Doing ‘well enough’

Rebecca Doyle, Claire Peatson and Rebecca Parmar with reflections from a female forensic service.

The role of a psychologist is diverse, not least in forensic settings. We need to be flexible, able to adapt to a changeable population and level of risk. During the Covid-19 pandemic, this has been magnified in somewhat unexpected ways. 

Our team of three works within a low and medium secure service for women with complex needs, part of a much larger hospital that also caters for men in secure services and a locked rehabilitation DBT pathway. Our shared experiences form the basis for this article. It’s meant to be a reflective, and at times cathartic, piece regarding the continuing impact of these unprecedented times on our professional practice. There’s no ‘correct’ way to adapt: we’re keen to prompt further discussion and reflection about the role of Psychology during this time. 

Each service and setting has had and is having different ways of working – for us, we continued to come in to our hospital to work, and never stopped face-to-face patient contact. We were also available to be redeployed to the wards if required, and were on-call to do so over the weekends during the peak of the pandemic. We believe that this way of working has had its benefits as well as its difficulties.

Small but surreal

Primarily, our aim was to continue to provide some sense of consistency and predictability for our service users in a time of uncertainty. For the most part, changes in day-to-day practice were small but surreal. We, and most of our colleagues in other disciplines, continued to go on to the wards for group and individual sessions, albeit with increasing levels of PPE as time went on. We are fortunate that there was already a well-established and routinely scheduled psychology provision across our female forensic pathway, including ward-based groups predominantly focusing on stabilisation and psychoeducation and using a variety of therapeutic models. Session content was adapted accordingly. 

We noted that service users requested more of a focus on DBT-informed skills and discussions rehearsing coping mechanisms, but also on bringing everyone together to share in collective difficulties. We aimed to provide a containing and reflective space when required, to talk about the ward community as a whole as well as individual thoughts, giving space to raise concerns but also share positives to unite the ward. Our service users responded well to this. 

We also considered together how our active threat-protection system and adrenaline-fuelled anxiety affects our ability to sit and focus on structured tasks, and considered the importance of distress tolerance and in particular ‘radical acceptance’ in these trying times. A focus was on on practical and physical activities to engage the body and mind, bringing soothing-affiliative systems online and promoting comfort and reflection. Cross-ward groups, including our DBT-informed ‘Graduate’s Group’ were, and continue to be, postponed to minimise risk of infection. We took care to be transparent about this with our service users.

The therapeutic relationship

The pandemic has proved to be an interesting test of therapeutic skill and the therapeutic relationship. PPE brings its own challenges, not just in a physical sense of discomfort or unease. We had to be mindful of a perceived reduction in warmth and reciprocal communication, and be more expressive in other ways. The felt distance between therapist and service user was also experienced more. In secure services a degree of physical distance is always there, but at first the distance felt magnified, and a sense of wariness existed for both psychologist and service user of ‘getting too close’. The skill that it takes for service users to work with this cannot be overestimated. Without additional cues of facial expressions, and less clear auditory communication, the importance of transparency, containment, and clear explanation in therapy becomes more important than ever. 

Care was taken in explaining to service users what was happening in the wider hospital, as well as with government policy. This included making resources for service users who struggle with understanding complex information, focusing on handwashing, physical distancing, and why they could no longer go to the shops to buy, for example, their favourite magazine. 

A more accessible and human side

Perhaps the biggest change to our working life was at the initial peak of the pandemic, in March and April. So many of our hardworking healthcare assistants and nursing members of staff were off sick, or shielding, that other departments were redeployed on to the wards for healthcare worker shifts to cover staff shortages and ensure a continuing safe environment for the people we care for. This included weekend ‘on-call’ shifts. This has been, at times, a controversial subject amongst the psychology profession and there can be an implication about the need to ‘ringfence’ psychological skills. There is a middle path – we consider that the time on the wards as healthcare workers has provided wider opportunities for systemic working and learning, outside of the ‘therapeutic hour’ that at times can be viewed as the limit of our input. It also provided opportunities for us to use our psychological skills in different ways, providing coaching to service users and colleagues as well as considering elements of functional analysis when on constant observations. 

Wider than this, as humans we are social creatures and crave a sense of belonging, for example as part of a team, even in a time where isolation and remaining distant can be emphasised from some fronts. There was a somewhat unifying sensation of being part of the wider team of the hospital, and a sense that we were all in this together. Not only was this a validating experience, it possibly broke down some of the barriers there can be associated with the role of a psychologist, tied up with the stigma of ‘needing to see one’, and presented a more accessible and human side to our service users and colleagues.

A shared experience

There have been benefits to going through a shared experience, and a feeling of being able to relate to service users and validate their concerns. The same emotions we experienced as staff members are also experienced by the service users we work with and support. It has been a time of mixed emotions and like most people, we have watched in alarm at the rising number of deaths attributed to Covid-19. There has been difficulty in negotiating the news of those you are working closely with (staff and service users) have become unwell, or are needing to shield themselves, and the feeling of watching the clock waiting until you become poorly. The ongoing hyper-vigilance of how you are feeling, and the ever-present guilt of not always knowing whether you are well or not, impacts to colleagues, service users, but also wider family members. 

Our normal physical habits have had to change. Office doors were at times secured open to reduce the number of times we touched handles. Hands became ever more dry and cracked in response to copious amounts of alcohol gel. Wrists became fruitlessly (but no less frequently) looked at for the time as we moved to a ‘bare below the elbow’ policy. Our polite and social habits, too, needed to change. No more making each other cups of tea. No more offering a reassuring hug to a friend or upset colleague. There has been a greater emphasis on isolation in a time when, socially, it is the last thing that we need. Paul Gilbert, in his continuing work on compassion and that very human need of belonging, highlights the use of language and the difficulties with the term ‘social distancing’. Instead ‘safe relating’, or the WHO’s ‘physical distancing’ are used, things that can feel more inclusive and hopeful. This is also something that our service users have responded well to discussions around, and has helped promote a more open interaction with staff.

Changes are still happening

More than ever, these events highlight the need to be compassionate to each other, and a need to be aware of the messages we feed ourselves. It is a skill to navigate everybody’s different coping strategies, and to be mindful of your own judgements and inner critic. We are doing ‘well enough’, and we are doing what we can. It is possible that we are desensitised to current guidelines and restrictions because we have been coming in to work every day, and are used to the PPE and the new structure of life. But it is important not to become complacent – either in terms of the continuing risk, or in terms of the effects of the current situation on others. Although things have been difficult for our service, we are also in a fortunate position where we do not have to fear for our employment or our income. Changes are still happening, and it is impossible to predict how this pandemic is going to progress. It is something that we must continue to adapt to personally and professionally. How we respond to it, and each other, is something that can only come through continuing to evaluate our practice and our responses.

Dr Rebecca Doyle

(Senior Forensic Psychologist, Elysium Healthcare)

[email protected]

Clare Peatson

(Forensic Psychologist in Training, Elysium Healthcare)

[email protected]

Rebecca Parmar

(Assistant Psychologist, Elysium Healthcare)

[email protected]

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