Working with complex clients: Staying grounded when you feel overwhelmed (with Dr Amy Talbot)

[00:00:05] Bronwyn: Hey, mental workers. You're listening to the Mental Work podcast, the podcast about working in mental health for early career mental health workers. I'm your host, bro Milkins, and today we are talking about how to stay grounded when working with clients who have complex concerns, and the work feels really overwhelming.

Have you ever walked out of a session feeling like the work is too much or that you're not doing enough? In this episode, we're diving into the emotional and clinical challenges of working with complex presentations. You're going to hear practical ways of managing feelings like anxiety, frustration, and uncertainty, all very normal feelings, so that you can stay effective and take care of yourself.

Here to help us out with this topic is our guest, Amy Talbot. Hi Amy.

[00:00:43] Amy: Hi, Bronwyn.

[00:00:45] Bronwyn: It's so lovely to have you on. I'm really excited for this conversation. I think you'll be really good.

[00:00:50] Amy: Excellent. Me too. Keen to get into it.

[00:00:53] Bronwyn: Can you please start off by telling listeners who you are?

[00:00:55] Amy: Of course. Uh, so as you said, my name is Amy. I am a clinical psychologist, and I've been working as a psychologist for about 15 years. I'm currently the director of the Talbot Center, uh, which is a large, uh, outpatient multidisciplinary service. Uh, we do a lot of work and engage, uh, a lot of early career psychologists as employees, uh, at our service, and we do student placements as well. Uh, and I'm also a board approved supervisor and trainer.

[00:01:25] Bronwyn: Yeah. Awesome. So when I looked up the Talbot Center, I had heard of you before you got in contact with me about the podcast, and I knew that you worked with a lot of complex presentations. So when we were talking about different topics that we can do, I was really excited that you brought up the idea of talking about complex presentations. How did you get interested in working in this area with complex, because I know it's a bit of a specialty for you.

[00:01:48] Amy: Yes, absolutely. So my early background was working with patients with severe and enduring eating disorders. And so naturally in that space, uh, there was a lot of complexity that we were working with. And also my other clinical interests have been working with clients where there isn't a really solid evidence base to work from, uh, or where there's limited clinical knowledge in the workforce in general.

So, for example, I do a lot of work with tick disorders, and whilst there is actually a good evidence base in that space, uh, most, uh, psychologists and healthcare practitioners, uh, don't know a lot about working with tick presentations. And so having worked with many clients who've had challenging healthcare experiences or who've been turned away from services, or felt that they were too difficult or complex for someone to help them. I became really interested in being involved in workforce development, thinking about how we can support practitioners to be confident and comfortable and sustainable in working with clients with these types of presentations so that the clients that I saw kind of earlier in my career and in my mid career so far would be able to access health care that would meet their needs, um, but also that clinicians would be willing to work with them in a longer term capacity as well.

[00:03:07] Bronwyn: Yeah, totally. I think it's really cool, and I'm curious to know, like right away, did you start working with clients who had enduring eating disorders? Like did you go into an eating disorder clinic?

[00:03:17] Amy: Yeah, so early in my training I did a doctorate of clinical psychology, uh, which the type of degree I did doesn't really exist now. So it wasn't a PhD research based doctorate, it was a clinical focused doctorate. And so we, the way our placements were structured was a little bit different, I think, than how placements are structured now. And I actually became interested in eating disorders because of the research.

So I wanted, I think, in my postgraduate training to engage in research where I felt like I could have a big impact and there wasn't a lot of research, uh, about effective treatment outcomes in restrictive eating disorders. And one of the things that we had to do was do a special interest placement in an area that mapped onto our research. And so I had the opportunity to work in an inpatient unit providing one-on-one therapy for, uh, clients who were presenting with longstanding eating disorders who, uh, were often very malnourished.

And so yes, I did kind of start out relatively early, uh, in my placement, and then I took a bit of a hiatus just briefly and did some other types of work, and then I went back into doing eating disorders work a couple of years into my degree, uh, into my, um, profession, yeah.

[00:04:34] Bronwyn: I'm interested to know what your reactions were in those early days, working with clients who are complex, but I guess, yeah, have severe and enduring concerns. I think all sorts of emotions could come up and one of them for early career psychs could be feeling quite overwhelmed, like, I wanna help these people, but I just don't know what to do. Do you remember what your initial reactions were?

[00:04:56] Amy: Yeah, it's, it's really interesting that you say that. I think, um, one of the things that I'm really grateful for is that the supervision and support and structure I got in that early placement, I think really actually set me up to work well with complexity. We were really supported to understand what our role was in that space, and I think because I understood my role really well, I felt less overwhelmed, uh, than going into it.

Going into it, I did feel kind of overwhelmed and unsure, uh, unsure about the role of psychologists in an inpatient unit where there was a lot of starvation, um, and I had heard that, you know, psychological interventions maybe aren't so useful for clients who are very staffed. And so I wasn't really sure what my role was going to be or how I could be helpful. Uh, and that can be a little bit overwhelming.

