Compassionate Mind Training for Caregivers in Residential Youth Care: Investigating their Experiences Through a Thematic Analysis

As caregivers, some participants felt that they were already available to care for others, and so, the perceived changes were more evident in the two remaining flows of compassion: “Regarding compassion towards others, I think I have always considered myself a compassionate person” (T33, RCH3). In fact, in what concerns compassion towards others, participants felt that the program reinforced their motivation to care for others: “I was already quite compassionate towards other people, but this was reinforced” (E32, RCH3). Some participants also reported that other compassion attributes, such as sensitivity and acceptance of others’ suffering, empathy, and a non-judgmental attitude had increased: “This training came, above all, to reinforce the idea of trying not to judge the kids for what they do” (E23, RCH2); “accept the suffering” (T33, RCH3); “putting myself in the other person’s shoes and trying to be more compassionate when the situation demanded it” (E13, RCH1); “Before this program, I was more directive in my intervention, and now I have started to try to see the girls’ side, to try to better understand them” (T32, RCH3).

Despite some participants having seen themselves as already having an intrinsic motivation to care for others, reports in the first person suggest that compassion attributes (e.g., sensibility to suffering, empathy) and competencies (e.g., compassionate thinking and behaviors) were strengthen (Gilbert, 2017b; Mascaro et al., 2020). Compassion seems to be felt and expressed not only towards youth, but also towards colleagues.

Caregivers from two RCHs reported that they started to notice their fears and blocks regarding receiving compassion from others, and perceived a greater openness to receive compassion from others, namely from colleagues: “I try not to interpret negatively the intention of the other and maybe I’m also more aware of the obstacles of compassion, related both with receiving and giving compassion. I try to get around them – Ok he’s just trying to offer you compassion, accept it” (T34, RCH3); “I’m more open to receive compassion. It was important for me, because I was always used to just giving, giving, giving; I’m that kind of person who could never say no. This training helped me to let others come in” (E21, RCH2).

This subtheme allowed to understand that caregivers started to become more available and open to receive compassion from others, including from their own colleagues in the workplace. Considering the interpersonal dynamic process of compassion between those who give it and those who receive it (Hermanto & Zuroff, 2016), when taken together, findings from this subtheme and the previous one suggest the existence of compassionate interchanges between team members.

It was unanimous that self-compassion was the flow where more changes were noticed: “The most significant changes were in self-compassion, but of course there were also features that changed both in giving and receiving it” (T12, RCH1). Participants from all RCHs recognized the importance of self-compassion, reporting that the tone and content of their internal speech were becoming more caring and supportive: “To me, it had some impact because I am very critical of myself, very demanding and it helped me to be more compassionate with myself and to think and act differently with myself and others, to quit from being so self-critical and highly demanding with myself” (E21, RCH2). Participants also mentioned some reduction in fears, blocks, and resistances concerning self-compassion: “I felt the biggest difference on self-compassion. In fact, I thought more about it, I had not thought about it before. I started to become more aware about it. I need it too, I’m here too, let me take care of myself now” (E32, RCH3). In some RCHs, participants reported an increase in their motivation to take care of their own needs, and it was often said: “if we take care of ourselves first, we will be more able to take care of others as well. That is, if we can manage our emotions first and manage them well, our way of relating with others will be different, much more tolerant, much more compassionate” (T22, RCH2). Self-kindness was also highlighted: “For me, it was more about self-compassion, being kind to ourselves. It was something that had never occurred to me before. It was easier to be kind to others” (T11, RCH1).

Despite the reported changes in all compassion flows, considering the specificities and challenges from this work setting, caregivers seemed to value that they also need to be cared for, with most caregivers highlighting the relevance of becoming more self-compassionate. The necessity to take care of their own needs, in order to take better care of youth in residential youth care, was greatly emphasized.

Some participants expressed difficulties with formal practices of meditation, as well as in accomplishing the weekly practice: “To me, it was very difficult to keep my mind in the present moment” (E13, RCH1); “The day is very busy, there were days that I could do the homework, others that I didn’t have the possibility to listen to the audios” (T31, RCH3). Sessions’ duration and frequency were considered an additional load for caregivers who worked in shifts: “These sessions, for some of us, were an extra working hour. For some people it meant coming to work on days off or before working hours, when they would still have 8 hours of work after the session” (T21, RCH2).

These findings suggest that barriers to compassion can reside in individual and organizational factors, related with challenges in engaging with such kind of program, mainly due its contemplative nature. Sessions’ frequency and between sessions practices can be challenging in a setting where the work overload is already demanding.

