One on One with consultant clinical psychologist and responsible clinician Dr Rachel Holt

Can you tell me a bit about your background and what inspired you to pursue a career in psychology?

I initially did a mathematics and philosophy degree at Cambridge University. After graduation, I worked for the Medical Research Council Applied Psychology Unit. I did data analysis, working alongside a psychologist who researched how brains function after stroke. I thought, 'hmm, this psychology stuff is interesting'. I then took a psychology diploma at London Guildhall University.

Why were you specifically drawn to clinical psychology?

I have a friend who is a medic; for years, we met one evening a week to run together. She talked about working with clinical psychologists, and said that she could imagine me as one. When I looked into it, I was told that the clinical psychology doctoral training was extremely competitive.

I was doing a lot of voluntary work at the time with young people at risk, via projects including detached youth work. So, I thought I would apply for clinical training once; and if I was unsuccessful, I would apply for educational psychology next. I was somewhat surprised when my clinical application to the University of East Anglia was successful.

You work as a consultant clinical psychologist and responsible clinician within a Forensic Intellectual Disability Community Service; what does your role entail?

Being a responsible clinician is a role more commonly associated with psychiatrists, but it is a role that can be undertaken by a variety of professionals, and isn't medical. 

Being a responsible clinician means that I have a legal role in relation to service users whose rights are restricted under the Mental Health Act. This includes leading on their care, completing legal paperwork, writing reports and presenting at tribunals, and reviewing and renewing their legal status; as well as working with inpatient settings for handover of responsible clinician when service users are admitted or discharged.

I use psychological models to lead my understanding of difficulties that are brought. This then guides interventions that may include individual intervention, but also involve supporting those around a person to engage with them in more helpful ways. I particularly draw on narrative models.

Initial descriptions of service users are problem-saturated, focussed on someone being disabled and dangerous. I seek to encourage exceptions to those dominant narratives – perhaps noticing when a person is helpful, kind or skilled – and using these to support development of pro-social parts of the person's identity.

And what does a typical day look like for you?

I spend a considerable proportion of my time chairing multi-agency meetings as we plan and review treatment pathways for service users. These meetings can include the person; their family; their advocates and solicitors; as well as health, social care and criminal justice agencies. 

We were delighted to have additional investment in the service a year ago. I meet regularly with commissioners to discuss, agree and feedback on how we are developing the service in response.

I also work with a small number of service users for direct therapy; provide training; co-create Positive Behaviour Support (PBS) plans; supervise trainees and qualified psychologists; and all the varied tasks of a psychologist in an intellectual disability setting.

What do you most enjoy about your job and what do you find most challenging?

The service users I work with have often experienced extreme trauma, and are now both vulnerable and pose a risk to others. Their lives are disempowered. When you're under the Mental Health Act, your responsible clinician is involved in most decisions about your life. When you're an offender, it can be hard to seek recourse if your rights are breached. When you have an intellectual disability, you live in a society designed for people without an intellectual disability. 

I want to do things in my professional life that address some of these inequalities, and give opportunities to everyone to be seen for the good they do and not solely for their worst actions; and to live meaningful lives where they are neither at risk nor a risk to others. When I manage to move towards this, I enjoy my job; and the times I don't, I find challenging.

What would you say a highlight of your career has been?

I worked for two and a half years as a responsible clinician in an intellectual disability medium secure unit, and during that time co-produced a service improvement suggested by a service user to bring equine therapy to the unit.

I knew nothing about equine therapy at the start; he guided the entire project. I was astonished at how effective equine therapy is. I am convinced that working with horses in that setting can be streets ahead of therapy without horses. We couldn't have done it without practical and financial support from the Trust. I sometimes look back and think: 'did we really bring horses into an MSU?' It was a fabulous project. 

Can you share a piece of work or development that has really changed or shaped your practice?

I qualified over 20 years ago, and a major change in that time has been the realisation of the need to decolonise our profession. I am acutely aware that I am in my role because of my white privilege. The continual need to face my own and structural racism is a challenging and urgent task, that I was less aware of earlier in my practice.

What is one thing you would want aspiring clinical psychologists or indeed early career psychologists to know?

Thanks to my career, I get to spend time with people who are hidden from much of society, and who I wouldn't come across otherwise. This is an absolute privilege. I have learnt more from my service users than I could ever give, and am hugely grateful for their generosity towards me.

Fauzia Khan is a Graduate Member of the British Psychological Society and Host of the 'Fauzia Khan interviews…' series. She currently works as an Assistant Psychologist within the NHS, whilst completing her Doctorate in Counselling Psychology.

Twitter: Fauzia = @itsFauziaKhan / Rachel = @RachelHH5