MICA: Improving the mental health and well-being of foster carers by reducing compassion fatigue: an assessment of feasibility.

Lead Research Organisation: University of Bristol
Department Name: Sch for Policy Studies

Abstract

Providing foster care for vulnerable children, who have often experienced abuse/neglect, trauma and loss, is demanding and stressful work. It requires foster carers to be have robust mental health and well-being due to the complex demands placed on them by the children in their care. Foster carers are at risk of experiencing compassion fatigue (emotional and physical burnout and/ or secondary traumatic stress) due to the demands of their role. The foster carer's home is also their place of work, so there is little opportunity to have a break to rest and re-charge.This not only affects their mental health and well-being, but also impacts upon the quality and consistency of care provided to the vulnerable children they look after.

A multi-stage intervention to reduce symptoms of burnout and secondary trauma and increase feelings of compassion satisfaction in foster carers has been proposed in collaboration the National Association of Therapeutic Parenting (NATP). This will combine three of the NATP's current discrete interventions - 1)education about the signs, symptoms and management of compassion fatigue, 2) peer support and 3) access to online support materials, into one cohesive multi-stage intervention.

The proposed study has been designed to: a) develop a sound logic model, b) assess the feasibility of trialling the intervention to foster carers experiencing symptoms of compassion fatigue, in order to improve their mental health and well-being and enable them to provide a more stable, empathic and consistent care environment for the vulnerable children they look after. and c) develop a manual and online support materials.

The assessment of feasibility will focus on six key areas: practicality, adaptability, demand/ use, acceptability, implementation and integration.

Technical Summary

Providing foster care for vulnerable children, who have often experienced abuse/neglect, trauma and loss (1,2,3), is demanding and stressful work (4,5,6). It requires foster carers to be have robust mental health and well-being due to the complex demands placed on them by the children in their care. Foster carers are at risk of experiencing compassion fatigue (emotional and physical burnout and/ or secondary traumatic stress) due to the demands of their role (4). The foster carer's home is also their place of work, so there is little opportunity to have a break to rest and re-charge.This not only affects their mental health and well-being, but also impacts upon the quality and consistency of care provided to the vulnerable children they look after (4).

A multi-stage intervention to reduce symptoms of burnout and secondary trauma and increase feelings of compassion satisfaction in foster carers has been proposed in collaboration the National Association of Therapeutic Parenting (NATP). This will combine three of the NATP's current discrete interventions - 1)education about the signs, symptoms and management of compassion fatigue, 2) peer support and 3) access to online support materials, into one cohesive multi-stage intervention.

The proposed study has been designed to: a) develop a sound logic model, b) assess the feasibility of trialling the intervention to foster carers experiencing symptoms of compassion fatigue, in order to improve their mental health and well-being and enable them to provide a more stable, empathic and consistent care environment for the vulnerable children they look after. and c) develop a manual and online support materials.

The assessment of feasibility will focus on six key areas: practicality, adaptability, demand/ use, acceptability, implementation and integration. An advisory group comprising foster carers, practitioners and policy makers will guide the study.

Planned Impact

The proposed study builds on recent work by the PI (Ottaway and Selwyn, 2016), which identified that many foster carers were experiencing symptoms of burnout and secondary traumatic stress (compassion fatigue - CF), and significantly struggling to provide nurturing and consistent care to the children they looked after. The PI has recently given oral evidence about the study's findings to the Education Select Committee's Fostering Inquiry. The aim of this was to raise awareness of the impact of compassion fatigue on foster carer mental health and well-being, and to influence national policy to improve the quality and provision of foster carer support. CPD teaching on CF is now embedded with the post-qualifying social work curriculum at University of Bristol, improving standards of training based on robust research evidence. Assessing the feasibility of this intervention for a RCT provides an opportunity to begin to build best evidence about 'what works' in terms of specific interventions to support the mental health and well-being of foster carers. This evidence will be disseminated to key stakeholders (policy makers, professionals, foster carers, academics), in order to inform debate and influence policy/ professional practice regarding the support needs of foster carers. It will also contribute to existing evidence about interventions designed to improve health and well-being.

Publications

10 25 50
 
Description Embedding study findings in postgraduate social work education
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Influenced training of practitioners or researchers
Impact The findings from the study have been embedded into postgraduate social work education and qualifying and post-qualifying level. This has led to increased knowledge about the signs, symptoms and management of compassion fatigue in foster carers, which social workers have reported has been influential in their practice. The influence has been reported as leading to a more empathic and less judgemental approach to foster carers in compassion fatigue, and a 'normalising' of the presence of compassion fatigue in this population, at a local level.
 
