In this In Conversation podcast, we are joined by consultant clinical psychologist, Dr. Lucy Maddox. Lucy is currently researching compassionate care and compassion fatigue in Child and Adolescent Mental Health Services (CAMHS) and is also passionate about the wider dissemination of psychology ideas.
Lucy has published several books, the most recent being ‘A Year to Change Your Mind’.
Discussion points include:
- What is ‘compassionate care’ and what does this look like in CAMHS?
- A definition for ‘compassion fatigue’ and how this differs from ‘burnout’ and trauma.
- How compassion fatigue manifests in CAMHS settings, and the impact, and the role of the pandemic.
- What organisations and individuals can do to mitigate compassion fatigue.
- The message to policymakers to foster compassionate care and reduce compassion fatigue in CAMHS.
- Why it is important to disseminate psychology ideas to the wider public.
- Insight into Lucy’s new book, ‘A Year in to Change Your Mind’.
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Dr. Lucy Maddox is a consultant clinical psychologist and NIHR clinical academic fellow. She worked in inpatient CAMHS services for several years and is now researching compassionate care in this setting. She has a new book out, A Year To Change Your Mind, ideas from the therapy room to help you live your life better.
- Paperback of ‘A Year To Change Your Mind’
- BBC Sounds podcast of ‘A Year To Change Your Mind’
- SENSE(LESS) Live with Dr. Lucy Maddox on ‘How do we cultivate compassion?’
- Paper ‘”The team needs to feel cared for”: staff perceptions of compassionate care, aids and barriers in adolescent mental health wards’ by Lucy Maddox and Manuela Barreto (published in BMC Nursing, August 2022)
- Paper ‘Compassion Fatigue, Secondary Traumatic Stress, and Vicarious Traumatization: a Qualitative Review and Research Agenda’ by Rachel S. Rauvola, Dulce M. Vega & Kristi N. Lavigne (published in Occupational Health Science, August 2019)
- Paper ‘What is compassion and how can we measure it? A review of definitions and measures’ by Clara Strauss, Billie Lever Taylor, Jenny Gu, Willem Kuyken, Ruth Baer, Fergal Jones, Kate Cavanagh (published in Clinical Psychology Review, July 2016)
- Paper ‘Predictors of compassion fatigue in mental health professionals: A narrative review’ by David Turgoose and Lucy Maddox (published in Traumatology, June 2017)
[00:00:07.530] Jo Carlowe: Hello, and welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a Freelance Journalist, with a specialism in psychology. Today, I’m interviewing Consultant Clinical Psychologist, Dr. Lucy Maddox. Lucy is currently researching “Compassionate Care and Compassion Fatigue in CAMHS.” She is also passionate about the wider dissemination of psychology ideas, and she is the author of several books, the most recent being, “A Year to Change Your Mind.” We’ll be covering all these topics in today’s conversation.
If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and do share with friends and colleagues.
Lucy, welcome, thank you for joining me. Can you start with an introduction about who you are and what you do?
[00:00:59.410] Dr. Lucy Maddox: Sure, thanks so much for having me on the podcast. I’m a Clinical Psychologist by background, as you said, and I’m currently undertaking a Clinical Academic Fellowship at the University of Bath. So, I’m working three days a week on a research project, which is trying to make an intervention to reduce empathy-based stress in staff who work on CAMHS wards, with the aim ultimately of improving compassionate care for the patients and the families who use those wards.
Part of my time is clinical still, and I also juggle that with looking after my toddler. I’m also really interested in sharing psychology ideas, as you said, so I’m not having that much time to write at the moment, but when I can carve it out, I try and do a bit of that as well.
[00:01:42.619] Jo Carlowe: You’re very busy, you’re working on many things. But let’s start with your research on, “Compassionate Care in CAMHS.” Lucy, what is “compassionate care,” what does it look like?
