Beyond technique in psychological therapy
Ian Florance talks to Gesthimani (Manya)?Merodoulaki about her views on the role and practice of counselling psychology
How did you come to be a psychologist?
I was born in Crete and educated there until I was 18. My family had told me stories about British allies in World War Two. ‘British’ and ‘excellent’ have long been two associated words so I wanted to come to England and learn English.
I won a scholarship when I was 15 and came to Cambridge University for a language summer school. It was wet and cold and I hated the place. Then the sun came out, we sat on the lawns playing guitars, and I knew I’d be back.
I decided to spend a year here when I was 18, polishing my English language skills before going back to Crete to teach children. Instead I started a modular degree in English literature at Richmond College, London.
I had achieved top grades for psychology at high school, so in the first semester I took an introduction to psychology, and subsequently changed to a social science degree. The modular course permitted choice, and I was taught by Ernesto Spinelli.?He introduced me to the existential/phenomenological approach, which became a very different way of experiencing life. Had I been Alexander, he would have been my Aristotle!
I consider my undergraduate years among the richest experiences in my life.
Did you take to psychology straight away?
I failed introduction to psychology the first time! I retook it and my final mark was a straight A. I wasn’t going to succumb to failure!
What were your aims at the time?
I’d always wanted to work with children. After my first degree, I took the Diploma in Psychology of Education and Human Rights at London University’s Institute of Education, followed by an MA in Psychology of Education. After that I started working in the NHS as an assistant occupational therapist in adult mental health day services in London.
Was this a good experience?
Mixed. I was desperate to work with disadvantaged people, to open up opportunities through their experience of an interaction based on respect. Some people may see this as naive but it’s a continuing motive for many practising psychologists. My counselling studies had already planted the seed of experiential learning and therapists’ ways of being alongside doing. The interpersonal relationship continues to be an important feature in my client work, training and personal life.
The first hospital I worked in was a converted Victorian workhouse in one of the poorest and most ethnically mixed areas in Britain. It was run down, psychiatry-ruled, and conveyed neglect and disrespect to clients and workers. I was very interested in mental health issues, but I thought I couldn’t stay in the NHS. Nineteen years later, I found I was wrong. There is something compelling about providing a service seemingly at no charge, having a sense of autonomy in practising, and being able to predict a reasonable income at the end of the month.
That job gave me good knowledge of, skills in and respect for psychoanalytic and psychodynamic approaches. I also got involved in running groups on areas such as relaxation, anxiety management, work-finding skills, and general support. I learned a lot from how my co-therapists practised.
Alongside full-time NHS work, I taught counselling skills one or two evenings a week. At weekends, I worked with children with learning and emotional difficulties in a private school, and individually with an adolescent with learning difficulties who had experienced abuse. This was the early 1990s, when I was training as a counselling psychologist at Roehampton University. At the time, there was no Division, only a special interest group in counselling psychology. Getting chartered took a lot of ingenuity, time and mental space.
My first job as a chartered psychologist involved adult mental health roles in Teesside. I worked in a community mental health team attached to a GP surgery and had a specific role in reducing the central psychology service’s waiting list. In the late 1990s I moved to Derbyshire near my then partner. I worked in adult mental health services there.
You seem to have moved around a lot!
It made me realise something important: psychology services are configured differently in different places, often shaped by the leader’s implementation of the latest government ‘good idea’. One of the services I worked in was impressive, filled with clever, committed people delivering high-quality services; another was chaotic, and interfered with opportunities for professional growth. We seem to be a profession very influenced by individual people and particular schools of thought.
Movement also shaped a continuing theme in my thought. From the mid-1990s, evidence-based practice was being introduced and became a dominant ideology, repressing approaches that were deemed not proven. I’m all for evidence-based practice, but I’m concerned about the all-pervasiveness of quantitative research and what I perceive as poor critiques of its outcomes.
At that time, counselling psychologists plugged holes in services that did not attract clinical psychologists. I hope this is changing to a more accurate appraisal of the breadth and depth of skills and knowledge that counselling psychologists contribute, especially in therapeutic and team-work. When I left my early post, elements of it were regraded to consultant level – yet, as a newly qualified counselling psychologist, I had coped with all the demands of the job.