But I think also in that, those early stages, like many of our students, I just felt really eager to learn something, uh, that was going to be helpful. And as I said, I had really great supervision where in, in the eating disorder space, I think in particular, there's a lot of focus in supervision on understanding, well, what is, like what is your role as a psychologist? What is your scope of practice? What is it that you can offer? What is, what is the client's responsibility?

Uh, and I think I was really well oriented to the importance of client autonomy and that client autonomy in the eating disorder space means not just that they have the capacity and can be empowered to get well, but they also have the choice not to move towards recovery. Um, and the importance of being able to accept that, uh, that I wasn't, it wasn't my job to kind of force someone to, to move in a particular direction... I think that was very freeing in those early stages of the work.

[00:06:42] Bronwyn: It does sound like you were very well. Supported. What I'm hearing is great support plus a lot of clarity in your role and what you can do and what the client's role is as well. And then acceptance of those roles, which it sounds like it really helped support your work in this area.

[00:06:56] Amy: Yes, absolutely. Absolutely.

[00:06:58] Bronwyn: So I'm wondering in your view, what makes a client presentation complex? Because the way I hear about this in private practice and where I've worked has been kind of like a supervisor saying to me, let's schedule you a few easy clients and then a few hard clients like pepper in one or two a day. So that's been the distinction to me, easy, hard, and it's never been, it's never really been made clear to me what they're thinking, easy, hard, and I guess, yeah, I'm interested in what you think is complex, not complex.

[00:07:27] Amy: I think that's a really good question. And when I was thinking about this in the lead up to, um, coming on the podcast, I was thinking about the fact that humans are actually complex by nature. You know, we work with humans as psychologists, and we are also humans, and we bring that humanity into the work. And so in some ways, all of the work that we do is complex because human beings are complex.

But I think when we're talking about complexity in a clinical capacity, the way that I think about it is... I, I think that there's a few different things that can make things complex. I often think of clients as being complex when there's not a really clear path of what you're supposed to do. So for example, it's not, they have this diagnosis, and this diagnosis has a really clear kind of treatment path and you should follow this treatment modality and then you get to this outcome. Um, and I think sometimes in the, our early training, that's what we think all of psychology is gonna be like. You identify what the concern is, there's some sort of clear path about what you're supposed to do, and then you get to the other side. So I often think complexity is when that that's not the case.

[00:08:35] Bronwyn: That's such a good way of putting it, and I've never heard it put that way before, but prior to this episode, I came up with a few examples of complex clients, like for example, somebody who has bulimia, and a substance use problem, and ADHD, and that really fits into your, there's no clear path because it's like, which one do I target in, if any, in isolation or altogether, is there something transdiagnostic or do I need a different way of thinking about this altogether? It really comes within your frame.

[00:09:00] Amy: Yes, exactly. And so you can definitely have that, like you can have those comorbidities or multiple presentations, multiple goals, uh, that fits within that frame. I think what fits within the frame is presentations that we don't know that much about yet. Uh, even if they are kind of single presentations. Or you're looking at systemic complexities as well. Then I think, uh, where out trying to work out, well, what can we actually influence or what can we help the client with? What's within our scope? Uh, but what about all these other influences that are impacting the client? And how do I navigate that when I, when I don't have control over, or can't kind of influence that directly? That can make it complex too.

[00:09:40] Bronwyn: So I was thinking things like, say the client has a large Centrelink debt or is undergoing a disciplinary process at work, or has insecure housing, or has an unsafe home environment... that comes under, what can we influence? So I guess these are questions that make it more complex to us.

[00:09:54] Amy: Yes, exactly.

[00:09:56] Bronwyn: Yeah. Um, so I guess in your response, what I'm hearing is that it's something about the client that makes it complex as well, but it's also the systems and the clinician's response as well?

[00:10:06] Amy: Absolutely. Definitely the clinician's response as well. You know, as I mentioned before, we're also humans. We bring our humanity to the work, and so sometimes things become more complex because of what is coming up for us or, uh, how the intersection between our experience and our background and our values and all of those things, and the client's experiences. So relationships are inherently complex because of those things, and therapy is a relationship.

[00:10:33] Bronwyn: I worked in a service early in my career that we were supposed to, in inverted commas, only accept mild to moderate clients. And, we had, it was kind of a joke amongst us because we were like, there, there must be this mythical, mild client. We never really got them. And I was just wondering your perspective, like do you think it's a, it is a myth that of the mild client or do they exist?

[00:10:56] Amy: I think that's a great question. I mean, they probably don't exist in, in my clinical caseload. Uh, so trying to think about what would do they exist? I think there are some people who have very clear, discreet concerns that they present to psychology for. So, you know, most things are actually going okay, and they've got this really discreet need that has like, maybe like a start time that wasn't that long ago. And they have, there's something very specific where you can do a short course of a very specific treatment and they might get what their needs met at that point in time out of the treatment.