[00:01:51.930] Dr. Lucy Maddox: Well, that’s such a good question, Jo, because there are actually lots of different definitions of “compassionate care.” And I think one of the interesting things is that compassionate care is often recommended, and we know that it’s really crucial, and that when compassion is missing from care patients report being less satisfied. And in fact, sometimes it can lead to really dire consequences, where there’s a lack of compassion in the system. For example, the Francis report, many years ago, flagged some of the fatalities that can happen when there’s not enough compassion in the system.
But when we think about what it actually, practically looks like, there’s less that’s known about that. So, we know that compassion is “the ability to be sensitive to the fact that somebody else is suffering, and also to want to help them,” but what that practically looks like in a healthcare setting is defined in different ways. And one of the projects, which I did before doing the Fellowship, which I’m now on, was to do some focus groups with staff who worked on CAMHS wards, to try and find out how they would characterise “compassionate care” for young people in that setting.
And they came up with a range of responses, but they fell into six themes. So, they talked about “a sense of emotional connection with young people, a sense of the young person being valued, a sense of the young person having the attention of the staff team, feeling understood, having good communication, and also, being offered practical help and resources.”
So, those are some themes that came up from CAMHS ward staff, and I think they overlap with lots of other work, by people like Paul Gilbert and Michael West, who’ve studied compassion in other settings. It’s a, sort of, work in progress, I think, trying to nail down exactly what those practical aspects are. And some of the research that we’re doing is trying to do that in a more measurement setting as well, so trying to find out how we can best measure compassionate care, and develop a better measure for that.
[00:03:54.240] Jo Carlowe: That’s really helpful, it’s a really helpful overview. What about “compassion fatigue”? In your papers, you describe this as, “distinct from both burnout and vicarious trauma.” Lucy, what’s your definition of “compassion fatigue”?
[00:04:07.870] Dr. Lucy Maddox: I guess it’s not my definition, but it’s – there’s been a lot of work done by Researchers Mathieu and Figley in particular. But the idea is that when we are working or being in a caring role, and we feel just, like, we can’t quite care as much as want to, or as much as we could before. So, it’s this, kind of, emotional exhaustion, and a diminishment in our capacity to care. And obviously that has really fundamental consequences then for the people that we’re caring for, but also for us, because we can get quite a lot of satisfaction from caring for others. And there’s this term “compassion satisfaction,” which is also quite interesting, and which is that motivation that we get from being in a caring role.
And compassion fatigue overlaps a bit with the concepts of burnout, which also is a type of emotional exhaustion, but which also involves depersonalisation and feeling like we’re less good at our job. And also, secondary trauma responses, so when we experience PTDS-like symptoms, to somebody else’s trauma, not our own. And all of those types of reactions have been characterised in this, kind of, umbrella term, which is “empathy-based stress.” And this is a term from a Researcher called Rauvola, kind of, suggested that we group those together. And I think that’s quite a useful term as well.
But I think all of these different reactions to working in caring roles are really useful for healthcare professionals to be aware of. Because it’s a normal response to being in this, sort of, stressful situation, and the more we know that it’s a normal response, the more we can talk about it, and reflect on it, and try and do something about it, rather than trying to hide it and think, oh, I’m not doing my job as well as before, and I can’t care as much as before, but I’m unable to talk about that.
[00:06:04.310] Jo Carlowe: Is that the typical thing that happens, that people try to conceal their empathy-based stress?
[00:06:09.100] Dr. Lucy Maddox: That’s a really interesting question, I don’t think we know enough about CAMHS settings in particular to know whether it’s typical. But certainly from research in other settings, that’s one thing that can happen. And it depends a bit on the context of the system that we’re working within. If we’re working in a system where it’s acceptable to talk about how we feel and reflect on that, in an appropriate way, in supervision spaces and reflective practice spaces, then that can be really healthy and productive, and mean that those conversations happen away from the young people that we’re working with, and mean that we can cope with those sorts of feelings.