Description Membership of advisory committee for the Teaching Recovery Techniques (TRT) trial with young people in care
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Participation in a guidance/advisory committee
 
Description Research partnership with National Association of Therapeutic Parents 
Organisation National Association of Therapeutic Parents
Country United Kingdom 
Sector Public 
PI Contribution The research team is conducting the two aspects of the research project, which is assessing the feasibility of bringing an intervention designed by NATP to a randomised trial.. Firstly, a systematic review is being conducted by the research team assessing the effectiveness of interventions designed to reduce symptoms of compassion fatigue in foster carers, adopters and kinship carers. The second aspect of the study is an assessment of the feasibility of the intervention via qualitative focus groups/ interviews and a cost analysis. Together with the industry partner, the research team is developing the theory of change and logic model, and will contribute to the development of the trial manual. It is aimed that by the end of the study period the intervention will be ready for robust evaluation.
Collaborator Contribution The organisation are contributing 20 days of their time as an in-kind contribution to developing, alongside the research team, the theory of change, refining the intervention in the light of results from the feasibility study, and developing the manual to ensure the intervention is ready to be piloted by the end of the study.
Impact Ottaway, H. and Selwyn, J. (2016) 'No-one told us it was going to be like this': Compassion fatigue and foster carers. Bristol: University of Bristol. April 2018 - Presented oral evidence by invitation to the Education Select Committee's Fostering Inquiry on the presence and experience of compassion fatigue in foster carers.
Start Year 2016
 