My goal to achieve a consultant grade took me to Lincolnshire. Then I moved to Rampton Hospital, in the role of Head of the Counselling Service for Staff, managing two other therapists. My manager was a non-psychologist and, again, there was a real difference in the way he guided and supported me. I enjoyed lots of leadership and management training. The organisation respected its staff and service users.
Can we return to your earlier comments about your strong reaction to imposed approaches?
I’m very concerned with power issues in social contexts, language and discourse, and particularly in therapeutic relationships. I believe that open debate is one of the best ways to advance science and civilisation. People can find creative ways to overcome oppression, and I would like to think that my approach to psychology facilitates such creativity and promotes tolerance of otherness. I’ve long had an interest in human rights and in equal opportunities, hence my focus. The person-centred approach seems the only one that pays more than lip service to power issues. And yet, that approach seems underused where it is much needed, such as in mental health services. It contrasts with ways of doing psychology which view individuals as requiring correction in their ways of thinking or their hormone levels.
Encountering feminist ideas in Richmond felt like someone flicking on a light-switch. Later on, I coordinated and taught the Women and Psychology course in Roehampton. I have also been a member of the Society’s Standing Committee for the Promotion of Equal Opportunities for a few years. Growing up during the dictatorship in Greece has influenced me in these areas.
I’ve been exposed to a variety of approaches to therapy during my career. I have serious concerns about the predominance of cognitive behaviour therapy. CBT fits well the medical model which prevails in the NHS, and the NHS is a major funder of psychology services. It can seem that unless we speak and think in medical terms, the profession may become marginalised. We often react to such a threat by adopting the language and spirit of the dominant discourse. Returning to the idea of tolerance, I am concerned about portraying happiness as the correct way of being and feeling. People are much richer emotionally, and it may be our role to enable people and wider society to be more accepting of this richness.
I question compliance to the CBT model. Clinical governance includes a degree of mindful autonomy and I’m not certain we use that enough.
Psychologists are versatile scientist-practitioners. We need room for debate, for a wider variety of approaches, and a pinch of pragmatism. We need to continue questioning our findings and searching for more understanding and knowledge.
Are there other concerns you have about psychology as a profession?
How do we obtain our knowledge? There are significant limits to what we can learn from nomothetic approaches, studying large groups of people to draw conclusions about the total. Our world is hugely diverse, so idiographic approaches are equally, if not more, suitable for psychological inquiry, understanding and knowledge. Sometimes I think that we try to explain psychological phenomena before achieving sufficient understanding of what they are. That feels like the wrong way around.
Finally, different domains could learn more from each other. For instance, we could all benefit from knowing more about the work of developmental psychologists, as well as those working with adults across the lifespan. In adult mental health we often discover the late effects of a difficult childhood, and we could invest more in examining timelines and work on promoting lifelong healthy development.
What are you up to at the moment?
I wanted to learn more about new ways of researching, of psychometric testing, about applying psychology to people in different circumstances and services. So, I started clinical psychology training in 2006, but the training remains incomplete. In the past year, I’ve been re-examining whether this path will deliver the outcomes I wish to reach while retaining what I value most about being a psychologist.
I am pleased to be working for a not-for-profit organisation now: I’m employed part-time by Relate Institute as their Clinical Supervision Programme Leader. In private practice, I provide clinical supervision (and contribute to the Division of Counselling Psychology as an assessor). I have been interested in clinical supervision since my earliest days of practice. I have read and written about it and provided it. Holding a training and education role also suits my constant thirst for learning.
What do you think about counselling psychology now?
I value its independence and integrity, though it is undervalued. We draw on a wide variety of approaches, use our experience of interaction within sessions to inform our work. While respecting evidence-based models, I believe that we retain a healthy doubting/inquiring approach to what constitutes evidence.
Having established its identity, counselling psychology now seems to me to have reached a crossroads: should it remain autonomous or pair up with another member network of the British Psychological Society? We need to consider carefully the costs and benefits of such options – and beyond questions of employability. Our philosophical roots make our field very distinct. We need to ensure we safeguard distinctive aspects of our professional identity. Counselling psychology is not a miniature or paraphrase of other specialities; it is an entity with its own identity.
