‘Look for small increments of change, not cures’

Nick Maguire (University of Southampton) talks to Ian Florance.

Dr Nick Maguire’s research profile on the University of Southampton website begins ‘My main research activity reflects my clinical interest in the mental health issues implicated in homelessness’. How can research underpin psychological practice in real-life areas? Nick offers compelling answers to this question and paints an exciting view of psychology’s future.

He begins by admitting ‘I probably wouldn’t get in to study psychology now. The quality of students has gone up and it’s a much stronger discipline.’ Yet back in 1992 Nick was accepted onto the course at Southampton. ‘My dad was an engineer and science has always been important to me. I was originally interested in chemical engineering but was something of an academic failure, and starting to work with people interested me in psychology over time. I left sixth-form college with just a couple of poor A-levels but did evening classes.’

Nick knew very early on that he wanted to qualify as a clinical psychologist, ‘though I had no idea how difficult it would be’. He worked in the NHS after graduating then applied for a clinical course.

‘Doing Sociology and Psychology A-levels at evening class made me realise there are many different ways of approaching a problem. That helped me hugely at university, where it was writ large that there was no one right way of approaching a psychological issue. I think that’s one of the strengths of our training – at an undergraduate level you’re taught to think critically and scientifically and later you’re made aware of meta-cognitive issues. Only a few other disciplines, such as sociology, do this.’ I’ve noticed that many employers of first degree psychologists in non-psychological jobs comment on this ability as one of newly graduated psychologists’ key skills.

What other areas influenced Nick? ‘I thought a lot more about serious mental health issues – my thesis was on psychosis and paranoia. I was and still am an empiricist at heart, so when I trained I wasn’t too impressed with people at the time practising psychoanalytic approaches. They seemed to be making empirically unsupported assertions. I think that situation has changed recently, and there’s good research looking at their effectiveness.’

Psychology needs to democratise
‘I always wanted to be a practitioner and, although I work in a university, I don’t see myself as a full academic. I bring a research base to practical problems. I do some management work at the university and clinical training informs that – management seems often to be about engaging people in the process of change and that is a basis of much clinical client work. I find the simple Prochaska and DiClemente model of change very useful in my work.’

Nick believes psychology has a central role in reaching out to excluded groups. ‘That is a significant strength of our discipline. My interest is focused on homeless people but increasingly we are drawn to other marginalised groups – some ethnic minorities, vulnerable migrants, sex workers, travellers – groups which themselves overlap. All of us fluctuate, go up and down, experience mood swings and sometimes more serious mental phenomena. But some of us get access to mental health professionals and some don’t. As a discipline we need to stretch what we do and where and how we do it, and, in that sense, psychology needs to democratise.’

Nick’s therapeutic interests are in CBT and DBT. ‘They are based on empirical, commonsense theories and you can get them across to people easily. If you’re going to help people address significant issues in their lives you have to provide them with tools they can learn quickly and which have an effect. CBT and DBT to some extent work in this way. They’re clear about how change takes place and enable people to make those changes.’

Fail better
Nick tells me that there are 40,000 homeless people in UK hostels. ‘More money became available for this issue in the early 2000s when the Labour government pledged to reduce homelessness by two thirds. A local charity, the Society of St James, got funding for a four-bedroom hostel and needed CBT help. I got involved and found that I was seeing the same problems in homelessness as those clients I was seeing when working in a community mental health team. It was clear that psychology’s urgent role in this area was to deal with issues which led to antisocial or asocial behaviours, which in turn led to eviction – drug taking and drinking for instance. Hostels have to have risk protocols that identify behaviour requiring eviction. That’s understandable for staff and client safety, but you also have to understand that risk protocols are a component in the problem of homelessness. The key is to help people formulate an understanding of why they’ve done what they’ve done – a central tenet of clinical psychology.’

Nick gives an example of a drinker who may have very low motivation to give up. ‘He might say “My Dad was a drinker, I’m a drinker. I’m never giving up.” By working with him you find that it’s a feeling of unfairness that causes him to switch from strong lager – which is his usual drink – to spirits, which are more likely to reduce cognitive functioning and increase likelihood of antisocial behaviour and lead to eviction. The issue then is to get someone in this position to commit to drinking spirits less. There’s no cure involved here. I often tell students that if you try to work to a curative model you’ll burn out in a few years. You look for small increments of change, not cures. And success, however that’s defined, is great when it comes. But the key is to fail better.’

Towards the end of our conversation Nick mused, ‘The further I go into this, the more I work with, among others, the homeless, the more I realise that an evolutionary attachment model is key to understanding damaging behaviours. You can see a link between attachment processes, abuse, problems with emotional regulation and how this leads to destructive behaviours. We have a lot of data on this and hope to write it up when I have more time.’

Nick returned to his view of psychology’s future as a means of including those who are excluded. ‘Psychology is moving away from primary care – issues like mild to moderate anxiety and depression are being dealt with adequately by IAPT. Psychology should be looking for new methods delivered in new ways to new populations in new environments. We need to be engaging excluded populations, such as people who are homeless, more proactively, for example using more imaginative communication methods than letters, and working where clients are, not just in NHS clinics. Our services should be as flexible as possible, delivered where people live or go, such as hostels or day centres.’

But he’s still very firmly an empiricist and demands evidence of efficacy. ‘I do a lot of work in this area with charities and also with commissioners. I’d like to see commissioners increasing their evidence base. I expect to be asked for evidence when I propose a programme or intervention. If I’m not asked for empirical evidence I wonder on what basis the decision is being made and whether we’re using other people’s money well.’

His future follows on from these concerns. ‘I want to serve this population better so my goal is to set up a Centre of Homelessness Research. Not for its own sake but so it can inform practice. I aim to use university resources and knowledge to serve client needs. Research in whatever form and practice should always go together.’

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A great quote by Nick, from the nudge tradition, but extremely pertinent to most applied psychology and a useful way to present and discuss with clients, customers, stakeholders or end users. Also, a pleasant article to read and empathise with.