In addition to training constraints, common fears, blocks, and resistances to compassion in its three flows (i.e., give compassion to others, receive compassion from others, and self-compassion) were also noticed. Being compassionate towards others was reported as demanding: “I think this is a more demanding kind of care” (T31, RCH3). Receiving compassion from others was somehow difficult for some participants: “I still have to progress a little bit more in terms of receiving compassion” (T32, RCH3). Despite being referred as the flow where major improvements were felt, self-compassion was also the flow where most fears, blocks, and resistances were experienced and reported: “It is self-compassion that we have to work on. It is the more difficult one” (E12, RCH1); “My self-criticism is still not in the right place” (E22, RCH2).

Since compassion is dynamic and reciprocal, fears, blocks, and resistances to compassion expressed by youth might also work as a barrier to compassion in residential youth care. Caregivers from two RCHs mentioned that some youths react with strangeness to the changes in caregivers’ behavior: “They are not used to this kind of intervention at all. In their family home they went through violence and shouting, so it makes them a bit angry when we are compassionate towards them, but of course, with time, they will eventually see that this is the right way” (T33, RCH3). Participants from the three RHCs also recognized that the establishment of warmth and close relationships is a process that takes time: “It is a construction that has yet to be done. We are working on it, but it takes its own time” (E31, RCH3). It was also referred that, given the endured mental health difficulties of traumatized youth, specific interventions tailored to youth are needed so that major changes can occur: “If the intervention that caregivers had was also delivered to youth, I think the outcomes would be different, we would have another type of outcomes” (T22, RCH2).

Baseline levels of fears, blocks, and resistances to compassion, both from caregivers and youth in care, could make more difficult the experience and development of a compassionate motivation and attitude from caregivers. Organizational factors, such as lack of time, were also mentioned as a barrier to be compassionate with others. Due to earlier adverse experiences with caring figures, caregivers also acknowledged youth’s difficulties when facing compassionate care. Nevertheless, caregivers also showed perseverance and recognized that a consistent compassionate approach across time, eventually paired with individual therapy to youth, could be able to reduce resistances presented by youth and improve residential care outcomes.

Participants from the three RCHs expressed their satisfaction with their experience of participation in the CMT-Care Homes, acknowledging its utility and value to the residential youth care setting: “I identified myself very much with this program, it helped me to reflect, and it helped me a lot in the intervention with the youth, with myself, and with the team. For me, it was very valuable” (T33, RCH3); “This training was very positive in all aspects, I liked it very much. Until now, I think it was the training that helped me the most to work with youth, to work with my colleagues, even in my personal life”(E21, RCH2). Participants also expressed their satisfaction regarding the fact that the program was specifically tailored to caregivers, aiming at the improvement of their own well-being, but also providing important, interesting, and useful new tools for work: “We can say that this training is like a 2 in 1. Usually, when we go to a training, we learn to intervene with our target public, and in this training, in addition to that, we learned other things that have to do with ourselves and our own well-being. Especially with meditation practices, we were able to find gains that we wouldn’t have found in other strategies. It was fundamental for us to complement our daily tools and our intervention strategies, but also quite important in the care for ourselves that we usually don’t worry about and which also wears us down in our daily lives” (T34, RCH3); “We touched upon some quite interesting and useful concepts for the field of residential care” (E23, RCH2). Furthermore, participants recognized the relevance of within sessions experiential exercises and between sessions practices: “Practical exercises were the ones that I liked the most and the ones I found most important. Even to get to know each other better” (E22, RCH2); “The weekly tasks were a way to practice and put into practice the learnings we had achieved in the sessions; I think it was important” (T22, RCH2). The safe group atmosphere was highlighted as enabling the sharing of personal experiences: “The sharing, I found it very interesting. I think it’s important for the team” (E22, RCH2).

The program and its compassionate-based approach seemed to be well received and considered valuable, both individually and collectively. Its aims, format, contents, and practices seemed to be adequate and to facilitate adherence and expectations regarding program outcomes. The fact that the program was not only designed to improve professional skills, but also to target caregivers’ own emotional needs and well-being, was highlighted in face of the daily challenges felt by the participants. The group format seemed to have allowed caregivers to share difficulties and insights and to show compassion towards other participants, after understanding that they were not alone in their difficulties. The theoretical framework and experiential practices were considered helpful. Satisfaction with the program and the recognition of its value to these settings might have facilitated the compliance with practices and transfer of learning.