The reality of work as a forensic psychologist
Carol A. Ireland looks beyond the TV and media portrayals at a difficult but rewarding career
The profession of forensic psychology continues to evolve and develop. Without doubt this is a reflection of the importance of psychology as a whole. It also highlights the particular wide-ranging benefits forensic psychology brings to society, not only when working with the perpetrators of offending, but when engaging with forensic organisations, victims, the public and government. A range of other applied psychologies work with offenders: clinical, occupational, health and counselling psychologists. This piece will focus on the work of chartered forensic psychologists.
One of forensic psychology’s continuing challenges is to explain what it really does as a branch of applied psychology, as opposed to the more ‘glamourised’ media and journalistic portrayals. Forensic psychology is an engaging profession and one which forensic psychologists can be passionate about. Yet the need to ensure an accurate image of forensic psychology must inform this. Programmes such as Cracker starring Robbie Coltrane, or more recently Wire in the Blood starring Robson Green (which portrays a clinical psychologist working in the forensic arena), are popular and entertaining but far removed from actual forensic psychology work. Not only are forensic psychologists passionate about their work but it seems there is a fervent interest in our profession from the general public, which is supplied largely through the filter of the media.
Programmes such as Cracker focus on what the producers feel are the more intriguing and exhilarating elements of the role. They are often somewhat distant from real life applied psychology. There are a large number of forensic psychologists who may shudder at being referred to as Cracker in any context, and prefer the scientist-practitioner role to be our defining feature.
It is therefore both crucial and timely to clarify what forensic psychologists can and do contribute in their work, including how they qualify, and the range of roles that a forensic psychologist undertakes.
Qualifying to become a chartered forensic psychologist is by no means a stress-free and uncomplicated process, but this is a profession for which standards are of vital importance. The initial steps are to get an undergraduate psychology degree and/or the equivalent GBR recognition. This is followed by the completion of stage 1, which is usually an accredited postgraduate qualification in forensic psychology (usually a one year full-time, two years part-time master’s degree), providing academic and theoretical knowledge. Finally, stage 2 requires a minimum of 320 days spent equally across four areas: conducting interventions, assessments and evaluations with clients; applied research; supporting and advising other professionals; and training. All of these activities are coordinated by a chartered forensic psychologist. This leads to the completion of eight pieces of work, two within each of the four areas, taking a minimum of two years to complete (although more realistically they’ll take closer to three years). These pieces of work are then submitted and examined by the British Psychological Society’s Board of Assessors. Successful submission leads to qualification as a forensic psychologist. Practitioner doctorates in forensic psychology are coming online (not to be confused with PhDs), which merge stage 1 and stage 2 under one academic programme. Currently the ‘apprentice’ model (stage 1 – university assessed and BPS accredited; stage 2 – field work assessed by the BPS) remains the most accessible and commonly used one.
Forensic psychologists work in varied environments: NHS hospitals, private hospitals, the National Offender Management Service (NOMS), the Scottish and Irish prison system and private prisons, the police, universities and private practice.
The work of forensic psychologists is far more diverse than is depicted in the media. We are not, for example, advocates for those on trial; nor are we support workers for those undergoing prosecution. There are other professions within whose remit this falls.
Whilst forensic psychologists will clearly have engagement with the perpetrators of offences, they may also, or alternatively be involved in working with victims, conducting applied research, designing and delivering training, contributing to policy and organisational consultancy. It’s a varied career – I can only give a few examples here.
Forensic psychologists often work with or in relation to suspected or convicted offenders: assisting in investigations and court decisions; assessment of their treatment areas; the design, delivery and evaluation of treatment interventions such as sex offender therapy, and interventions targeting propensities for violence, emotional regulation, adaptive thinking, and the development of healthy beliefs that support an offence-free lifestyle.
A particular area of specialisation is assisting an organisation or court in the completion of assessments that explore the risk presented by the individual to the general public, as well as in family cases involving children. Work with victims includes supporting their recovery, apprehension of offenders and informing local police and government policy on victim support issues.
Forensic psychologists also engage in a variety of forms of qualitative and quantitative applied research, such as the exploration of individual factors related to offending, therapy evaluations and protective factors around offending.