But I think that's very few of the people that we're working with. Uh, most people that we are working with have complex systems that they're part of, whether that's their family system or their work system, or even the healthcare system itself is complex, uh, and adds unique layers that we need to navigate in the work that we do.

[00:11:51] Bronwyn: Yeah, I completely agree, and I often think as well, sometimes, well, perhaps often, we know that people usually don't reach out for help immediately when they first notice a mental health concern, or a concern in their life showing up. They might try their own solutions for a bit. They might do a few of their own self-help type interventions, and then they might make up their way to a psychologist, but that might be 6, 12, 2 years down the track. Um, so these problems may have, uh, perpetuated or these factors may have come more, become more concrete, making it more of a pervasive problem.

[00:12:24] Amy: Exactly. Exactly.

[00:12:26] Bronwyn: Yeah. So I'm curious to know, you have supervised a lot of early career psychs and in general, what thoughts and emotions have you observed in early career psychs when working with complex clients?

[00:12:37] Amy: Yeah, I was thinking about this. I think there's a couple of really common ones. Definitely uncertainty, uh, a lot of uncertainty about what to do? Whether they're the right person to help this client, what, what can be done to help this client? What role they should take? So lots of uncertainty and, and questions about what to do.

And I think in the context of that uncertainty, there's often also anxiety, uh, and worry and sometimes worry that they're not going to do a good enough job, uh, because they don't know enough or they're not able to help. I think it comes from a place of really wanting to be able to help. I think there's also emotions around, sometimes, frustration or, um, more in points of stuckness, for example, uh, where we're kind of faced with various different challenges to change and to moving in a shared direction. And that can understandably lead to frustration.

Sometimes I see, um, early career psychologists presenting with guilt or shame, uh, in the context of complexity. So I think that idea that I'm supposed to be doing something more than I am. I'm supposed to know. Other people know, but I don't know. There must be some, like maybe there's something about me or I'm not doing a good enough job or, so that can kind of give rise to guilt and shame experiences as well.

[00:14:04] Bronwyn: Yeah. And how normal, how normal are those emotions?

[00:14:07] Amy: It was so normal, so normal. Uh, they're experienced by almost all psychologists at various points in time, not just early career psychologists. I still experience frustration sometimes in my work with, with clients or uncertainty or worry that I'm not doing a good enough job or, you know, guilt or shame that I haven't kind of managed it in, in the best possible way. Uh, so absolutely normal as human beings doing this work.

[00:14:33] Bronwyn: It's really reassuring to hear because I think that sometimes, and you, you may have witnessed this yourself, but we can come with that feeling of shame and, and shame is a particularly isolating emotion. We feel like we're the only ones, uh, experiencing these thoughts or feelings, and that might lead us to feel shamed, like there's something wrong with us. But from what I'm hearing from you, from your experience supervising many, many people, is that that's quite a normal experience to have.

[00:14:58] Amy: Yes, absolutely.

[00:15:00] Bronwyn: Thank you. Yeah. And so I wanted to ask as well, like just given your experience, what common myths or maybe beliefs do you think the early career psychs might hold about working with complexity? I know you mentioned one before that like we should have all the answers. Um, is that one you see or are there others that pop up?

[00:15:18] Amy: Yeah, definitely the idea that we should have all the answers, and sometimes also the idea that there's like one right answer and you have to find it. Like, there's a perfect course of action and I just don't know what that is. But if I can work it out, then it's, it's gonna be like this miracle outcome for the clients. So sometimes, like feeling that they should have the answers, but also that there's, there's some specific answer that they're supposed to know that they haven't quite worked out yet.

[00:15:44] Bronwyn: Uh, I can totally relate to that. Like, I was like, are you inside my head? I was really obsessed for a while with trans trans diagnostic intervention, so that very reason I was like, there must be something that I can target that gets above all of these problems and that I can do, and that it makes a coherent intervention because I don't want it to be messy and I want it to make sense to them. And yeah, just trying so hard to find the perfect solution.

[00:16:06] Amy: And I think that's actually one of the common behaviors we engage in when we believe that we do all this research and all this upskilling trying to resolve this problem. But actually in some ways it makes the problem worse because we don't find the outcome, and then we just start to kind of further believe that there's something inherently wrong with the way that we're approaching things, 'cause everybody else has worked it out, but we actually don't know yet, when actually, in reality, no one else has a perfect solution, uh, to mental health related concerns either.

I think that there's a couple of other ones as well. I think the idea of what evidence-based therapy looks like, um, that evidence-based therapy, which ties into this idea of there being this perfect kind of solution, is delivering a manual, focusing on skills, um, doing very specific things, when in reality evidence-based work... the evidence-based is much broader than just the manuals that we have.

Uh, I was doing some work yesterday doing some training in working with a ARFID and at this stage the evidence-based for treatment interventions for ARFID is pretty minimal, but the evidence-based overall is not minimal. We actually know quite a lot about the factors that contribute to people developing feeding related concerns. Uh, we know quite a bit about what might be helpful in that regard. There's clinical experience and wisdom. There's lived experience we can draw from. There are other sources of evidence or what- pieces that we can draw from to help us work out what to do. And so I think that idea that the narrow kind of perspective of what it looks like to do evidence-based work can sometimes contribute to that anxiety or that idea of trying to find the perfect outcome.

