Relationship over Technique or Technique over Relationship?: Reflections on a Conference on Psychological Therapies in the NHS

Clinical Psychologist Chris Clinch presents a personal summary of his experiences at the DCP South West Conference in February 2016

Chris Clinch (Clinical Psychologist in Somerset) writes a personal summary of his experiences at the conference, which was then shared through the Division of Clinical Psychology network and reproduced here with a light edit by Mary O’Reillly:

This conference was partly hosted by the BPS and had some high level contributors from government and the NHS. We were therefore offered a glimpse into the ‘bigger picture’ of how well mental health is understood (or not) by those in positions of influence. My role for DCP South West was to report back and to expand the conversation via twitter. I was new to this and may have got carried away in the twittersphere but it was, after all #timetotalk.

Tweet: Perhaps looking after the workforce is actually the biggest challenge for the NHS

Professor Sir Simon Wesley, president of the Royal College of Psychiatry reminded us that the NHS can be a painfully difficult place to work and began the key theme (for me at least) that ran through the two days: The currency of our work is compassion, relationship and understanding. We need to receive the same compassion and understanding from our organisations if we are to provide it.

Tweet: Effective care happens when there is safety, relationship, understanding and a whole person view.

You can, of course decide to do away with compassion and understanding, as if it is a luxury which the NHS can no longer afford. You might instead adopt the narrative of productivity, where generic workers become more like technicians administering doses of therapy than whole people trying to understand other whole people within relationship. However, the evidence is that you might end up with large percentages of therapists who feel depressed or like failures (BPS survey of 1400 therapists, also reported in The Times) and (surprise, surprise) your therapy will be less effective and recovery rates will be lower (Prof. David Clarke, head of IAPT slides). Whilst Alistair Burt MP saw IAPT as a world-beating success, Jeremy Clarke CBE, Therapist and Chair of Ministerial Advisory Group for Mental Health didn’t hold back on this – he said that IAPT ‘needs to understand why it hasn’t worked.’ My conclusion was that the thinking behind talking therapies is psychologically sound, but the impact and sustainability of the project has been undermined in organisations that have lost sight of relationship and the need to be flexible and person-centred in how it’s delivered.

Tweet: Care suffers amidst mistrust, disconnection, toxic organisation and reductionist approaches

Mathew Patrick, Chief Executive of South London and Maudsley Trust put it well, when he described the ‘soufflé phenomenon’, where an organisation can present itself as buoyant and uplifted by new ideas, whilst the centre is in fact collapsing. How refreshing to hear him say ‘we have to engage with staff on the front line – their lived experience is hard. They are sensitised to rhetoric’. In truth, it was alarming to hear the results of the BPS survey, but the formulation wasn’t hard to sketch out – people like us who are experiencing deteriorating services, poor employer engagement and loss of autonomy are struggling. What is more, to use a CAT therapy phrase, it’s ‘out of dialogue’. Dr Claire Gerada, head of College of GPs @clarercgp was candid, calling the government on “the madness of double speak and lies in calling ‘cuts’, ‘efficiency savings”.  The BPS charter for psychological staff wellbeing and resilience was presented as the start of a fight back. This wasn’t just lip service, whichever way you cut the cake the evidence is that looking after and developing staff seems to make sense – in terms of recovery, financially and ethically.

Tweet: @PaulBurstow: ‘We have to embed supervision and reflective practice if we want to serve the people we serve’

Conference was partly reassured by various speakers that psychologists could be an important part of the solution. Karen Turner, Director of Mental Health at NHS England seemed to say better line management was needed (slides) although I couldn’t help thinking good supervision and fewer cuts might be more effective. Surely we are well placed to understand the client holistically? Who can model reflection? Who can support colleagues to thrive (or perhaps survive) via good supervision? Who can provide the evidence of effective intervention?

There was much talk of parity of esteem between mental health and physical health. This was of course encouraging, although at times I worried that some speakers therefore mistook mental health as essentially ‘the same’ as any other physical health issue, with organic causes and medical solutions. Technique over relationship. Surely this is the path to prescriptions for call centre therapy and overwhelmed staff who feel like they are failing to cure their ‘patients’? Prof David Haslam (Chair of NICE) slides made great efforts to challenge this, stating that we should not be involved in ‘cookbook medicine’ and that NICE guidance ‘should be made meaningful for the individual service-user’ by a generalist clinician (sounds familiar?). Relationship over technique.