Title The 3 R's Programme: Re-boot, Rejuvenate and Re-Connect 
Description The 3 R's Programme - Re-boot, Rejuvenate and Re-Connect (Funder: MRC Public Health Intervention Development grant). Aims This intervention, designed and developed in partnership with the National Association of Therapeutic Parents, aims to improve the well-being of foster carers through reducing their symptoms of compassion fatigue (CF). Compassion fatigue can be alleviated by reducing levels of burnout and secondary trauma, and by increasing levels of role (or compassion) satisfaction. Reducing levels of compassion fatigue and increasing compassion satisfaction in foster carers is anticipated to improve family stability (including placement stability), increase rates of foster carer retention, and reduce the prevalence of compassion fatigue in the foster carer population. Background 'Compassion fatigue' is an emotional, physical, and biological response sometimes experienced by people who work in helping professions. Compassion fatigue arises as a result of the emotional toll borne by carers who hear about the trauma suffered by those they support, or who have to watch and manage its consequences (Figley, 2002). There is no agreed definition of compassion fatigue but it is widely understood to be a combination of burnout (feelings of physical and emotional exhaustion, anger, frustration, hopelessness, depression and feeling inefficient in one's job) and secondary traumatic stress (becoming directly affected by the trauma experienced by those for whom one cares). Compassion (or role) satisfaction is defined as the sense of fulfilment or pleasure that people in caring roles derive from doing their work well, and the support they receive in their role. It is thought to mitigate the adverse effects of burnout and secondary traumatic stress (Stamm, 2010). Compassion fatigue is characterised by exhaustion, anger and irritability, negative coping behaviours, a reduced ability to empathise, reduced satisfaction with one's work, and impaired decision-making (Cocker and Joss, 2016). Specific symptoms associated with compassion fatigue include low mood, depression, anxiety, sleep disturbance, intrusive thoughts and nightmares (Cerney, 1995). The longer-term effects of compassion fatigue include poor mental and physical health (Sprang, 2007), a reduction in empathy towards those being supported, and subsequent deterioration in the relationship between the carer and the person they are supporting (Hunkaser, 2015). Compassion fatigue is thought to increase the risk of leaving the professional role (Conrad, 2006). Compassion fatigue affects the performance of a wide range of professionals, including emergency services workers, hospital staff, mental health professionals, humanitarian aid workers, and social workers (Conrad, 2006; Hunskaer, 2015; Musa, 2008; Sprang, 2007). However, as a concept, compassion fatigue has received little attention in respect of those who have responsibility for caring full time for children who have experienced abuse or neglect and trauma in their own homes, namely foster carers, kinship carers, and adopters. Given that family-based alternative care is the most prevalent type of placement for vulnerable children who cannot live with their birth families, this is particularly surprising (Department for Education, 2020). Within studies of carers for children who have experienced abuse/neglect and trauma, elements of compassion fatigue have been described as blocked care (Alper, 2015; Hughes, 2012), and stress and strain, with high levels of stress being identified (Farmer, 2005; Murray, 2011; Selwyn, 2014; Fuentes, 2015). Typical stressors faced by carers and adopters include managing children's emotional needs and challenging behaviour, placement disruptions, allegations, lack of professional support, difficult contact with birth families, social isolation and strained relationships with other family members (Farmer, 2005; Farmer, 2008; Selwyn, 2014; Palacios, 2019). High levels of strain have been associated with low foster carer satisfaction and intention to leave the profession (Sinclair et al., 2004; Farmer, 2005). The concept of compassion fatigue arguably goes further than issues of stress and strain by describing not only the direct effects of supporting people who have experienced trauma (burnout and secondary traumatic stress), but also the wider impact of role satisfaction on mental health and well-being. As well as living with, experiencing and listening to children's accounts of maltreatment, foster carers aim to promote the child's developmental recovery by providing empathic, attuned parenting. This requires them to engage empathically with the child's experiences of trauma on a regular basis, without the formal clinical supervision provided to therapists who engage in similar emotional labour. Furthermore, because they care for children in their homes, carers have no separation between their work and their home lives, unlike those in other stressful helping professions. Cocker and Joss's (2016) systematic review of compassion fatigue interventions for health care, emergency and community service workers highlighted the fundamental importance of being able to have this separation on a regular basis in order to rest and re-charge from the demands of the role (Cocker, 2016). Regular access to respite that also meets children's needs for consistent care remains challenging in the context of foster care in the UK (Biehal, 2012; McDermid, 2016). Foster carers have also reported that professionals can view requests for respite negatively in terms of perceived commitment to the children and capacity to cope (Farmer, 2008; Ottaway, 2016). A recent study in 2016, by Ottaway and Selwyn, shed light on the prevalence of compassion fatigue amongst foster carers in England. The study found that 77% of the 546 foster carers studied were suffering some symptoms of compassion fatigue (burnout, secondary trauma and low levels of role satisfaction), which significantly impacted not only on their mental and physical well-being, but also on their ability to provide consistent and emotionally responsive care to the children they looked after. Given that foster care is the most frequent type of out-of-home placement in England for vulnerable children cared for by the state (Department for Education, 2020), it has been important to develop an intervention which aims to lessen the burden on compassion fatigue in the foster parent population. Participant eligibility criteria The intervention will be delivered to foster carers who fulfil the following eligibility criteria: - have moderate to high scores on the burnout and/or secondary trauma scales of the Professional Quality of Life (ProQOL) Scale (Stamm, 2010) and have low scores on the compassion satisfaction scale - currently have children placed in their home on a full-time basis whom they are caring for as foster carers The intervention will also include the supporting professionals (supervising social workers, children's social workers and fostering team managers) who provide on-going support and supervision to the foster carers in the sample. Social workers who have been qualified for at least 12 months will be eligible to take part if their agency agrees to participate in a trial of the evaluation. Local Authority (LA) fostering agencies and Independent Fostering Agencies (IFA) will be approached to be involved in the evaluation of the intervention. Participating agencies must be open to their foster carers using the principles and techniques of therapeutic parenting to care for children. Programme Structure The intervention will be delivered to foster carers and supporting professionals over a period of three months. The programme involves two separate strands of activity: one strand is delivered to foster carers, the other to supporting professionals (fostering team managers, supervising social workers and children's social workers). The table below summarises the activities involved in each strand: Strand Activities Intervention for foster carers: - One-day compassion fatigue workshop for foster carers - One individual session of trauma interruption therapy (Havening) - Weekly individual empathic listening sessions of up to 1 hour duration for 3 months (12 sessions) - Monthly peer support meetings for 3 months (3 sessions) Intervention for supporting professionals: - Half-day compassion fatigue workshop for supporting professionals - Monthly reflective