Whereas, if we’re in a culture where it feels like there’s shame or blame attached to feelings like that, or, like, there’s not space to be able to talk about how we feel as individuals, then that becomes a lot more difficult. And, of course, there’s also the individual component of what we’re like as people, and whether we like to share how we’re feeling or not. So I think it’s a bit of an interaction between the two.
[00:07:10.770] Jo Carlowe: How does compassion fatigue typically manifest, in CAMHS work? And what impact does it have on both workers themselves, and their younger patients?
[00:07:20.690] Dr. Lucy Maddox: So, there’s not been enough research in CAMHS setting in particular, to really be able to say precisely what’s going on. But we know from research on different types of empathy-based stress in other settings, that it’s really bad news for patient care. So, you know, if staff are not feeling looked after themselves, and they’re feeling burnt out or compassion fatigued or experiencing secondary trauma, then it makes them less able to do the work of caring for others. You know, it makes them more likely to cut off from the emotional reactions that they might be experiencing, and it might make them avoid certain situations where they feel like they’re going to be feeling overwhelmed.
There’s been some studies of burnout in CAMHS workers, and one study suggests that about 50% of CAMHS workers have moderate to high degree of burnout, which is quite – I mean, that’s quite high. I think it’s worth knowing as well that the studies in general are really variable. So, in other fields, it ranges from about 7% to about 80% prevalence of compassion fatigue, so it’s really, really variable. But more qualitative studies as well suggest that in people, for example, working on psychiatric inpatient units for young people, then there is a higher degree of burnout.
So, some of these jobs, they are really stressful, and people are dealing with high volumes of patients that they’re seeing, and/or very severe presentations. And if they’re feeling like they’re not well enough resourced to manage that sort of emotional stress, you know, burnout and compassion fatigue are sort of inevitable really.
[00:09:01.390] Jo Carlowe: Lucy, I was wondering about the impact of the pandemic in relation to compassionate care and compassion fatigue?
[00:09:06.940] Dr. Lucy Maddox: It’s had a really big impact on this research area actually. So, when I was preparing my application for – my funding application for the Clinical Academic Fellowship, I was looking at the research that was around in the area of compassion fatigue and empathy-based stress. And in the time since writing that funding application and then starting the Fellowship, the field has totally proliferated in terms of research. So, there’s been absolutely loads done on looking at healthcare staff burnout and compassion fatigue and secondary trauma. And I think that’s a really good thing, because it might advance the field.
I guess that quite a lot of the research was done in a really difficult time, and during the pandemic, and there’s, sort of, things that could be done in terms of longer-term follow-up and making sure that there are really robust controls, which have been hard to do during the pandemic. So, there’s a lot more research around to look through, but it’s not necessarily got those, sort of, robust controls, or those, kind of, more longitudinal measures. So, there’s still quite a lot to find out.
But I do think that the pandemic made us think about healthcare workers, and the, sort of, burden that healthcare workers are under emotionally. And I’m sad that it’s not translated into more governmental support really, because I think we’re still at a point now where healthcare workers are trying to get better resources for themselves, to be able to continue doing difficult jobs.
[00:10:41.680] Jo Carlowe: I do want to ask you about policy, and the role of policymakers. First, I want to ask you about organisations themselves, what can they do to mitigate the risk of compassion fatigue? And what can CAMH professionals themselves do, to prevent this occurring, or to turn things around, when it’s already occurred?
[00:11:00.850] Dr. Lucy Maddox: I’m going to have to be careful not to go on about this too much, ‘cause I could talk about this for ages. There is lots that organisations and individuals can do. And we know from the organisational psychology literature that the best approaches are when we try and tackle both. So, when we offer individuals ways that they can best cope with the situations that they’re in, and at the same time, think about, okay, what can the system around that person do to better offer them support?
So, from a systems level, there’s lots that we know, from really basic workforce safety planning, that sometimes I think gets overlooked or forgotten about. For example, there’s the Health and Safety Executive Management Standards Framework, and it goes through several areas which management can think about in relation to their employees, and can just check through and think, are we providing all of these things? And that’s a really great place to start actually, if you’re a Manager or somebody leading in an organisation, just checking in with that document, and seeing whether those factors are being met.