Despite the mentioned difficulties reported with the weekly challenge practice, it was referred that, in general, caregivers had integrated the new learnings into their daily lives. Regarding meditation practices, participants reported using compassion exercises (e.g., compassionate friend and safe place) and mindfulness practices. It was stated that they tried to bring the focus of attention to the present and to breathe mindfully, and to appreciate the present moment: “On a personal level, I became more aware of things, being focused on the present moment; I took some exercises that we practiced here and tried to practice them on a daily basis. I think it had a positive effect. I think we spend most of our days on ‘automatic pilot’ and life goes by without one being aware of what we are doing, not having the capacity to enjoy the moment. I think the training was positive and it was something I also applied to my daily life” (E23, RCH2); “I started to be a little more in the present. Still planning, but without ceasing to enjoy the moment” (T11, RCH1). Participants also reported that they were more aware about the focus of their attention and their emotional states, recognizing their need to slow down: “The practical exercises that we did between sessions allowed me to become more aware of the need to slow down the mind, the body, to be more present” (T21, RCH2). Some participants also reported that they applied some practices with their relatives or that they did some practices together: “This week my husband was very stressed. So, I took home these practices and explained to him how it works. We started doing exercises together. We talked about the safe place. He’s trying to create his safe place on his mind. So, I’m applying that at home as well” (T12, RCH1).

Participants from the three RCHs also specified that the program was particularly useful to help them in dealing with youth. During care provision, participants sought to use a more compassionate communication, using a calmer voice tone, congruent with a friendly facial expression. In addition, they reported to start using more affective and proximity behaviors (e.g., hugging, touching): “Speaking with a calmer voice, valuing touch, our facial expression; having the notion that this is very important. Those non-verbal signals that we express have great impact on youth” (T11, RCH1); “We do not have to be afraid of giving affection. I can say that touch has become more important to me” (T22; RCH2). This non-verbal language was combined with a more compassionate intervention, in the sense of trying to better understand youth, placing themselves in their perspective, mostly in order to stimulate a more soothing response in youth: “I can perceive some changes from the whole team towards the youths. I have a much more active attitude in giving compassion to youths. Maybe I have a much more active attitude in noticing and being more attentive when the youth is suffering, being with him or her and trying to alleviate their suffering” (E23, RCH2). This greater willingness to listen and understand was used to mediate and solve conflicts and to create more moments of dialogue with the youngsters: “I am more receptive to listening; things are now more talked about” (T11, RCH1); “the compassionate mind training is useful to the daily relationship with the youngsters and to solve the basic conflicts that arise on a daily basis. It is also useful to find a strategy that better suits the situation, not putting the youth ‘in the red’, nor us, and trying to avoid the conflict and solve it in a different way” (E31, RCH3). Some participants also reported that they had tried or had the intention to do some practices with youngsters: “One caregiver did mindfulness with the youngsters” (T11, RCH1).

In addition to the care practices, participants from the three RCHs also tried to apply the programs’ theoretical model in the daily work dynamics, using it in relation to themselves, colleagues, and youth. For example, the three affect regulation systems and related colors (i.e., red for threat, blue for drive, and green for soothing, Gilbert, 2017a) seemed to be frequently used both to understand and express one’s emotions, as well as to identify the emotional state of colleagues and youth. “Glasses of compassion” and “Common Humanity” were key terms of the CMT-Care Homes also frequently used: “We interpret the behavior of others in the light of the three systems. Previously, if a colleague arrived in a bad mood, I would think something like – here she goes again, turned inside out! – But now I might think – OK, she is in the red system, I won’t criticize her, I won’t judge her attitude, because something happened to her to be in the red system – I think that the knowledge of these emotion regulation systems makes it easier, not to criticize so much, not to judge so much and we really put on the glasses of compassion and try to better understand the behavior of others. Before, we didn’t put on our glasses of compassion; and now, we stop and put on our glasses to think - What is she feeling? Why is she behaving in this way? How can I help her?” (T34, RCH3).

Despite the mentioned difficulties with formal meditation practices and with some the weekly challenge practice, formal and informal practices were used by some participants to enhance mindful attention and compassionate emotions, thoughts, and behaviors. Transfer of learnings related with the theoretical framework and compassion competencies seemed to occur to personal and professional life contexts, concerning themselves, co-workers, and youth. Particularly, caregivers referred that the new knowledge and skills were greatly applied when providing care and to solve conflicts. Collectively, caregivers seemed to create more space to listen and dialogue with youth, while trying to communicate and act in a more compassionate way, resorting to a soothing voice tone, touch, and affection. Theoretical knowledge regarding the evolutionary perspective about the human mind and suffering and the role of compassion in the regulation of the three affect regulation systems (i.e., the threat, the drive, and the soothing systems; Gilbert, 2017a) seemed to be acknowledged and used between colleagues in the work dynamics, facilitating the awareness, communication, and regulation of their own and others’ emotional states. Despite not being asked to do so, some caregivers took the initiative to teach and practice meditation with their own relatives and with youth in care.