[00:17:47] Bronwyn: I think that's really important to, uh, to discuss. I think partially because as well, we might look for research articles and be like, oh, okay, we've got these, or we've got the manuals. But rarely do we think about the lived experience perspectives, and I really like how you've brought that up. It's like we actually do have a lot of feedback and anecdotal evidence from people who have directly experienced it.

[00:18:09] Amy: Yes. And from your client, right? Your client can tell you about their experience and you can learn from them and you can learn together about their experience rather than feeling like you have to know the answer. And I think that ties into what I was talking about earlier in my experience as a student learning about eating disorders work, starting to learn and wrestle with, well, what is my job as a psychologist?

And I think part of what is challenging in working with complexity is if you don't have a really good understanding of what your role is and what your job is, that perpetuates those feelings of uncertainty and anxiety and overwhelm. If we think that our job is to facilitate a particular outcome for the client or to help them in a particular way, or to deliver a particular intervention, um, rather than maybe understanding our job in, in a broader context of our job, is to journey with and to embark on a journey of curiosity and understanding the client's experience together with them, rather than coming in as the all knowing I have all the answers, here is all the stuff that I'm going to give you. It, it's like a shared experience of learning about the client and their, the things that are contributing to what is challenging for them and what ideas we might have that we collaborate on, that we might move forward with. And so I think shifting and understanding what our, what our job is and our role is really important, uh, in working with complexity.

And these ideas are all kind of tied together. So the other idea I had about what we see often is having an idea that therapy is supposed to go in a particular way. And if a client deteriorates, for example, then that means that you've done something wrong or that you didn't do a good job. Or if a client isn't progressing in the way that you expected, that it's likely to be attributed to the self instead of considering that this could just be part of what it looks like to do this work in this complex space.

And so I see that a lot. Lots of vulnerability to imposter syndrome because when things aren't going the way that you thought they would go, it must be you. It must be you and your inexperience and not knowing what you're doing, rather than being able to consider that it could be other things that are contributing to this.

[00:20:24] Bronwyn: I have totally noticed that, and a funny thing that I've noticed amongst psychologists is that if the client is improving, we are much quicker to attribute that to environmental factors. We're like, oh, they, they did the work. The environment is supporting them. It certainly was anything to do with me, and when they're deteriorating and doing bad, we're like, I'm terrible, I'm the cause of this.

[00:20:43] Amy: Yes, absolutely. I see that a lot as well. Uh, and both, both can't be true. Similar to like if we, if we want to endorse client autonomy and understand that it's a broader picture where we contribute somewhat, but ultimately there are many contributors to client's mental health outcomes, um, then starting to understand that kind of frees up a lot of guilt and a lot of overwhelm, uh, in being able to fit into the piece that we can do, and that's within our control.

[00:21:10] Bronwyn: Totally. I just wanted to pick up on your point about us having an idea in our head of how therapy is supposed to go, and I just wanted to add in the potential dynamic of clients and families also having an idea of how therapy is supposed to go, maybe perhaps not recognizing that their own concerns don't fit neatly into like, we are doing CBT and we're doing 12 sessions of this.

And I think that can be quite challenging. And having worked with, um, clients who have eating concerns myself, I do think that that's a major challenge for families as well. Um, to kind of get on board with like, we might not be going in a linear path here. I just wondered what your perspective of that is and how that might contribute to us feeling overwhelmed.

[00:21:49] Amy: Yeah, absolutely. I think there are often other people's expectations, whether it's the client themselves, the family, there might be third parties that are involved in some regard, and they can have expectations as well. It could be schools or workplaces or funding providers or various different people and all those expectations might not align, uh, and also might not align with what is actually possible in terms of treatment progress. And so, that can definitely contribute to the overwhelm and the pressure and the sense of needing to deliver and the, the, the burden of responsibility, feeling like it falls on us as the therapist.

And one of the things I've been, I think, quite mindful of. In working with complexity is, is being really explicit about those things from the outset, both in terms of asking explicitly about other people's expectations. What do you think this is gonna look like? Um, how do you, like, how will you evaluate whether or not we're doing effective work together? Uh, how are we going to, to evaluate that, um, in, in the work that we do? And talking about that together, having people name that out loud gives us the opportunity to gently correct things that might not be aligned with how we're anticipating that therapy is actually going to go.

[00:23:07] Bronwyn: Such great points. And I really love how you say like, let's talk about this. Like, let's make it overt and make it explicit, like what are our expectations here? Rather than I guess, getting to a situation where there is tension, but neither of us are talking about it.

[00:23:21] Amy: Absolutely.

[00:23:23] Bronwyn: And so, if this conversation is bringing up feelings for listeners where they're like, you know what?

I am feeling really overwhelmed, or I am feeling really stuck with complexity. What would you say to a listener who's feeling that way right now?

