protect themselves.
When delivering training to frontline workers on the subject of trauma and self-care, I will often quote the words of Rachel Naomi Remen, a Clinical Professor of Family and Community Medicine in the US, who states: ‘the expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as being able to walk through water without being wet.’9
Five themes emerged from the participants in my research that shone a light on what could potentially positively buffer the impact of listening to and being with traumatised people. I have developed these themes into what I call the Five Pillars of Protection, to provide a model for working with social workers and professional helpers, that can support, nurture and sustain them in their work.
Five pillars of protection
Very simply, we cannot work with or acknowledge any concept if we have no awareness of it. Worryingly, the social workers in my study had never received any training in trauma and fatigue prior to starting in practice. I know that this is changing, but it’s striking that while they were all well trained in policy, theory, law and practice in order to actually ‘do’ the job, they did not feel that they were given enough awareness of, or support for, how to be ‘in’ the job.
BACP recommends supervision for any practitioner who is providing therapeutic support, or who works in roles that require regularly giving or receiving emotional support. In my experience, specialist domestic violence practitioners, social workers within children’s safeguarding teams and the counsellors within specialist domestic violence agencies, were listening to and supporting clients living with the impacts of trauma, every day. It makes sense that all those who give emotional support and listen to the trauma of their clients as part of their role, would benefit from clinical or therapeutic supervision. However, it’s not unusual for supervision to mean different things to different sectors and organisations. Clinical supervision, management supervision, case supervision, and just ‘supervision’, are all terms that different practitioners will use.
In my experience, social workers and specialist DV practitioners are able to access management supervision as a support mechanism to help them to manage cases effectively and safely. However, it is rare to find frontline workers experiencing a therapeutic form of supervision that asks them how they are, in addition to tending to their clients’ needs and addressing the context and organisation in which they are working.
3 Peer support
Workers can find significant support from their relationships at work as a form of informal supervision. Participants discussed peer support as a valuable contribution to their experience when working with trauma and survivors of domestic abuse. It’s well recognised that having colleagues to debrief with and offload to is vital in building practitioner resilience. ‘Bouncing ideas off colleagues, not being judged, using co-workers as sounding boards, and research sharing,’ were all phrases used to describe the idea of valuable peer support, in the work of Kapoulitas.10 The encouragement of peer support could be a valuable and relatively cost-effective tool to encourage as a part of best practice.
Social workers have told me that the best types of support are informal supervision with a colleague, maybe in the car going on a joint visit, or simply by being with the team in the office. They have also commented on the importance of one’s peer group in the office, the opportunity to offload, to reduce the feeling of being isolated and overwhelmed. Peers are also important when it comes to spotting colleagues’ changes in mood and capacity to cope with stress. It is very usual to hear from practitioners that it has been their colleagues who have noticed their suffering and exhaustion, before they have become aware of it themselves. Worryingly, social workers have expressed the view that peer support is likely to lessen as resources and therefore teams become reduced and more stretched. The climate of austerity means that too many practitioners lament the loss of conversation in the office, even the judgment of it, and have a fear that it is perceived as ‘skiving’ or not getting on with the work.
4 Being trauma informed
The concept of being ‘trauma informed’ was explained to me by a specialist DV practitioner who felt that it had real meaning for the service she worked in. The longer I’ve worked in this arena, and the more social workers that I’ve listened to, the clearer it becomes that a knowledge of trauma is essential for them too, and something that they don’t feel prepared for. ‘Trauma informed’ is an approach that suggests taking responsibility for the likelihood that trauma will have impacted on service users, and therefore can be an effective attitude to adopt in order to spot the signs early on, for both service users and practitioners.
Practitioners and helpers need to be able to rest and recover from their professional roles. Physical and emotional exhaustion are often discussed when helpers talk about their work, typically using words such as ‘fatigue, knackered and zapping all of your energy.’ Significantly, all of the participants had come to understand the importance of self-care, but not before they had realised the impact of their work on their wellbeing. Practitioners need to find ways of practising self-care, and the participants I spoke to mentioned many unique ways to do this, giving examples of walking in the country, yoga, socialising, mindful colouring books, and time with family. Interestingly, John Norcross, Professor of Psychology at the University of Scranton, outlines self-care strategies, suggesting that ‘counterconditioning’ of burnout can occur through physical activities and healing activities, such as yoga, alongside other distractions, such as reading and watching films.11 One social worker said that practising self-care can reduce the impact of the work, and this means, ‘doing what you enjoy doing,’ and activities that ‘validate who are you are and bring some of your identity back to you.’
