Celebrating the LGBT+ community

As this year's theme seeks to showcase the amazing work of LGBT+ staff working across the NHS and other healthcare settings, especially during the pandemic, Rob Agnew tells us, among other things, what inspired him to follow the path into clinical psychology.

What led you to become a clinical psychologist?

So many things, one of which was Agent Dana Scully in X files (who wasn't even a psychologist in the show but she was a queer icon with all the authority and competence that men are usually portrayed as having). But probably the most significant factor was my own experience of mental health issues as a teenager. There was a bit of complex childhood trauma and a lot of undiagnosed ADHD (undiagnosed until well after I qualified), and eventually it developed into pretty awful OCD. It was a really lonely and scary adolescence, and I didn't know that I could talk about it and get help. Also, I couldn't handle the idea that the best I, or anyone, could hope for was luck and spontaneous remission. I eventually went back to university at 21 after a failed first attempt due to my overuse of 'maladaptive coping strategies'.  By this time, with the help of the book Cognitive Behavioural Therapy for Psychiatric Disorders, I had worked on my OCD, was a good deal better and had decided to do clinical psychology.

You've worked in many hospitals during your career. What do you enjoy most about working in a healthcare setting?

I think I'd have to say multidisciplinary working. To me psychological thinking makes the best sense, and is of most use, when embedded in the thinking of other professionals, the patient/client and their family. I love sharing goals, co-creating approaches, sharing achievement, learning from other professionals and the constant reminder to be irreverent to my own 'knowledge' and position.

You've had many roles as a clinical psychologist in neuro-rehabilitation teams. Can you tell us briefly about what this work involves.

Yes, I've worked in a good number of neurorehab settings but I'm not a clinical neuropsychologist by qualification. I've been fortunate to work with and learn from some excellent clinicians. Every neuropsychologist will have their own type of swagger, but in general it's about having an in-depth knowledge of the brain and brain injury, and how that impacts on function, behaviour, relationships, self-concept. It's about having a knowledge of standardised assessment and being able to use that information as part of a formulation to direct and optimise MDT treatment, and to recover and improve psychological functioning after neurological damage. Clinical practice puts neuropsychologists in situations where there is very challenging systemic, behavioural and therapeutic work to be done with the brain injury survivor and their family, who are very involved in treatment and healthcare decisions. Neuropsychologists also have other roles, such as capacity assessment, and must keep a lot of plates spinning when it comes to their skillset.

If a patient you had treated (and/or their family) was asked about their experience, what do you hope they would say about you and the service/interventions you provided?

I hope that they would say that I felt approachable, trustworthy and that they felt they had someone in their corner during the hardest times of their life. The unique selling point of clinical psychologists is that, as well as being trained (or at least until recently) in multiple psychotherapy approaches to a working level, we are also trained to think psychologically. Clinical (and counselling) psychologists can use various approaches and tools to identify what change is safe and meaningful; working specifically towards that within the context of a person's culture, ethnicity, religion, race, sexuality, gender identity and all the other demographics we must consider. It's also vital to give the person you're working with space to exist in the work as they are, not as you need to see them because of the model you're trained in or that you favour.

Is there any work you've done in healthcare of which you are particularly proud?

I designed and set up a service for the NHS treating functional neurological disorder (FND). It was a departure from the standard CBT model and was, to me, a really good representation of what clinical psychology can offer. We used multiple therapeutic models and delivered it as an 8-week group programme. We had incredible and fast results for people who had been living with functional disability for many years. Many left the service able to see and walk again after resolving the FND. I worked alongside an excellent assistant psychologist and physiotherapist, and was steered well by a senior nursing manager. It was a dream situation that I'll never forget.

This year's LGBT+ History Month seeks to throw the spotlight on work of LGBT+ staff during the pandemic? How did the pandemic influence the way you worked?

I was very lucky to be invited to work in setting up an NHS post-Covid service which was hospital based and that really helped me to get things back on track, as I had found working at home extraordinarily difficult. I worked alongside great psychologists, physios and occupational therapists in trying to make sense of all the challenges thrown up in this unknown territory. We were seeing younger, working people needing our services and support although it was older people who were more physically affected. There was a lot of communication, exploration, research and conferring across services, and although it was unnerving, it was a beautiful thing to see everyone pulling together. I was really proud to be a part of that service at that time.

The NHS Staff Survey 2023 highlights the inequalities that LGBTQ+ workers face, saying they have a worse experience of working in the NHS compared to colleagues. Have you faced prejudice/discrimination in your working life compared to non-LGBTQ+ colleagues, for example, with career progression, or witnessed discrimination against other members of the LGBTQ+ community?

I have never experienced direct discrimination in the NHS where I feel that I have been disadvantaged because of my sexuality. But I'm a white, cisgendered man, and job interviews are a context where those privileges outweigh a good bit of any disadvantage. However, I have had to sit through meetings with staff and listen to them describe being bisexual as a state of indecision, I've watched staff object to working with acutely unwell gay people because they were 'too camp', I've seen staff object to using the correct pronouns for a young trans person citing gender critical beliefs as a defence (which it is not) and I have witnessed a general reluctance to making any changes that accommodate LGBTQ+ people (e.g. LGBT+ History Month activities in CAMHS units).

From your experience, what is the impact of violence and/or any form of abuse on staffs' mental health

Caring for people involves some kind of attachment. Authentic attachment is what makes us feel safe. When you attach to someone, and they abuse or attack you, it can be deconstructive to your sense of safety at a fundamental level that is difficult to articulate. I, and many other workers in the NHS, have experiences from our childhood that have left us with issues to live alongside. But even a person without a particularly turbulent background will suffer death by a thousand cuts to their sense of safety and personhood with repeated experiences of violence and abuse. To make it worse, we masculinise the response we have to violence in clinical services, and we often meet it with more violence in the form of restraint. We also, as clinicians, masculinise the expectations of our reaction to it at the individual level. We're expected to just deal with it and get on with things, and if we can do this, we even feel proud of ourselves. But it's important to be realistic about violence and abuse, and to see it for what it is and where it exists.

What kind of support should the NHS offer to staff experiencing mental health problems?

The work that NHS staff undertake is a risk factor for poor mental and physical health. You cannot expect a population of people to deal with injury, illness, mental unwellness, risk of violence, enacted violence, high expressed emotion, abuse and death whilst remaining in a constant state of hyperarousal for between 40-to-60 hours per week, and for it to have no effect. The way we will deal with this without support is to close ourselves off emotionally, and that is not good news for our staff or our patients. The nature of the work in the NHS presents risks that we would otherwise not face, and there surely is some kind of duty of care to ensure that exposure to these factors in the workplace is psychologically safe and to make a meaningful attempt to prevent or undo any harm. That is why the BPS campaign calling for investment in vital mental health and wellbeing support for NHS and social care staff is so important.

Given that at least 1-in-20 NHS staff are from the LGBTQ+ community [NHS Staff Survey -2023], is there any specific support not currently available that you would like to see offered to them?

I think the NHS is receptive in general to the needs of the LGBTQ+ communities. However, where services reach into the lives of LGBTQ+ people, there could be more representation at higher levels so we are allowed to speak for ourselves. In terms of what 1-1 support for mental health and wellbeing the NHS could offer staff, it would be great to see a statement of commitment to providing specifically affirmative approaches for LGBTQ+ staff (and patients). This is an approach that celebrates and validates the identities of LGBTQ+ people, as well as acknowledges the stigma and obstacles that they may face.