[00:23:36] Amy: Well, I would say to start with, uh, welcome to the club. Uh, we're we, you know, we're, we're all, you know, obviously not so direct as that, but, this is a, a common experience that we have as therapists, and I would definitely want them to know that they're not alone, that their peers are experiencing it as well. And that experienced psychologists who work with complexity a lot also have these feelings.

So you know, you don't kind of grow out of it through experience, which I think sometimes we believe in our early career, we believe, oh, if I just learn the right thing. Or learn this treatment model or have enough things to draw on or have enough experience or have seen enough things, then I won't feel like this anymore. And I, I think that's not entirely correct. We, we remain in the mess and the humanity of it, and therefore we remain vulnerable to experiencing overwhelm and anxiety and uncertainty about the work.

And so I think that's, that's the first message, is that it's really normal. It's part of being a human being. It's part of caring. About the work that we do. These feelings come up because we really genuinely care about the outcome, uh, and we want to do good work with our clients.

And the next piece I would say is make space for that feeling. Sometimes I think as therapists, we feel like we've just gotta always be okay with everything and that we- there's not like a specific space for us to feel what we feel or to process what we feel or to think about what's coming up for us. And so that might look like having supervision or it might look like doing some sort of reflection or meditation or journaling or whatever it looks like to, to care for and look after your own feelings.

And then the third thing that I would, that I often say to my supervisors is, let's come back to the core principles that we're going to work from here. In the context of that uncertainty. So it might be looking at, well, let's go back to what are the patient's goals? What is your formulation? And what do you think is gonna help based on the formulation, move the patient from where they are now to where they want to be. Uh, and if the answer is, "I don't know", then I'll say, well, what do you need to know in order to work that out? Let's be curious about that and go and find that out together with our client.

[00:25:51] Bronwyn: Such great advice. I particularly love your supervision line of questioning there because quite often we forget like, what does the client actually want out of therapy? And so clarifying that in our own minds can be really helpful and provide guidance. And if we don't know, like you said, what do we need to do to be able to find that out? It's such a great way of cutting through that uncertainty, because with uncertainty, we're just feeling like we're floundering, like we're drowning, and that there's so much so we need something to tether onto, and it sounds like that provides a really great tether.

[00:26:21] Amy: Yes. It's like the anchor, right? You can always come back to in terms of, well, what, what do we share with the client that we've agreed that we're going to be working on together? And, it, it's okay not to know. This is, this is the other thing that I would probably say. It's okay not to know. And actually your clients don't always even expect you to know.

One of the things that is in the literature about, I mentioned I was running some training about ARFID, so this is at the top of my mind, there was this really lovely lived experience piece where they interviewed people about their experience of help seeking in ARFID, and one of the very specific things that the family said was, we don't expect the health professionals to know everything or to have all the answers. We expect them to listen to us and understand our experience.

[00:27:11] Bronwyn: Isn't that beautiful.

[00:27:12] Amy: It is 'cause I can do that, right? I can listen to someone and understand their experience. That feels achievable. It feels manageable. It feels like something I can offer that I've been told by people with lived experience is valuable to them.

[00:27:27] Bronwyn: It is so valuable. And then when I reflect on my own experiences with health professionals as psychologists, like we also see health professionals too, it's like, yeah, that's what I want as well. I'm not actually expecting them to have all the answers.

[00:27:39] Amy: Exactly. It's freedom, right? We don't have to know everything. We don't have to have the perfect solution or the perfect outcome. Uh, and this comes back to that idea of, what is our role in psychology. And if we believe our role is to have a perfect solution and to have all the answers and to have the right model, then that's going to keep us in that space of feeling overwhelmed and really burdened by the responsibility of the work and complexity.

Whereas if we reorient our idea to how do I show up? How do I be curious together with my client, how do I listen genuinely to what is happening for them? How do we together work out what a way forward might look like in the context of their goals? Those things sound much more achievable.

[00:28:21] Bronwyn: I feel like with the first way of framing it, it's like you're automatically setting yourself up to have a lot of pressure on yourself, which, yeah, can feel overwhelming. Whereas there was the second reframing, it really sounds like you are framing it as like a fellow traveler going along with the, the client, and that feels much nicer.

[00:28:38] Amy: Exactly, and it's, it feels within our control. I think this is the, this is that thing that wrestling, if we're constantly setting an expectation to facilitate something we don't have control over, we are setting ourself up to experience a lot of negative emotions and a lot of overwhelm. Uh, but we can be a fellow traveler with our clients.

[00:28:59] Bronwyn: And I like that as well because it opens space for learning. So one of the things you said before was perhaps we have an expectation or a belief that like if I just gain enough experience, then I won't have these feelings of uncertainty in the future. But your reflection is that no, that's not true. Like even as a mid-career psych, you're like, I still feel frustrated. I still feel uncertain. And I think that's one of the double-edged swords about psychology. It's like, the best thing about it, in my opinion, is that you can keep learning. There's, there's never a shortage of things to learn. And then also a difficult thing about psychology is that there's so much to learn. You can always keep learning. Um, but I think that's so true. But if we open ourselves up to being like, I'm just gonna walk alongside this client and we're gonna learn and we're both gonna learn together and I can be curious, that's okay.

