Being 'out there' in unfamiliar territory
At the British Psychological Society's Division of Clinical Psychology 2020 conference in Solihull, a group of Psychologists from Sheffield discussed ways in which they were branching out beyond the organisations where you would typically expect to find them (the local NHS trust and the University) and into other settings.
Ellen Duff spoke about working in the Community Enhancing Recovery Team (CERT): “CERT has many recognisable features of a community-based mental health team – we have a multidisciplinary team including care co-ordinators; we work with service users and their families in their own homes; as a Clinical Psychologist I offer individual, group and family work for service users and Case Formulation and Reflective Practice for staff. So far, so familiar. There are two additional factors though that make the service unique – our partnership with South Yorkshire Housing Association (SYHA) and the formulation-led whole team approach."
CERT was first established six years ago as a creative way to address the growing problem of service users from Sheffield being sent to out-of-city placements – typically locked rehabilitation or secure facilities – often many miles from home. The practice of confining people in hospitals far from home to work on their mental health recovery relies heavily on the assumption that the problems we work with and the solutions we seek lie within the individual. Within this way of thinking social networks, meaningful connections with the community and the safe base of a home are at best secondary considerations. When CERT was set up, they took centre-stage.
Because we consider safe housing to be fundamental to people’s wellbeing, CERT’s partnership with SYHA’s Living Well Project is crucial. Each service user has a SYHA key worker who first helps them to find, decorate and furnish a house. They also guide people through the benefits application process to ensure they are receiving the regular income they need. Then they continue to support tenants to manage their tenancy throughout their time with CERT and for a short while after they’ve moved on. The house someone lives in when they work with CERT can be their home for life after CERT too, when they move on to SYHA’s General Needs housing team like any other tenant.
CERT work with people who have been detained in hospital for significant periods of time, or who have struggled to manage in the community before, ending up being admitted to acute wards repeatedly. They may not trust services, feel unconfident in their own skills, struggle to manage traumatic memories, cope in ways that put them in danger, be afraid of other people, of their own feelings or unshared experiences. The emotional work it takes to establish and maintain social connections in your community alongside these experiences is huge.
The support we provide people to work through these issues therefore needs to be thoughtful and considered, based on strong relationships and an in-depth knowledge of the person. This can be a challenge when service users work with around 10 Recovery Workers in their mini-team. The formulation-led whole team approach allows multi-disciplinary staff, including SYHA key workers to share their experiences and knowledges of the person, which are then brought together in a formulation diagram and in plans for how to work with the person in the coming weeks until we discuss them again. Each time staff see this person they carry with them the shared understanding of the whole team in the formulation. Staff report that this gives them confidence to provide consistent, psychologically-informed support even in complex and challenging situations. Most importantly, perhaps, they say it helps them retain a compassionate, human connection to the person.
In recognition of the unique and high quality service we provide, CERT have won a number of awards, including Best Specialist Service at the National Positive Practice Awards 2019 and RCNi Team of the Year Award 2019.
The Sheffield Clinical Psychology (DClinPsy) training programme has strong links with CERT and the programme is keen to train psychologists who are able to work across agencies and with local communities. Liza Monaghan, Director of Clinical Practice on the course, explained how they have been developing new trainee placements with public and third sector organisations, which aim to develop leadership skills in trainees and support psychological working in new settings with themes of prevention, partnership and community working. This is in line with the NHS long-term plan and with the roles identified by psychologists as top priorities for profession at the DCP conference in 2017 (Hughes, Lavender & Latchford, 2018). These roles included “working with/influencing government/policy makers” “community psychology /‘genuine co-production”, “training, supervision and consultation with relevant staff on psychological ideas”, and “public health/prevention”.
One such innovative third year placement was described by Claire Bone, who worked with South Yorkshire Housing Association (SYHA) in 2018/19 under the title ‘Trainee Adventures Exploring the Clinical in the Organisational’ Claire detailed how, with the support of Natalie Newman at SYHA and supervised by Sue Walsh and Fiona Goudie in the NHS Trust[*], they aimed to create psychologically-informed partnerships across organisations. The placement was at a homeless families service where reflective practice and case formulation were used to support the team using concepts from Cognitive Analytic Therapy. Claire learned to work with “new systems”, using social media to communicate ideas, developing a proposal as a business case, and focusing work at the level of the team and organisation rather than the individual. It was important to make explicit the different “languages” of the organisations, particularly when considering the use of CAT alongside the strengths-based approach of the housing association. The trainee, supervisors and organisation all had to tolerate “being out there” in unfamiliar territory. The trainee undertook a placement without existing psychological input or infrastructure to forge a new role, and the organisation entrusted and supported her to act in the best interests of their customers.