The personal impact that the participants described in their interviews suggested that their work at times had affected the very core of who they were as human beings. This can emerge as a mistrust of others, a loss of identity, and losing touch with and withdrawing from people. One social worker explained how she could end up actually withdrawing from the very people who make her who she is, and self-care for her was making sure she didn’t withdraw.’
Who is responsible?
When I read the Community Care article, ‘HCPC suspends social worker with mental and physical exhaustion over failure to manage own health’,1 I was prompted to revisit the issue of responsibility. Frequently, practitioners describe not taking time off when they are unwell because of not wanting to let their service users down, or the guilt at leaving their team to cope without them. Taking responsibility for our own health and wellbeing is a part of the training that I deliver to social workers on resilience and self-care. However, there needs to be a healthy balance between personal responsibility and organisational responsibility. Employers have a duty of care to their employees; and a combination of statutory duties, under the Health and Safety at Work Act 197412 and common law, both aim to protect employees. However, I’m aware that there is difficulty with this area of law as it is challenging to evidence actual psychiatric injury and the damage that can occur due to occupational stress, which is where this area of responsibility would legally lie. This leaves me concerned about whether we could see more practitioners suspended from practice due to not taking responsibility for their own wellbeing.
The five pillars of protection came from my research and from the stories of practitioners talking about their work and their lives. Importantly, all five areas allow for the possibility of practitioners making changes themselves, and this is key. Taking back what might be perceived as a loss of control during a time of scarce resource can hold real power and increase feelings of autonomy for practitioners.
All of my participants, either through research or training, entered caring professions because they were, and are, passionate about supporting others and making a difference. We need to be able to replicate this care and passion for the practitioners themselves. An awareness of risk, regular quality supervision, being trauma informed and a commitment to cultivate and prioritise peer support and self-care, could make all the difference. The risk of not doing so, is that practitioners are left feeling neglected, disposable and the cycle of losing experienced practitioners continues.
Reviewing the social work literature, it’s clear that professional trauma and fatigue can have an impact on practitioners working with trauma, and that the lack of organisational and structural understanding can exacerbate this. While not absolving or accepting the politics of austerity, our profession has a role to play in supporting social workers and other helping professionals to adapt and change in the current environment to provide support that acknowledges the reality of their working lives.
Sass Boucher is a registered BACP counsellor and psychotherapist in private practice and an affiliate counsellor with EAPs. Sass worked in the domestic abuse sector for over 10 years, latterly managing services. She trains social workers and other human services practitioners in professional self-care and resilience and is co-founder of SelfCare Psychology. www.sassboucher.com
1 http://www.communitycare.co.uk/ 2018/09/04/hcpc-suspends-socialworker-practising-unregistered/
2 http://www.communitycare.co.uk/ 2018/10/11/basw-launches-multiprofessional-initiative-protect-careworkers-mental-health/
3 http://www.communitycare.co.uk/ 2018/10/04/cuts-stress-long-termsickness-social-workers/
4 http://www.communitycare.co.uk/ 2018/10/01/social-worker-distresstaken-seriously-enough-employers
5 https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/ labourproductivity/articles/sicknessabsenceinthelabourmarket/2016
6 https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/ attachment_data/file/591914/ SFR08-2017_Main_Text.pdf
7 https://www.basw.co.uk/system/files/ resources/basw_62617-9_0.pdf
8 http://www.communitycare.co.uk/ 2018/09/05/council-takes-promptaction-ensure-manageable-caseloadssocial-workers-rated-outstanding/
9 Remen R. Kitchen table wisdom. New York: Riverhead Books; 2006.
10 Kapoulitsas M, Corcoran T. Compassion fatigue and resilience: a qualitative analysis of social work practice. Qualitative Social Work: Research and Practice 2014;14(1): 86–101.
11 Norcross J. Psychotherapist self-care: Practitioner-tested, research-informed strategies. Professional Psychology: Research and Practice 2000; 31(6): 710–713.
12 Health and Safety at Work Act 1974 [Online.] Legislation.gov.uk. 2018. [accessed 19 November 2018]. https://www.legislation.gov.uk/ ukpga/1974/37/section/7