[00:29:42] Amy: Exactly. Exactly. And I agree about the learning. It is so wonderful that there's so many opportunities for learning and growth and movement within the one profession. Um, but it, it is, it is a vulnerability as well, feeling like, because there's always going to be more to learn. And you know, always it does- it doesn't matter. Even if I learn everything that was available now, next week, there will be more to learn because we're humans and we're still learning about what it means to be a human being.

[00:30:08] Bronwyn: Yes, absolutely. I wanted to shift our focus to kind of in the moment, like, when we feel emotionally heavy, when we hear clients, let's say traumatic material, um, I wanted to focus on how do we actually stay grounded in the moment when we are hearing difficult things being told to us or we are going home, and then we're sitting with the multiple difficulties that the client is bringing to us.

[00:30:35] Amy: Yeah, I think this is a really important question and there's so many different things depending on what it is, uh, that you're experiencing. One of the things I would say is it's really important to learn about yourself, and understand what things bring, bring things up for you or what things make, make it more heavy for you or make it more challenging and you notice yourself carrying it home more than you did.

So an example for me is that I am, I, I would describe myself as reasonably high energy. So I probably talk a bit faster than other people, and I... like have reasonably fast processing speed. And so when I work with clients who are a bit more on the anxious side, I don't find that I feel particularly drained by that because anxious people also tend to talk a little bit faster. Uh, and you know, so my energy naturally, my natural energy level kind of matches where they're at.

Whereas when I work with clients who have low energy or are a bit more in the depressive space, uh, and I need to really slow down quite a lot, and pause more and take more breaths... I find that really exhausting.

And so one of the things that I, so that's, that's an example. This is something I've learned about myself. Uh, not everybody is gonna be like that. You're gonna have different things that that affect you.

And what I do to manage that is, uh, when I'm working with clients who have lower energy or are more depressed, I move a lot more in the session. So I'm more likely to use a whiteboard, for example, because at least then I'm moving my body and I'm doing something to kind of maintain an energy level that isn't much below, or it's so much below my standard energy level. Uh, or even I'll just move a bit more in my chair. Like I might uncross and recross my legs, or I might be more inclined to write things, um, down on my piece of paper.

And I'm careful about how many of those clients I see back to back. I'm careful not to have, you know, an anxious client followed by a depressed client for, I don't wanna have like a, a real rollercoaster of that.

So there is some kind of really practical things you can do to support yourself in, in that space. So one, one part is learning about yourself. Knowing what affects you, what works for you, what doesn't work for you.

[00:32:48] Bronwyn: I couldn't agree with you more, by the way, and we have a similar cognitive style. I have a fast processing speed and the clients I work best with are anxious clients. But I have colleagues who have said to me, I cannot work with anxious clients. So knowing yourself is very important.

[00:33:02] Amy: Yes, absolutely. So, and it's not gonna be the same, right, for each person. So it's about knowing yourself, not taking kind of what works for me and, and applying it to you, uh, supervision. And, uh, debriefing is really important. So I remember when I used to work on my own, uh, without a team. Now we have quite a large team, so there's always people around for me to debrief with.

But there was a time when I worked in a more isolated capacity and I had a bunch of, uh, psychologist friends who I had on speed dial in my phone. And so, you know, when I needed to debrief or I was carrying something and there wasn't another space for it, I was able to kind of get that consultation and support from peers. Uh, and then of course, like more formal supervision as well.

I also think, uh, engaging with parts of myself that are not the psychologist me has been really important. So I have a child. Uh, actually it's been much easier for me since I became a mom. I find that you're kind of forced to focus on things that aren't, um, that aren't, aren't work or your psychologist self. So, you know, I, I have these really lovely moments of being reminded when I'm with my son, of the, the bigger picture outside of the, the work that I've done with this particular client or someone... being reminded of simplicity and a view of the world that's very different than kind of what I get to exposed to, that I'm exposed to in the work. So connecting with, with other parts of the self that are not the psychologist self and really being present in that and investing in that has been really important.

Uh, and then like creative expression I think has been quite an important component for me. We've been doing a... uh, activity at work where we set like, uh, priority expectations for ourselves for the week. And then we do a reflection on what we learned about from the previous week, uh, based on what we tried and, and what worked. And one of the things that I've been reflecting on recently is I, I did some project work that was more creative based and I'd been carrying quite a lot of heaviness around particular client work, uh, in the lead up to that. And my reflection was, oh, it's, it's actually such a nice break to do something very different with my brain, um, and to invest in something creative and joyful. So I think using our brain in different ways is important as well.