Another thing that we can think about from a systems level, is this idea of job demands and job resources. So, thinking about what demands are being placed on staff, and thinking about what resources are available to them, and thinking about how can we reduce the demands, or/and how can we increase the resources? Sometimes it’s not possible to change the demands that are being put on us in a busy healthcare system, but maybe there are resources that we could be putting in, in terms of things like supervision and really effective and caring management, that could be really helpful.
Then on an individual level, there are things that have been found to be beneficial. Partly, it’s to do with being aware of our own stress response, and being aware of the things that we do to cope with that. So, again, stuff that we might do really in quite a, kind of – it’s the bread and butter of some of our work, we would do it with young people that we work with, and think with them, for example, about their stresses that they’re experiencing, and the things that help them to feel less stressed. And we might also think with them about, is there anything that they’re doing which feels like it’s relaxing them but actually is counterproductive?
And we can do that sort of stuff with ourselves as well. Often it’s the really basic stuff like, you know, you get too busy and stressed at work and you don’t have time to eat properly, and you don’t have time to exercise, and that makes you feel worse. It can be some really low level interventions there, but still, really, really helpful.
There’s also quite a lot of interesting research on how we talk within a team. We’re working in a trauma setting, or in a setting where young people and families are talking to us about traumatic events that have happened, is that something that gets shared around the system? Or is it something that we can really think about, okay, how much do staff need to know about this? Can we be really intentional in the way that we talk to each other? And there’s this idea of low impact debriefing, that we, kind of, signal to somebody else that we’d like to talk about something traumatic, we check in with them if it’s an okay time, and then we only share the details that we need to share, so we’re, sort of, quite careful with each other about that.
And then there’s more research again on using mindfulness at work, which is not for everybody, but there is a good evidence base that it can be quite helpful in terms of preventing and reducing compassion fatigue and burnout. And also, thinking about self-compassion. So, thinking about how we talk to ourselves and treat ourselves after a hard day at work.
And I think some of that also overlaps a bit with that idea of compassion satisfaction that I mentioned earlier, and how often do we, at work, really have the chance to celebrate the stuff that’s gone well? Because normally when we sit down and have a meeting and think about how we’ve cared for somebody, normally that’s prompted by something not going so well. And that’s really important, to have those spaces, for reflection and learning. And I wonder as well, is there some time for having some spaces for reflecting and learning on and celebrating times when we’ve done a really nice piece of work, and it’s impacted on somebody’s life in a really positive way, because those stories can keep us going really, in this sort of work.
[00:15:11.930] Jo Carlowe: Yeah, that’s fantastic, really, really helpful advice. Lucy, I think you mentioned this in the introduction, but you’ve been focusing on creating an intervention for people working on mental health wards for teenagers, to prevent compassion fatigue, and to improve compassionate care. Can you tell us about this intervention?
[00:15:30.300] Dr. Lucy Maddox: I can tell you about where I’m up to now, but it’s very much a work in progress, so I’ll tell you where we’ve got to and what we’re going to do. It’s a three stage project, and the first stage is systematic literature review of, “What are the interventions for reducing empathy-based stress or improving compassionate care on mental health wards?” So, I’ve just – I’m just getting to the end of that now, and I’m just pulling together those results. So, it’s really nice to be able to look at, okay, what is working and what’s not working and why might that be?
And the next two stages are co-developing the intervention with staff and ex-patients and parents and carers and Commissioners and Managers who have worked on or experienced CAMHS wards, and developing the intervention with them. So, using what we know from the literature, but also using people’s own experiences of being on CAMHS wards and working on CAMHS wards, designing an intervention.
And then the third part is to pilot it, and so that’s piloting it in two wards in the UK. And in fact, I’m really excited, ‘cause I was just speaking to the first pilot ward this morning and checking in with them, and we’re about to start running some of the focus groups. So, I’m really delighted about that.