Tweet: Lord Freud, Minister for welfare reform says ‘promoting mental health in govt has been wading through treacle’, but things changing

To be honest, Lord Freud, millionaire banker with the job of pushing through unwelcome welfare reforms, the guy who suggested people with disabilities are ‘not worth’ the minimum wage, was going to have a tough time here. He coped with it well….by not taking any questions and leaving by a side door. However, he did give an insight into how government is coming round to an understanding of the importance of addressing mental health. This may be because it is expensive for people to be claiming benefits and not working, but nevertheless mental health is now being taken seriously in the right meetings. This was echoed by Alistair Burt MP Minister for Community and Social Care, who said he is ‘chased relentlessly’ by Luciana Berger MP (Shadow Minister for mental health) and Norman Lamb MP (ex-minister for health) on these issues. Paul Burstow (another ex-minister for health, now an NHS chief executive) advocated for parity of esteem for mental health and physical health and I was left thinking that these voices would be more valuable in government, rather than in opposition.

I felt that, despite my scepticism, these leaders ‘got it’ and were pressing a narrative in the right meetings with the right people. Luciana Berger in particular seemed to be an ally of Psychology. She called for a ‘mental health impact assessment’ on ministerial decisions, and was prepared to criticise the NHS for complacency around IAPT. She suggested that the drop out rates are too high (26%) and recovery rates for anxiety and depression were modest for those who remained (45%). In a similar vein, she recognised the trend towards ‘call centre IAPT’, which she considered ‘not for everyone’. I said under my breath, ‘should call centre therapy be for anyone?’

Paul Farmer and Jaqui Dyer, chairs of the Mental Health Taskforce urged us as professionals to read, discuss and promote their report (see link), which represents a five year plan to address the predicament of mental health services. They reminded us that MH has not been a priority in health, but there is a real window of opportunity. For Jacqui Dyer, her own therapy was ‘a lifeline to who I am and who I could be’. Well, she found out that she was an expert by experience and a black woman with power. What she ‘could be’ turned out to be a truly influential voice where it matters because of her experiences and insights, not in spite of them.

There are several other important presentations from the conference still available, such as the Manchester model of integrated care and Peter Fonagy on Children’s Services / CYP IAPT’s Future In Mind report (slides).’

Chris’s hope is some of this motivates you to follow some links to other discoveries. He found the conference to be confident and outspoken, which contrasted with the psychological voice nearer home. It was refreshing to look outwards and reflect on some of the values that sustain us as Psychologists. This is what the DCP exists for locally and nationally: we can be stronger as a collective voice.

chris.clinch@sompar.nhs.uk

Image: Jo Hemmingfield, the DCP Experts by Experience English Lead, makes a point during one of the conferences sessions:

Tough Mudder Challenge: Third Year Trainees Support MIND’s Get Set To Go Initiative

Reflections on the benefits of exercise and psychological well-being

In a time of stress and juggling multiple demands whilst writing our theses, a few of us third year Leicester Trainee Clinical Psychologists have reflected on our experience of the benefits of physical exercise in supporting our own wellbeing. We feel that our anecdotal evidence has shown the benefits of being active, for example in sustaining the motivation and concentration required to undertake our doctoral projects. Physical pursuits have included hiking, running, cycling and gym classes and for us these are all culminating in taking part in a national event called Tough Mudder (more on that later!). These activities have injected some balance into what could have had the potential to be a time of very narrow focus for us and they have been an invaluable source of stress relief.

Many people have questioned why we would not prefer to sit at home and relax or socialize with friends as a way of relieving stress, and giving the left side of our brains a break from this intense work period (we do of course do that too!). Being fairly fit and healthy individuals, we have all had personal experience of taking part in exercise/physical activity and reaping the rewards both physically and mentally. The post-workout buzz and social benefits are perhaps for us the most rewarding parts of this current challenge. This made us think about what we know about mental health and the benefits of physical activity…

In our clinical work focusing on promoting exercise/physical activity and supporting individuals to get out and about, is possibly neglected at the expense of focusing on the core underlying difficulties within our client’s psychological worlds. Without invalidating the role of the latter, in our recent challenges, we were reminded of Maslow’s (1943) hierarchy of needs, which points to our basic physiological needs (i.e. being fit and healthy), as being one of the fundamental building blocks to our overall psychological wellbeing.