[00:35:23] Bronwyn: Yeah, I completely agree with that as well. I was just reflecting on the feelings that I have when I engage in creative- creativity, and it is so joyful and it is so simple, like joy. Um, and it's such a great delight to be able to use your brain in different ways, like you were saying. So there's a few really good strategies that you have given us there. And I think it's like, we all know these cognitively, but it's like doing them is another thing entirely. I'm just curious, like how did you make the decision to make space? Because you're a psychologist, you're a mum, you're a business owner as well. Was this a deliberate conscious decision on your part?

[00:36:01] Amy: Yes, I think it has been actually. Um, and, also, I've had good supervision from people who have constantly reminded me that I need to be able to do that. Um, my current supervisor in particular that I've been wrestling with, um, some career decisions around where to invest my time and energy more recently, and, you know, we, we come back to that all the time in supervision. She's like, what are you gonna do if all these things pan out? Like, how, how are you gonna manage that? How are you gonna still have space? So sometimes having accountability with someone else, whether it's a supervisor or, um, you know, my husband is quite good at saying to me, you know, you need to take some space for that. Or you need to like, make some more space for that. And sometimes I schedule in, like in my diary, like an actual appointment. Like here I'm gonna have space, uh, to reflect or to make space for, uh, what's coming up for me or my feelings.

I have quite a strong response to systemic challenges, so... you know, if my client really needs a, a different kind of service or system and that's not available, um, that makes me very angry. And so I have to work through that quite a lot. And we talked about systemic issues being part of complexity. And what I have, what I have found works there is I need to make space to just be angry. Like I have to do that first. I can't do the rest of it if I don't make the space to be angry. And then I kind of refocus and go, okay, well what is within my control? Where can I make a difference for this client? And also, how can I invest in a broader kind of advocacy space to make a, a bigger picture difference.

Uh, the other thing that I meant to mention that has really worked for me, is I have like a box. Uh, it, it's in a visible space, uh, in my house, in my home office, and inside the box is letters and cards and drawings and things from clients that I've kept over the years. Uh, and when I'm finding things really, really challenging. Because it's in my line of sight. I see the box and I open up the box, and I read all the stuff inside of it, and I look at it and I'm reminded that the work I do is meaningful. Even if it doesn't feel like it right now, in this moment.

[00:38:10] Bronwyn: I love that one in particular. I've got, actually, a client painting that a client painted for me a few years ago, hanging up in this room right now. And whenever I look at it, I, I also feel very, I feel very happy and like I reflect on that work and I'm like, that was really meaningful. Because you're right, sometimes we can be like, particularly with complex clients, we can be like, am I doing anything of value here? Am I, am I making a difference? Am I being helpful? 'cause we all wanna be so helpful and it's so important to have those reminders. So I love that you brought that up. Thank you.

[00:38:40] Amy: You are welcome. And yes, it is hard to remain focused on, you know, are we doing anything meaningful? What is the outcome of this going to be? And to remain hopeful. I think that, that space of hopefulness is a really important space to be in as a therapist, both for our own wellbeing and for our clients when they're not able to hold that hope for themselves. And you know, a client said that to me recently actually. They said, you know, I remember our very first session and the conversation that we had, uh, and they said, and you were hopeful even when I wasn't.

And I think it's hard to sustain hopefulness when nothing seems to be changing, and there's a lot of systemic barriers and there's a lot of different things going on. And so being able to remind myself about the hopeful points that the points in the work where people did see the fruition of that, um, that's been really important in grounding myself in the hope even when it seems messy and hopeless.

[00:39:40] Bronwyn: Mm. Hope is very important. I'm so glad you brought up that aspect because reflecting on that, it's like working with complex clients, it's something that I need to hold onto as well. And I do say that to the client because my definition of hope is simply the belief that things can be different. Um, and I, and I hold that a lot and I'm like, things can be different. This won't be forever. Things can change, and it's really important to hold that, particularly for our complex clients, because like you say, they might not hold that for themselves.

[00:40:05] Amy: Yes. It's one of the really key things I learned in supervision, actually, in working with severe and enduring eating disorders... One of my supervisors once said to me, well, the work Amy, is to hold the dialect all the time that things can be better than they are right now. That's the hope, and that things may never change.

[00:40:26] Bronwyn: Yep.

[00:40:26] Amy: And to be willing to sit in that space as well, to, to hold both simultaneously so that there's not too much pushing, um, of the client towards change. But there's a space for them to change if they can and they want to.

[00:40:39] Bronwyn: And even hearing you talk about that, I'm like, gosh, that's, that's a hard space to be in, you know? It's not easy to hold that dialect all the time, and it's no wonder that we can feel these feelings of overwhelm or frustration, and that's why it's important to do all the things that you mentioned before, like supervision, creativity, space for yourself.

[00:40:55] Amy: Yes, exactly.

[00:40:57] Bronwyn: Yeah. Amy, is there anything we haven't touched on so far that it's really important for listeners to know about working with complex clients?

[00:41:05] Amy: I think maybe the only thing that I would add, maybe just to expand a point from earlier, is that when you don't know what to do and you're really not sure, just be curious. Lean into the curiosity and ask open-ended questions and listen. And eventually the path will become clearer about what it is that we might need to do.