So, I can’t tell you exactly what the moving parts are going to be in the intervention, but that’s how we’re going to develop it. And it’s very much trying to use principles of something called “intervention mapping,” which is a research process for making an intervention. And also, really thinking about co-design, so making sure that the people who are going to be having the intervention input from the very beginning, into the design. And so there’s a great research advisory group who I’m working with as well, made up of staff and ex-patients and parents and carers and Commissioners, who have been part of the project from the very start, and hopefully will be until the very end, but it’s a bit of a watch this space.
[00:17:22.699] Jo Carlowe: Hmmm, absolutely, it sounds very exciting. Let’s turn the spotlight onto policymakers then, you mentioned the importance of them earlier. What’s your message to policymakers? So, it’s for policy-makers at both national and at a local level, what can they be doing to foster compassionate care and reduce compassion fatigue in Child and Adolescent Mental Health Services?
[00:17:45.490] Dr. Lucy Maddox: That’s such a lovely question to think about, and it’s very hard, isn’t it, actually to, sort of, get in the room with policy-makers. I think the key message really is to think about looking after staff as an integral part of the services that are being commissioned or being worked with. I think it’s around in the national consciousness at the moment that we need to look after healthcare staff, and I think COVID has helped with that.
I still think there’s a tendency to, sort of, want to do something to help, but not quite know what’s effective, and offer something at quite a surface level that maybe, at best, helps a few people but not everyone, but, at worst, can actually sometimes be counterproductive, if in fact you’ve got staff who are really struggling with the demands they’re under, and a lack of resources. If you’re then rolling out an intervention which can seem sometimes a little glib, or a little too surface level, then I think you’ve got the risk there of just irritating staff as well.
So, I think it’s about really trying to tailor interventions to a local context, and listen to what staff are saying that they need, and thinking about this multi-level approach as well. So, whilst individual level interventions are really important, and some of them are effective, you know, only offering individual interventions has the risk of making it seem like it’s only individual staff’s responsibility, whereas actually it’s a balance of organisational responsibility and individual responsibility, for trying to make sure that we’re healthy at work. So, thinking about it as well, perhaps using tools like that HSE Management Checklist, you know, thinking about it from this more systems perspective as well.
And, I guess, sort of, bigger picture, how can we bring in those things that we think about in terms of compassionate care for patients? How can we bring that in for staff as well at every level? So, how can we make sure that staff are feeling valued and understood and paid attention to and listened to, all of those things, at every level of the system, right up to the management, right up beyond that?
[00:19:51.440] Jo Carlowe: Lucy, I know you’re passionate about the wider dissemination of psychology ideas. Why is this important? And is it of particular importance when it comes to the wellbeing of younger people?
[00:20:01.909] Dr. Lucy Maddox: I do it because I really love it and I really enjoy it, and I think that’s something that’s really important too, actually. I think if something is worth trying and seeing if you find it fun. Because there’s this idea called “job crafting” in the organisational psychology literature, which is where you tweak your job a little bit to be more of what you like. Thinking about public engagement can be one way of tweaking your job to bring in something that is just a different way of sharing ideas, and talking to a different audience, which can be really pleasurable.
But I do think it’s hugely important and public engagement in the true sense, so really involving young people and their families, involving their voices in what we do, so in the building of services and in the research that we’re doing, I think is crucial. And often, young people get left out and it’s really hard to get ethical approval actually, often, to work with young people. And that’s in a way really understandable, because it’s very important that we safeguard young people, and, at the same time, sometimes I wonder if it becomes so hard that it really puts people off.
And the young people in the advisory group that I’m working with, they say it just feels so important when their voice has been heard and understood, and it feels like to them they’re bringing something meaningful, from a very difficult experience. And I think it definitely helps to make services and research better as well. It’s a win-win situation really, there’s no reason not to do it, and I do think it’s hugely important in CAMHS work.
