Thank you, baptism of fire…

Assistant Psychologist Hannah Smith on the value of front-line work in preparation for a therapeutic role.

Recently I’ve been reflecting on my experiences a lot, as is typical of the application process for clinical training (which I’m sure many readers will be familiar with). It got me thinking about my first job in mental health – as a healthcare assistant (HCA) on an adult male psychiatric intensive care unit (PICU), and the grounding that this role gave me for my current therapeutic role.

As an HCA pursuing a career in psychology, which I am aware is common in both the NHS and the private sector, I always knew that the role was a stepping stone. But I didn’t realise how valuable a stepping stone it would be.

Emotional grounding

The first time I stepped on to the ward, 22-years-old and fresh out of university, I was greeted by some incredible people. I was humbled by the strength and resilience of everyone on the ward, staff and service users alike. I was given some words of wisdom from one of the Lead HCAs at the time, Tony: ‘There is a very fine line between working here, and being here’. He told me never to forget that, and I won’t – I’m so glad I heard those words so early on in my mental health career. As challenging the stigma and persistent ‘otherness’ of mental health is still a frequent topic in The Psychologist magazine and in society, I fully appreciated, in practice, the striking fact of mental health not discriminating whom it affects. On the ward there were service users of all ages, backgrounds and professions; this range including ‘R’, a Cambridge educated biochemist with a PHD.

Personally, I became all too aware of the risks to staff on my very first shift. A staff member was seriously assaulted in the face, resulting in a chipped tooth, a split lip, and she even has the scars on her nose to show for it now. It’s important to note that I have not seen an incident as serious since then – these incidents are rare and managed effectively if they do occur, but mostly are prevented brilliantly by the team. However, this experience warned me to never become complacent with risk, and that mental health environments are unpredictable and dynamic.

Clinical grounding

Research tells us that the therapy relationship is one of the most important contributors to positive outcome measures in service-users, and is perceived to be so by psychologists (see references below). The PICU environment was challenging, but the greatest gift I got from it was the continued opportunity to develop my skills of building rapport and effective communication – skills vital to building strong therapeutic relationships. Obviously there are endless applications to developing communication skills, yet it is, of course, particularly important if you’re wanting to do a job that revolves around the way you interact with someone.

As the service users were all detained due to their being too high a risk to themselves or others, things could get tense at times, but there was a strong focus on de-escalation and prevention of incidents by using these skills. I spent many a shift forming bonds with service users, establishing trust and rapport with informal chats and simple activities like playing chess, pool and Connect Four. Even in the midst of an incident, kind words and actions and clear communication, went a long way – when the trust is there, you listen to each other and learn from each other. For instance, during restraint, brushing hair away from the face of a service user if it’s in front of his eyes; or perhaps speaking directly to the service user rather than ‘about’ him with the team, informing him of what’s happening, using a calm tone of voice, narrating your movements where appropriate so he knows what to expect – ‘I’m going to let go of your arm now’. This was also relevant in the informal 1:1s I would have with the service users, over a plastic mug of tea in the dining room, following incidents; chatting about what led up to them, how they felt afterwards, and how we could collaboratively avoid them happening again. I suppose this was a mini chain analysis, though I didn’t know it at the time!

Furthermore, despite the challenges of this role, it was highly rewarding to see the amazing impact of front line work on recovery and the effect of the team pulling together to support our service users. Although I became very aware of the broad range of what recovery is for different people, and what’s possible or realistic (and what’s not!), there were some incredible improvements I bore witness to. However, this range was broad indeed – there were drastic differences. For example, on the one hand service users with chronic illnesses who had suffered for years and were awaiting transfer to inpatient rehab to stay hospitalised indefinitely – like ‘J’, a very witty gentleman who had unfortunately been institutionalised for years due to schizophrenia; and on the other hand service users, like ‘S’, who went from frequently and aggressively shouting in my face at the top of his voice in his first week, to singing Alicia Keys duets with me at the top of his voice whilst cleaning the dining room in his last week, before he was discharged home. Being exposed to such a range of outcomes was extremely grounding, and it is always helpful to reflect on staff expectations versus what is possible for the service users in our care. 

I’ve been extremely lucky that I have been an assistant psychologist for over a year now, but I could not have got there without the grounding of being an HCA. These roles are extremely hard work and exhausting, and I will always hold the utmost respect for strong front line staff who continue to do them day in / day out. People like Gary, another Lead HCA, who has worked on the PICU for over ten years, and continues to approach each shift with kindness, acceptance and patience, and for whom no job or request from a service user is too much trouble.

Many of the blogs I read about progressing within psychology focus so much on that dream next post (assistant psychologist, trainee psychological wellbeing practitioner etc.), that I feel the importance of roles like an HCA gets neglected somewhat, especially if one is considering it a stepping stone role like I did at the beginning. In essence, I want to highlight for anyone pursuing a career in any field of psychology who feels stuck in a front-line role, to have faith. Be mindful – stop thinking about the next job that could be just around the corner, and be present in the amazing, learning rich environment that you are in, working with incredible, resilient staff and service users alike. Soak it all up, because even on the longest, worst days, it’s most definitely worth it.


Stamoulos, C., Trepanier, L., Bourkas, S., Bradley, S., Stelmaszczyk, K., Schwartzman, D., & Drapeau, M. (2016). Psychologists’ perceptions of the importance of common factors in psychotherapy for successful treatment outcomes. Journal of Psychotherapy Integration, 26(3), 300-317.


[2] Norcross, J. C. (2014, June). Conclusions and recommendations of the Interdivisional (APA Divisions 12 & 29) Task Force on Evidence-Based Therapy Relationships.

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