[00:41:28] Bronwyn: I love that. Has gotten me, uh, unstuck in lots of stuck situations. Usually I ask a question along the lines of like. Can you describe what that is like for you? I'm really interested to know what this experience is for you. Um, and I can get them to explain more because quite often it might be that I'm not quite understanding or I'm not getting something and that they need to describe it a bit more, so I need to elicit that. Um, so being curious, Yeah, has gotta me unstuck in a lot of situations.

[00:41:55] Amy: Yes, me too. Uh, one of my early supervisors, you can see the importance of supervision, I think coming through in all my, all my answers. Uh, one of my early supervisors said the best question you can ask as a therapist is, tell me more about that.

[00:42:08] Bronwyn: Oh yes, yes. Great question.

[00:42:10] Amy: And you know, it, it applies in pretty much all situations. So, uh, it can, it can buy you the time to think, uh, but it also, as, as you said, understanding the nuances of what the client is trying to communicate to you, uh, really helps us to work out how to move forward together.

[00:42:28] Bronwyn: It does. Absolutely. Um, I love that. Thank you. What do you hope that listeners will take most of all from our conversation today?

[00:42:36] Amy: I think a couple of things. I hope that listeners will recognize that these experiences are normal when working with clients of complexity and that even experienced psychologists have these experiences and so it, you don't grow out of it or find your way out of it as a result of learning more or doing more or finding out more.

And so then I hope that the second part of what they might take out of it is that without knowing more and doing more and learning more, you actually have a lot of the skills that you need already to be able to work effectively with complexity. We just need to go back to relationship, being curious, understanding the formulation, understanding the goals, and we can work out kind of what to do from there.

And so I hope that people will feel encouraged to persist with working with these clients. I said at the beginning that I became interested in working with early career psychologists around complexity, so that our clients would have more options and more spaces where they felt supported and held and understood.

So I hope that people will take away that it is possible to work in complexity if you are purposeful and mindful about how you care for yourself and you're put in place, the right supports around supervision and debriefing and so on. Um, and we're mindful of what our role is in the work. And once we have that freedom associated with understanding the role correctly, everything else can kind of fall into place.

[00:44:10] Bronwyn: Mm, 100%. I love everything that you said, Amy. It's been so wonderful and so clarifying as well, and it really just helps, yeah, put it into perspective what it is to work with complex clients. If we have supervision, very important, if we know our role, if we know what we can and can't do and what the client's role is as well, we can really move forward.

[00:44:31] Amy: Exactly.

[00:44:33] Bronwyn: Amy, if listeners wanna learn more about you or get in touch, where can they find you and are you accepting new supervisees?

[00:44:38] Amy: Uh, yes, we are accepting new supervisees. I'm happy for people to get in touch about that. Uh, the best way to contact me would probably be through the Talbot Center. So if they were to look up, uh, the Talbot Center on our website, uh, there are a number of avenues that you can get in touch with us through there, um, via phone, email, or web inquiry.

Uh, I am also on LinkedIn, so feel free to connect with me on LinkedIn. Uh, and the Talbot Center has accounts on socials like Facebook and Instagram, so you're welcome to reach out to us or follow us there as well.

[00:45:10] Bronwyn: Wonderful. And I'll make sure all those links are in the show notes. And so your- what are your areas of specialty, Amy? In case any supervisees wanna get in contact with you?

[00:45:19] Amy: Yeah, so obviously I enjoy working with complexity and supervising supervisees around complexity. Uh, and in relation to that, I'm very interested in, uh, professional identity, helping supervisees to understand their role as psychologists, uh, and think about how we practice sustainably.

I'm also very interested in formulation. I feel that formulation driven care and refining formulation skills are quite important in facilitating good work in the context of complexity. In the absence of knowing anything else, if you can understand your client well and make hypotheses about what might be happening for them, then it gives us a lot of options for how we might approach the work that we're doing. So some of those things, uh, that are a bit more. Uh, broad strokes, uh, interesting to me for supervisees.

The other thing in terms of clinical interests, uh, I do a lot of work in eating and feeding related concerns. Um, so I'm happy to do supervision in that space. Uh, I do have a background in, uh, pediatric care, so child and family presentations, uh, family therapy, systemic work, um, that sort of work.

Uh, and my other area of interest is in, uh, obsessive compulsive and related disorders. So tick disorders, OCD, BDD, uh, trichotillomania, body focused repetitive behaviors. Um, so they're some of my kind of more clinically focused interests.

[00:46:33] Bronwyn: I feel like I should have asked you, what are you not interested in? There's a lot there. Thank you so much for coming on the podcast, Amy. It's been a real delight to have this conversation with you.

[00:46:43] Amy: Thank you for inviting me, Bronwyn. I'm really excited for people to be thinking a bit more about how they can be sustainable, uh, when working with complex presentations.

[00:46:51] Bronwyn: Lovely.

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Thanks for listening to Mental Work, I'm Bronwyn Milkins. Have a good one, and catch you next time. Bye.