[00:21:30.380] Jo Carlowe: How can both CAMH professionals and academics better disseminate their ideas to the wider public?
[00:21:37.730] Dr. Lucy Maddox: I think there’s so many ways. I think once we begin to think about that idea of giving psychology a way, there’s lots we can do at quite a small level, or quite a large level. You know, even just tweeting about – not about patients, but about clinical theory ideas or theory papers that you’ve read, or psychological concepts, kind of, explaining them, or sharing something in the news that you think has a psychology angle on it. There’s so many things that you can do, that don’t take very long at all, sort of, up to writing longer pieces, longer blogs, or writing comment pieces or books even.
And also thinking about, you know, different media that you can get involved in, there’s so much. So many different sorts of social media and podcasts and YouTube and all sorts of different things. So, I think it’s finding out what you like and what is feasible for you. How much time do you have and what do you enjoy engaging with? So that it doesn’t feel like a bind, so that you’re enjoying it as well, and then I think that comes across in the communication.
[00:22:35.240] Jo Carlowe: You mentioned books, Lucy, you’ve recently published a new book, “A Year to Change Your Mind,” what’s it about?
[00:22:40.700] Dr. Lucy Maddox: It’s about ideas from the therapy room, which I think are helpful for everybody, so helpful for everyday life. So, it’s ideas that I noticed I was using a lot in the clinical work that I was doing with young people and with some adults, and also, ideas that I used a lot myself. So – and it’s structured around a year, so each chapter is a different month. So, sort of, January is about that pressure for New Year, new you, and making decisions and making changes, and ideas around that. February’s about feeling, sort of, stuck in the gloom, and how you get going again.
I think probably listeners of this podcast would be very familiar with all the psychological ideas that are within it. The aim is to share it with people who maybe haven’t come across the ideas and to share them in a evidence-based, and also with a bit more of a personal voice.
[00:23:33.480] Jo Carlowe: What else is in the pipeline for you, that you would like to share with us?
[00:23:37.290] Dr. Lucy Maddox: The focus groups, which I mentioned earlier, are just going to be happening in the next few months. So, if there is anyone listening who is somebody who works on a CAMHS ward or has worked on a CAMHS ward, or has experienced a CAMHS ward in any other way, as a parent or carer, or as a young person, and if they’re interested in taking part in those focus groups, some of them are going to be run online, and it’s all about asking people, “What do you think would be important to make sure we include in these interventions?” So, if people are interested, they’re really welcome to get in touch with me, they can just email me at email@example.com, yeah, I’d be really interested in hearing from them.
In terms of other stuff, the paperback of “A Year to Change Your Mind” is coming out next year, I believe, or people can listen to it as an audiobook, but there’s also a BBC Sounds abridged version, which they can listen to. That’s mostly what I’m up to.
[00:24:36.380] Jo Carlowe: Great. So, lots going on. Finally, Lucy, what is your take home message for our listeners?
[00:24:42.130] Dr. Lucy Maddox: Well, I think probably most listeners are going to be Researchers and Clinicians, although I wonder if perhaps there might be some parents too, or perhaps some young people. But I think probably my take home message applies to all of those audiences, which is that, I think trying to think about taking care of yourself is really important in this work, and really important to try and see it as a priority and not something that’s selfish. Because the more we feel well-resourced and well-nourished and depleted, then the better able we are to care for others.
So, it’s really not a selfish act, to make sure that you’ve got time in your day to be doing things that are giving you a little bit of nourishment, or a little bit of a breather. In fact, I’d say it’s really crucial in this sort of work, try and be compassionate to yourselves, and make sure that you’ve got time, even micro snippets of time, to be resourcing yourself.
[00:25:41.020] Jo Carlowe: Lucy, thank you so much. For more details on Dr. Lucy Maddox, please visit the ACAMH website, www.acamh.org, and Twitter @acamh. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with friends and colleagues.