At the individual level, participants reported enhanced emotion and behavior regulation, reduced suffering, and increased well-being. Acquiring knowledge about the functioning of the human mind, as well as the mind training practices, seemed to enhance self-awareness and encourage self-reflection, facilitating healthier cognitive emotion regulation strategies, such as stop and think before acting, perspective taking, change priorities, and reducing both rumination and self-criticism: “From a personal point of view, I think that it has created in me a greater awareness about my emotions, my way of functioning, how they affect my behavior... I am more aware of the changes that occur throughout the day, and, therefore, there is also a greater intentionality not to be taken over by these emotions and try to regulate them in a more positive direction” (E23, RCH2); “It helped me to change the perspective” (E32, RCH3); “I am not so distressed in my day to day thinking – oh I failed, I failed, I failed” (E13, RCH1); “Especially when I fail or things do not go the way I wanted, instead of beating myself up, I adopt an attitude of trying to better understand myself and what is happening” (T23, RCH2). Caregivers reported being able to manage their emotions, having less reactive behaviors, and perceiving a greater level of self-control: “I feel that I already react differently to certain situations, I’m not so explosive” (E13, RCH1).

The CMT-Care Homes seemed to help caregivers to better tolerate and deal with difficult emotions and stressful situations, contributing to a reduction of negative affect. Particularly, participants reported feeling less stress and guilt, as well as less emotional exhaustion: “During this program, there were so many difficult situations in this care home, that it would have probably taken me further down” (T33, RCH3); “I feel that I have changed, I am less stressed” (T22, RCH2); “I stopped blaming myself so much” (E12, RCH1); “Before doing this training, I would feel much more tired, much more exhausted, and maybe it would impact the rest of the working day” (T32, RCH3). Caregivers also perceived an increased well-being: “It helped me very positively, it brought me a lot of awareness, as the days went by, I began to feel better and better in the workplace” (E21, RCH2). Particularly, they highlighted an increase in positive affect linked to the emotional states related with the soothing system (calmness, easiness, peacefulness): “I feel good, I feel calm, quieter” (E33, RCH3); “I think it gave me a little bit more peace, personal peace” (T1, RCH1); “The truth is I’m much happier with myself” (T32, RCH3).

This subtheme allowed to understand that participants became more aware of their own emotions and started to use healthier emotion regulations strategies, reducing rumination, self-criticism, and reactive behaviors. Findings also suggested that participants seemed to cope better with stressful experiences that previously were sources of suffering. Negative affect seemed to reduce, while positive affect seemed to increase, rising the perception of well-being.

Effects of compassion were also felt at the team level, namely on interpersonal relationships, self-efficacy, and motivation to work. In what concerns relationships between team members, in the three RCHs, a greater ease of communication, more positive interactions, and cohesion were noticed: “The communication between the whole team became very positive” (E21, RCH2); “I think it was positive concerning relational issues; at least, I felt much less stressed in the team meetings” (T22, RCH2); “the fact that we are more united strengthens the functioning of the whole team” (T11, RCH1). At one RCH, participants stated greater openness to ask colleagues for help, when facing difficulties: “We are more able to trust in each other, to be able to call someone else when we think we are unable to solve a particular issue” (E23, RCH2).

Enhancements in self-efficacy seem to have also been found. Participants reported increases not only on self-confidence, but also on holding a common language based on the theoretical model (e.g., three affect regulation systems; Gilbert, 2017a), and higher coherence concerning attitudes and actions among team members: “It gives us more confidence in our daily practice” (T34, RCH3); “Between us, we can even talk about the red, the green and the blue...we can even share situations and knowledge or strategies in another way” (T11, RCH1); “There was a positive impact on the team, there was more trust between the members, in the work that each one of us had to do” (T22, RCH2). At last, CMT-Care Homes also seemed to contribute in improving motivation to work, with caregivers reporting also higher professional accomplishments: “I wanted to come to work again, to be here, to enjoy my work” (T22, RCH2); “We feel much more fulfilled” (T33, RCH3).

Overall, this approach may have contributed to improve relationships between colleagues, namely by increasing cohesion, facilitating communication based on a shared theoretical framework, and safeness in relying on colleagues for help. It may also have enhanced motivation to work, as well as the confidence and sense of professional achievement.