Physical exercise has been linked to a number of positive mental health outcomes including: reductions in depression; anxiety; and improved cognitive functioning (Callaghan, 2004). Of course, many factors will be at play including the rush of endorphins throughout the body, the impact of feeling connected to others and associated health benefits, including weight loss. More generally, exercise has been linked to brain health. Exercise can improve brain plasticity, even in elderly populations and can reduce risk factors for a number of age-related diseases (Cotman et al., 2007). There are also cognitive benefits; exercise quite literally has been evidenced to ‘jog’ our memories!

Furthermore, the benefits of taking part in group activities such as themed races extend to the comradery and idea of ‘being in it together’. The key message conveyed by the Tough Mudder organisers is one of team work and support; it is about crossing the finish line together, not who gets there first. In challenging times, the benefits of social support have been shown to help those with mental health difficulties combat isolation (Anderson et al., 2015) and improve psychological well-being (Cohen, 2004; Kawachi & Berkman, 2001). There continues to be an air of stigmatisation surrounding mental health which is likely to compound the loneliness that one feels (Oliveira et al., 2015). Having the opportunity to connect with others in a similar situation is invaluable; even more so in sports activities where there is a common goal or target to collectively reach.

Drawing on the support of others to work towards that finish line, whatever that may look like, can only serve to build companionship and togetherness. This echoes our experiences, as we have found that the process of immersing oneself in a research project can be quite isolating. Through the experience of various physical activities we have been able to connect with others, have a sense of purpose and improved self-efficacy. I’m sure you would agree that the latter is of great value, particularly during times when it may feel like other parts of life are being neglected.

Despite the evidenced benefits of exercise and our own personal experience of the positives of being physically active, the UK is reported to be the third most inactive population in Europe, with two thirds of adults failing to take part in enough physical activity to maintain good health (Heath et al., 2012). It is not then surprising that physical exercise is a neglected area within mental health work (Callaghan, 2004), given our national reputation for being fairly sedentary and sloth-like.

All is not lost… The Millennial generation of today (those born in the 1980s and onwards) are showing increasing interest in a range of new fitness trends. Being native to the new ‘digital instant satisfaction’ mentality of the world we live in, us 1980s babies have grown up in a society that craves instant feedback, satisfaction and reward. Knight et al. (2015) have suggested that millennials are perfect examples of experiential learning theory i.e. learning through direct experience. Outdoor recreation is one such example, where individuals learn through practical experience and gain direct feedback about how they have performed. Themed races such as Colour, Tough Mudder and Zombie runs are becoming more popular, particularly with younger generations (Knight et al., 2015). Lorraine and Meghan took part in the Derby Colour run around the grounds of Chatsworth house earlier this year. The ethos of the day was not about competition but about taking part, and most importantly getting the most amount of dye thrown on you as possible! This was followed by a ‘dye party’ where even more colour was spread and everyone joined in together to create an atmosphere of achievement, triumph, freedom and fun!

 As we mentioned earlier, we are currently training and preparing to get very muddy, as we have entered Tough Mudder 2016! We wanted to acknowledge how exercise has helped us through the DClin Psy course by setting up a fundraising page for the Get Set To Go initiative set up by the charity MIND. Get Set To Go aims to promote exercise for individuals with mental health difficulties. The aim is to find the right activity so individuals experience not only the physical but the mental and social benefits of sport. The Get Set To Go initiative started in 2015 and is currently supporting individuals in eight different locations across the UK. We have all found an enormous benefit from staying active and wanted to support the Get Set To Go initiative, to help others experience the same. If you feel you would like to donate please follow the link:

 https://www.justgiving.com/Meghan-Thurston2

 Lastly, we wanted to spread these ideas and would welcome comments and personal reflections from others, about times when being physically active has helped in supporting individuals through challenging or demanding times.

‘Run when you can, crawl if you must: just never give up’ Dean Karnazes

Andrew, Laura, Lorraine and Meghan

(Third Year Trainee Clinical Psychologists)