A number of forensic psychologists are involved in the development, implementation and evaluation of training initiatives. The remit of such training can be varied, and based on the needs of both staff and other clients. It may include: staff development of awareness and the application of knowledge and skills for working with offenders, such as interpersonal skills and motivational approaches; organisational issues such as awareness and management of bullying, management of self-harm and the utilisation of diagnostic tools, such as psychopathy assessments.
The consultancy role is varied and wide-ranging. It can include working with management on the assessment, initiation and evaluation of change within an organisation, leading on or supporting policy development, the alleviation of stress, consulting on critical incidents within an organisation, consulting and advising on government projects, as well as assisting in the auditing of government initiatives, in agencies such as Her Majesty’s Inspectorate of Prisons.
Not to be taken lightly
This is not a career that should be considered lightly. It can take a long time to reach the requirements, and it involves continual development. More importantly, the views and decisions made by a forensic psychologist can have substantial implications for clients, particularly offenders: their expertise can be crucial in decisions made regarding their incarceration and/or restrictions on their freedom.
It is also not a career for those seeking a ‘9 to 5’ job or whose sole focus is to make individuals ‘better’. Rather, the focus of some psychological interventions with forensic clients is on managing risk rather than its complete removal. Decreasing risk can increase a client’s chances of returning to the community and may enhance their quality of life. But these improvements need to be balanced with ensuring the public is kept safe. This can be one of the hardest lessons learned by those new to the profession. You either accept the reality of how difficult the work can be or become disillusioned with it and seek a career elsewhere. Personally, I find forensic psychology intensely rewarding, and I feel fortunate to have found myself within a profession that I find both engaging and valuable.
Job Title: Lecturer in Medical Education (Admissions)Employer: Undergraduate Community Medical Education, University of Dundee
The job title doesn’t immediately indicate the technical and groundbreaking content of this job. But Dr Jon Dowell, Director of Undergraduate Community Medical Education and Admissions Convenor, gives a flavour of its importance. ‘We’re on a roll,’ he says, ‘but we need to keep on refining things. I’m looking for someone who is going to stay here, build our reputation, work on a long-scale research programme as well as build their own academic career. In that sense we’re focusing on the long term.’
What exactly does the job entail? ‘I joined two years ago as the clinical academic responsible for admissions. I’m actually an academic GP. I was disappointed that we were relying on UCAS form information and interviews to select students for admission to medical degrees. I wanted to improve the way admissions were handled here, and provide something of a benchmark for other UK institutions. I asked for academic support when I joined and that’s where this post came from.’
What progress has there been? ‘We’ve streamlined and analysed the information we get from the UCAS forms, but we’ve gone about as far as we can with that. We’re also looking at how we can best assimilate the information from the UK Clinical Aptitude Tests. However, last year we introduced the Multiple Mini Interview, which involves ten ‘stations’, seven minutes each, at which questions are asked on different topics. We’re happy with the trial, but we now need to develop it and assess its validity in detail. We’ve already had visits from other organisations to see what we’re doing.’
What will the successful candidate contribute? ‘They’ll manage the research effort into how well the admission system is working. They must be comfortable with and expert in psychometrics and human measurement. There are specialist statisticians around, but this person must plan the effort, get involved in analysis, draw out the implications, write them up and implement them. It’s going to take five to ten years to establish the validity of what we’re doing. The person will be an active member of the admissions team and we’re looking for them to develop the system creatively. So, to give an example, how might we assess “integrity” during the mini interviews? We’d want this person to take the issue and come up with a workable new solution. They will need to look at best admissions practice internationally and introduce new ideas here. The job also involves a small lecturing component: increasing the psychological input into the behavioural science programme.’
Although the advertisement suggests preferred psychological specialism, Dr Dowell stresses that he’s open to other specialisms. ‘The successful candidate, obviously, will be comfortable with various statistical techniques and the management of large amounts of numerical data. But we have helpful links within the medical school, the Centre for Medical Education and a variety of other research groups who can help. There is also good administrative support in place. The successful candidate needs good interpersonal skills to get support and must want to promote what we’re doing. We have a lot of good will and we need to build on that.’
You can find this job with many others on www.psychapp.co.uk.
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