A care pathway

Jamie Durrance is Chartered Clinical Psychologist at Rowan House, a specialist medium- and low-secure unit specialising in the care of adults diagnosed with personality disorders, learning disability or developmental disorders, challenging behaviours and/or a forensic history. As we start to talk, in a quiet Italian restaurant in Norwich, she describes her teenage self as 'energetic and driven'. She's thought carefully about what she wants to say, which is good practice for any psychologist about to be interviewed by the media. She's only 33 but has already faced huge challenges and takes time to think through her answers.

'I had a good childhood, though my parents split up when I was five and there was less support and understanding at that time for a family in that situation.' In retrospect, two experiences seem to have influenced her later interest in psychology. 'When I was 14 my stepfather had a terrible car accident and was in a coma for a month. There was extensive neuropsychological damage. He recovered fully but it did change his personality for a while. Then, I had to drop out of my second year of A-levels when glandular fever developed into chronic fatigue syndrome. I didn't handle it well. My mum was an aerobics instructor so I was used to a physically energetic environment. All my peers were having a good time and I had been very focused on going to university to study law and politics.'

Jamie finally did this, after taking her A-levels a year later. 'I went to Keele and after a term decided to leave. The subject wasn't for me and I needed time to regroup. I worked, then decided to study psychology.' What made that choice for you? 'The advice of a friend who is now a clinical psychologist. It wasn't a fully thought-through decision: it just seemed like a good option.'

Theory can't prepare you for practice

'I went to Aston – a big city university – which suited me. I'd grown up in Crediton, Devon so I wanted to experience living in a city.' She says she was 'relieved' when she enjoyed psychology. 'It felt like I'd made the right choice and I started thinking early on about how I could apply what I was learning. I enjoyed neuropsychology, but I think what happened to me when I was younger made me want to specialise in clinical work. A lecturer advised me it was simply too difficult to get onto the clinical course: and that only made me more determined! However, my first practical job convinced me I could actually be a clinical psychologist. And I think that's an important step for anyone considering a clinical route, theory complements practice but it cannot replace it.'

After her degree, Jamie worked in an acute psychiatric ward. 'This was a shock to the system. I wasn't naturally a "fluffy, helping people type person" but found that I did have the people skills to do the job. I also found I enjoyed directly working with individuals who had complex mental health problems and the challenges this entailed.'

Engaging people who haven't asked for help

Jamie's next job, an assistant post in a regional secure unit in Norwich, has helped to define her later career. 'People with complex personality disorders and offending histories are fascinating. You're trying to engage people who haven't asked for help. There's a constant tension between establishing a healthy, trusting therapeutic relationship and making recommendations on risk. You have to deal with extreme emotions, including personal attacks. This requires a great deal of self-regulation and the ability to focus on the underlying vulnerability of your clients.'

Jamie studied for her doctorate at the University of East Anglia after a year as an assistant, during which she completed a number of standard placements. 'I enjoyed most of them but found myself enjoying working with adults who experienced severe and complex mental health problems the most. I was also becoming more and more interested in both group and individual therapeutic approaches in which interpersonal relationships were a key part. My thesis was on the influence of personality disorder traits on emotional regulation strategies and psychosocial functioning within individuals diagnosed with clinical depression. The academic side was very intense.'

Thinking about thinking

Following her doctorate, Jamie worked for another year before joining Rowan House, where she's been for the last three years, a year of which was spent working half-time in order to also work part-time within a local NHS acute service. 'Rowan House is run by Care Principles, originally a service set up in 1997 for those with learning disabilities. Care Principles now operates 17 secure hospitals, community hospitals and care homes offering specialist services for a range of mental health and developmental disorders. I work in the medium-secure service treating males aged between 18 and 65 who have a diagnosis of complex personality disorder with co-occurring offending behaviours. This was set up by Ron Tulloch a few years ago. Our patients are often referred from prisons and other psychiatric hospitals, including high-secure hospitals.'

'Our Personality Disorder Unit is currently quite small – although there are plans for expansion to provide a care and treatment pathway – but we offer very specific treatment. We deliver to a structured timetable, including intense group and individual therapeutic sessions, and all staff work closely together as a team to help create an environment in which safety, containment and stability is the focus. Almost all of our patients, by the nature of their diagnoses, will have experienced chaotic, disruptive and abusive early life experiences that have led to insecure attachment patterns and high levels of unregulated emotional reactions. Therefore, we provide them with medium- to long-term treatment which enables the provision of a secure base and clear, boundaried feedback on their behaviours.'

According to Jamie, consistency is critical across a multidisciplinary team. 'A couple of hours therapy a week delivered by a lone psychologist won't work with our patients, and so all staff have to be clear about what we're trying to achieve and how we're going to go about it. Our patients are often quite clever at driving wedges between team members, so we must be cohesive. In addition, there's a real danger of staff burnout, so regular formal and informal supervision and support is a must.'

Since the main approach to patients' conditions is psychological, Jamie sees herself as a leader within the team, '…which I guess suits me as I'm naturally someone who likes to lead rather than follow. But I'm not a know-it-all! I learn every day and, in my view, if you're not learning you're not helping. You learn about patients and you learn abut yourself. Self-reflection is a critical tool. You have to be honest about your mistakes and flaws, look at your own reactions to often highly emotional situations. In a sense we're teaching patients meta-cognition – to think about their thinking – and staff have to practise that as well. It should be a skill psychologists can offer in a variety of situations. Your own therapy helps you here. Constant self-evaluation can be draining, but I enjoy it. The more awareness you have of your own approach the better.'

Outcomes are important to Jamie and her work. 'You can take people so far in a medium-secure unit. Our idea is to be able to move patients through a care pathway. Ideally, we are aiming to develop a low-secure unit for patients to progress to, offering the consistent support of the same key professionals in an  environment with less security and more community access in which to "test out" what they have learnt.'

There's still so much to learn

Jamie's comments – in the now busy restaurant on Norwich's newly refurbished waterfront – highlighted a tension between her real drive and commitment to her work and a sense of how demanding it is, both physically and personally. I raised this with her and, after a hesitation, she began to recount how important this issue is to her personally. 'I became very ill two years ago. I won't go into detail but I was young to get the condition. I had fantastic support and also engaged in my own course of psychotherapy in which there was an emphasis on mind-body links. After this I went back to work part-time for a while. The whole experience has affected how I balance my professional and personal life and my approaches as a therapist. You do need time to "smell the flowers" and there's a danger for psychologists, particularly in the sorts of the area I work in, that you let your life get out of balance. As I said at the beginning, I have always been quite driven, but there's more to life than a career. So it's nice to sit here and talk it over!'

And the future? 'I'm going on after this meeting to an interview for a diploma course in cognitive analytic therapy. I want to do a little bit more academically and I'm in the process of writing up some case studies. As ever, I'd like to get more feedback on what I do. But I don't see myself as moving away from patients with complex personality problems. The last ten years have seen personality disorder move back to the centre of clinical work and, increasingly, of psychological practice. There's still so much to learn.'