At the organizational level, compassion effects were perceived on the quality of care, on the climate felt at the RCH, which became more affiliative, and on youth reactions to caregivers’ interventions. Care provision became more intentional, based on selected techniques, reducing the probability of resulting from automatic reactions to the behavior of others: “We are aware that if we use a certain strategy, we will obtain certain behaviors or reactions, having a different receptivity” (T11, RCH1). Participants stated that they now use more appropriate and assertive care practices, which are more effective as well: “We provide care in a more appropriate way” (T11, RCH1); “I think that the Compassionate Mind Training promotes such a balance between what we have to do, and the way we do it. We now act in a more assertive way” (T32, RCH3); “we can more easily reach the goal, when adopting a compassionate posture” (T34, RCH3). A more compassionate intervention focused on understanding the emotional needs of youth appeared to be useful for managing critical episodes, avoiding escalating behavior and physical restraints, as well as reducing punishments: “I think it has a direct impact on how critical episodes can be managed” (T21, RCH2); “With a more compassionate attitude you don’t perpetuate so much instability, aggression, so we don’t need to use so many physical restraints” (T34, RCH3), “I don’t penalize so much; I try to be a little bit more understanding in order to try to understand what’s going on” (E31, RCH3).

Caregivers from the three RCHs concluded that CMT-Care Homes seemed to contribute to promote an affiliative climate at the RCH. Although recognizing that it is not always easy to establish a close and trusting relationship with some youth, participants mentioned increases in affectivity, proximity, and positive interactions: “I feel a change in being more open to receiving compassion, you can see that in the connection I make now with youngsters. I am more available for a hug. It has contributed positively to a closer relationship with them” (E23, RCH2). Even though difficulties still exist, the RCH was also reported as a calmer and more peaceful place: “The house is calm” (E11, RCH1). In two RCHs, participants also mentioned a greater tolerance of caregivers, not only in relation to others (colleagues and youth), but also regarding their own shortcomings, as well as greater interpersonal trust in one another: “We are more able to trust each other” (E23, RCH2); “I felt that I was much more tolerant with myself and with the youth… Changes in the team that ended up being felt by the youth; the fact that we were more tolerant towards each other” (T22, RCH2).

Besides showing fears, blocks, and resistance in being treated with compassion, some changes were spotted on youth, and were interpreted by caregivers as reactions to a compassionate care approach. Caregivers mentioned that youngsters were more available to talk, they were less defensive, and expressed less reactive behaviors: “The way I react has changed, and so has changed everything else. We can even talk about what happens, and he/she does not need to yell or react in a bad way. Yes, things have changed” (T12, RCH1); “I noticed that when he comes to talk to me, even if he has messed up, he comes much more predisposed to talk because he also knows that he will be more heard” (T11, RCH1); “When we ask to talk to them, they don’t ask anymore ‘What have I done?’” (T33, RCH3); “They have changed, they end up lowering and changing their voice tone. There are immediate outcomes” (T22, RCH2). Caregivers from two RCHs have also reported that youngsters seemed calmer and more stable, showing fewer conflicts in the peer group: “The boys are in a quieter time” (E13, RCH1); “I believe most of the girls are stable” (T32. RCH3), “They don’t provoke each other so much anymore” (E21, RCH2). One RCH reported that youth would more easily apologize and some youngsters seemed to show greater self-control: “When they get nervous and are under stress, if we respond more calmly, they even realize more quickly that they are making a mistake and right away or shortly afterwards they apologize” (E14, RCH1); “I believe the boy is able to control himself a little bit more, he does not react so impulsively anymore, not even with his colleagues” (E13, RCH1).

After the program delivery, care provision seems to be provided in a more intentional and technical way, being considered more adequate and assertive, as well as less authoritarian and/or based on punishments. Hence, care quality seems to have improved, becoming more efficient as well. The organizational climate may have become more tolerant, calm, and affiliative, and these are key factors to the healing process.

Regarding the perceived indirect impact of CMT-Care Homes on youth, caregivers recognized that, immediately after the program delivery, more time is needed to assess for stable behavioral changes. After the program completion, changes were observed concerning youth reactions to the caregivers’ attitudes, and youth were described as being less reactive and defensive, and more open to talk and to apologize. Considering that most youths placed in RCH have been exposed to traumatic experiences and present mental health difficulties, caregivers recognized that youth would benefit from a compassionate-based intervention specifically tailored to attend their difficulties.