Case studies described particularly difficult staff experiences due to working in the context of violence and abuse experienced by their customers. For example, staff described feeling as though they were “policing the jungle”. They talked about “the impact of working with women who harm their children”, focusing on building understanding as well as holding children in mind as the customer. They also talked about feeling like “surrogate parents” at times, and considered how best to support customers and children as well as managing the boundaries of their roles.
Staff fed back that reflective practice in particular allowed them to come together and challenge each others’ thinking in constructive ways, as well as reflecting on expectations, how they know they’ve done a good enough job and the team strengths they draw on. Claire reflected in particular on building an awareness of the capacity for clinical psychology to have impact in the world outside of the clinic. The organisation was very supportive of the project and open to learning, and changed practices from themes that arose around service closures as an example. This was a highly interesting project that involved all parties taking chances and managing uncertainty, and a large part of its success was due to the motivation and trust developed between those parties and across the organisations. Key considerations for the future were reflected on, such as how cross-organisational partnerships can continue to be forged to engage better with those experiencing inequality, and how university training courses might continue adapting to capture these diverse aspects of the role.
City of Sanctuary
Further trainee placements at SYHA and other services that support people who are homeless are currently being organised to build on this momentum. Liza spoke of how a number of organisations, who have not previously worked with psychologists, have been keen to develop these partnerships and supportive of trainee placements and research. A current third year trainee, Helen Wigglesworth, gives the following account of her experiences:
“I am a third year trainee currently on placement at The Sanctuary, a third sector organisation supporting asylum seekers and refugees to access services (e.g. clothes banks, housing, healthcare, etc.), as part of a wider City of Sanctuary movement. I am also on placement with Public Health in Sheffield. Within these community psychology placements, I have firstly been able to gain “leadership” competencies, around understanding commissioning and service development, establishing a role for psychology, and writing bids and business cases for interventions. Moreover I have needed to “learn a new language”, communicating psychological models in a way that is understandable and relevant to non-mental health professionals, and sensitive to their concerns. Lastly, working as a lone psychologist, as a trainee, outside of the NHS “bubble”, I have gained experience in managing feelings of uncertainty and of being outside of my comfort zone. Overall, I would encourage other courses and trainees to set up or seek out placements like this for third year. By being out of my comfort zone I feel that I have gained knowledge and experiences that I may not have otherwise had at this stage of my career, but which I do not doubt will be useful for the future”.
A graduate of the Sheffield programme, Diane Morrison, focused on the wider political context and talked about Psychologists for Social Change (PSC), which began as a movement responding to the psychological and emotional distress caused by the UK government’s decision to implement austerity measures. PSC is interested in how psychology can be used to inform policy and political action, and in how mental health is informed and affected by our social and material contexts. Campaigns include briefing papers on austerity and inequality (‘‘Psychological Impact of Austerity’, ‘Improving Discussion on Inequality’) and last year’s Psychologists for Social Change Manifesto, which focuses on the qualities that make a healthy society.
The PSC Sheffield Group has been drawing on ideas from social justice activist and therapist Vikki Reynolds, who encourages ‘leaning in’ – connecting with and building solidarity with others who may be doing community work, so we can hold each other accountable in our collective desire for a more just society, whatever our differences.
At PSC monthly meetings in Sheffield, the group has been exploring and planning how to use collective ‘power’ and voice to highlight social inequalities by talking about how mental health difficulties are produced socially and politically, with family, friends, in the workplace, in the community, and at local events. The group has been sharing information about, and building links with, initiatives that aim to build trust and social cohesion in local communities. Through this, ‘pockets of resistance’ have been noticed in many places, such as housing and public health, which support feelings of connectedness, shared values, and hope for change. By sharing community psychology ideas PSC Sheffield has felt more confident about highlighting the impact of government policy or associated narratives on people's lived experiences both personally and professionally and have observed the power of ‘the ripple effect’ – that small conversations can make a wider difference[†].
[*]Claire Bone, Sue Walsh, Fiona Goudie, Sheffield Health and Social Care NHS Trust; Natalie Newman, South Yorkshire Housing Association
[†] Psychologists for Social Change Sheffield meet on the second Thursday of every month, upstairs in the Red Deer pub on Pitt Street, at 6.00pm. Come and join us in making the personal political.
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