group coaching sessions of up to 2 hours duration for supervising social workers over three months (3 sessions) Each of these components is described in detail below: One-day workshop for foster carers Foster carers will participate in a one-day psychoeducation workshop about compassion fatigue. This workshop is designed to be a first step for participants in recognising, understanding and, ultimately, overcoming compassion fatigue. Participants in our focus groups described their anxieties about appearing "unable to cope" and the stigma and shame they felt at feeling negatively towards the children they were caring for. With this in mind, the workshop aims not only to educate participants about compassion fatigue, but also to destigmatise and normalise the experience of it. As the first stage of the intervention for foster carers, the workshop will also provide a guide to what participants can expect from the other components of the support package (e.g. listening circles and peer support). Foster carers will be introduced to their Listening Circle Coordinators and their Empathic Listener at the workshop, in order to encourage them to engage with the support package as a whole and alleviate any anxiety around making use of the follow up support. In terms of educational content, the workshop will cover: what CF is and how it relates to burnout and secondary trauma, how CF prevents carers from engaging empathically with children, how to identify the signs CF, how to manage the symptoms of CF by using self-care techniques and by accessing a supportive network of family, friends and other foster carers, and how to prevent further episodes of CF. A key aspect of the workshop involves changing foster carers' attitudes towards respite and self-care. This content is delivered through presentations, group work, role play activities, and training videos. Participants will also receive a copy of 'The A-Z of Therapeutic Parenting: Strategies and Solutions' (Naish, 2018) to take home. The book provides an introduction to the principles and techniques of therapeutic parenting. The workshop will be facilitated by NATP trainers who have experience of caring for traumatised children. In the focus groups, carers emphasised that the personal experience of NATP facilitators (who understood the challenges of living with children who have experienced trauma) was particularly important to them. Participants felt that "being with people who get it" helped them three ways: it allowed them to experience empathy from the facilitators who understood what they were going through, it alleviated their sense of social and psychological isolation, and it reduced their feelings of self-blame and stigma. Each workshop will be attended by up to 25 foster carers who are based in one region. Because of the importance of being in a supportive environment with people who understand the experience of compassion fatigue and can relate to one another empathically, the workshop will provide ample opportunities for foster carers to interact with one another. Participants will work together to complete structured activities as well as having time to socialise during unstructured breaks. Havening (Trauma interruption therapy) Havening is a trauma interruption therapy which aims to reduce symptoms of primary and secondary trauma. Havening is a novel brief intervention which aims to treat symptoms caused due to traumatic encoding of negative events by using sensory input to alter thoughts and behaviour (Ruden, 2013). During a Havening intervention, a negative event and its associated emotional state are called to mind and the practitioner applies a gentle touch to the forearms, which is coupled with distracting tasks. This process is hypothesised to increase serotonin levels which can disrupt reconsolidation of the link between the traumatic memory of the event and the psychological distress it causes (Gursimran et al., 2015). Havening is thought to be appropriate for use with foster carers who are displaying signs of primary trauma due to children's negative externalising behaviour and for those experiencing secondary trauma as a result of engaging empathically with children's experiences of trauma on a regular basis. A small group of foster carers who had previously undergone Havening provided by the NATP participated in this intervention development study. They reported that Havening was effective in reducing distress and anxiety triggered by particular behaviours their children engaged in (for example, aggression or inappropriate touching). However, further research is needed to understand: whether this effect is limited only to very specific behaviours, how long the effect lasts for, and whether it can be casually attributed to the havening intervention itself, rather than to other aspects of the intervention. The NATP has been delivering Havening for some time now and have an experienced team of practitioners who have been trained to facilitate the intervention. Peer support groups (Listening Circles) Following the one-day workshop, foster carers will take part in a programme of follow-up support. Carers will attend a peer support group, facilitated by the NATP, once a month for three months after the workshop. These groups, known as 'Listening Circles', are currently held across the UK and are attended by NATP members including birth, adoptive, and foster parents, as well as kinship carers. Listening Circles offer participants the opportunity to socialise, share parenting strategies, and access practical and emotional support from peers. This is particularly relevant to foster carers who may find themselves feeling isolated as a result of working within the home environment. Listening Circles differ from traditional peer support groups for foster carers in two ways. First, they are attended by other parents/carers (rather than being targeted solely at foster carers). Second, and in contrast with peer support groups facilitated by fostering agencies, Listening Circles are not attended by supervising social workers. Focus group participants were positive about this aspect of the Listening Circles. For many carers, the complex power dynamic between themselves and the social workers who concurrently support and scrutinize them, resulted in them feeling unable to admit when they were struggling. They felt it was important for carers to have safe spaces where they were able to be honest about their experiences and receive non-judgemental support from 'people who get it', without fearing that the routine difficulties of fostering would be documented by their agency and result in interventions from social workers. Each Listening Circle is facilitated by a volunteer Listening Circle Coordinator (LCC) who schedules the meeting and facilitates discussion. LCCs are trained in safeguarding, confidentiality, and all have experience of therapeutic parenting. LCCs are not paid for their time but expenses are covered and LCCs receive benefits in the form of free NATP annual membership and vouchers to put towards attending NATP training courses. Currently Listening Circles vary in their format and structure. Most groups meet in public places such as cafes, but others are held at the LCC's own home. Groups also vary in how structured discussion is; some groups have invited speakers and discuss a particular theme each week, whereas others simply offer a social space for carers to meet and support one another. In order for Listening Circles to be 'trial-ready', a consensus needs to be reached upon which of these two formats is most appropriate for the intervention. Although there is not necessarily a need to manualise the provision of peer support, it is important to ensure enough consistency between group 
Type Health and Social Care Services
Current Stage Of Development Initial development
Year Development Stage Completed 2020
Development Status Under active development/distribution
Impact None yet - intervention still under development. 
 
Description Workshop with local authority in South West England 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Invited workshop with local authority social workers to raise awareness about compassion fatigue and appropriate methods of intervention. The content of the workshop was based on the present study's findings regarding development of an intervention, as well as the previous study's findings on the prevalence and experience of compassion fatigue in foster carers.
Year(s) Of Engagement Activity 2020