Careers - ‘People often need to tell very painful stories’

Ian Florance speaks to Antonia Bifulco (Middlesex University and the Centre for Abuse and Trauma Studies

Professor Antonia Bifulco lives in Acton, an area I don't know that well. It turns out to have a huge number of rail and underground stations, but none of them are near Antonia's house. Acton Mainline, where I arrived,  is one of those long platform, windswept, unsheltered, closed ticket office and thoroughly unwelcoming versions of the modern rail station. After a pre-Christmas walk through what proves to be a fascinatingly varied, diverse and lively suburb of London, I arrived at Antonia's house. By contrast to the station, she couldn't have been more welcoming.

Antonia is Head of the Psychology Department at Middlesex University as well as co-Director of the Centre for Abuse and Trauma Studies (CATS). Our talk was long and fascinating, so I can only touch on some of the themes.

You need to collaborate to explain                            

'I grew up in Derby. My father was Polish and became a computer programmer after serving in the Special Operations Executive (SOE) during the war. My mum was a teacher.' As a teenager Antonia was interested in psychology and philosophy 'and so I studied them on a combined degree at Exeter. There were only four people on the course and I married one of them! The degree was half science, half arts. I'd been pre-warned about the statistical elements of the course which I still found difficult. I also have a rat phobia so I was glad there were no classic rat experiments! But I got really interested in mental health issues and also in personality. Professor Paul Kline was at Exeter and was looking at whether psychoanalysis was testable. I found that fascinating.'

Like a lot of people finishing their degrees Antonia applied for a clinical course but didn't get in. 'We moved to London, and I saw an advert for a PhD in social science linked to a major multidisciplinary research project looking at the role of the early loss of a mother in the onset of depression. I had to take  a Diploma in Sociology at Bedford to prepare for the PhD work.'

Like many other interviewees in this section of The Psychologist, Antonia pays tribute to specific individuals who influenced her career course. In particular she mentions George Brown, who was Professor of Sociology and Director of the Social Research Unit at Bedford College, University of London, together with Tirril Harris. 'Their book Social Origins of Depression was published in 1978, exactly the time I was starting at Bedford. It argued that, at least in part, life events provoke mental disorders, but only amongst those with vulnerability. This has had a huge influence on my approach. Much recent psychological thinking and application downplays the influence of the context of people's life events; it concentrates on within-individual processes and, increasingly, on genetic explanations.'

Antonia explains that she did her PhD at a time when sociological and political factors in their widest sense were factored into psychological accounts of human beings. 'Since then, '70s feminism, gender studies, a focus on culture and ethnicity studies and other approaches have influenced how psychology has developed. More recently computer models, scanning, cognitive approaches and of course genetics have, in turn, affected it and the sociological influence all but disappeared for a while. But things are changing. I'm particularly excited about the findings of epigenetics – that environment can cause hereditable changes in genes and that these changes can be investigated. I think people who take my approach always knew this but it's wonderful to have it confirmed and it opens the way to new research, new explanations, new ways of helping people.'

This early research experience influenced Antonia in a number of other ways. 'You need more than one type of knowledge and disciplinary approach to do research well and creatively. At the time – the late '70s – the Bedford research group comprised influences from sociologists, anthropologists, psychologists, psychoanalysts and others. The need for multidisciplinary and multi-knowledge working has grown as issues have become even more complex since. You need to collaborate to explain.

'Our research took place in the London community, not within institutions or with patients. This reflected George Brown's thinking, as did our use of biographical interviews to generate base material for analysis and research. George hated questionnaires, he liked talking to people and preferred narrative interviews. It seems odd to think what a new approach that was back then. We felt we could talk to people, find ways of analysing what they said and generate genuinely useful conclusions about how life events and lifespan vulnerability affected subsequent behaviour and mental health. Underlying this approach were a number of principles. We took people seriously, working with them rather than on them. We didn't assume that we knew better or that their accounts needed expert interpretation – after all, they were the experts on their own lives. We were not letting structure, analysis or our hypothesis distort the evidence we collected, something I still feel is critical and underappreciated.'

Antonia gives an example from this earlier research. 'Our hypothesis was that losing a parent when young was a major cause of depression. But the interviews kept turning up other life experiences which had some sort of causal relationship with depressive states, and we couldn't ignore that. In fact, what we found was that it was the quality of care and abuse that influenced the later development of depression rather than the actual loss of a mother. John Bowlby's concept of attachment became a key explanatory concept for all this and features heavily in much of the work I'm doing. This involves organising courses in attachment styles, childhood abuse and neglect and parenting for both researchers and practitioners.'

I think of myself more as a psychologist nowadays

'Increasingly, I have become interested in applying research to practice. In addition to the areas I've mentioned, I'm working on training and development activities designed to introduce more story-based interviews to a variety of professions. Social workers take to it easily – it gives them more stringent analytical tools to deal with their usual approach. Family therapists also like the way we go about things. Many clinical psychologists find the method too lengthy, though it is based on existing clinical interviewing. I suppose that the fact it hasn't been recognised fully yet for CPD in psychological services hasn't helped its acceptance.'

Antonia is unusual in that she worked on the same topics and in the same institution (she stayed at Bedford College and then at Royal Holloway College when the two colleges were merged) from 1977 till 2010. 'In the last 13 years I've looked at risk factors with many different age groups in the Lifespan Research Group at Royal Holloway.' But in 2009 she became co-Director of the Centre for Abuse and Trauma Studies (CATS) at Royal Holloway. 'This resulted, in part, from meeting Julia Davidson. She is a criminologist and is interested in offenders. At the time she was doing work on online grooming. I had a small research team within my Lifespan Research Group and we were interested in victims. You put the two areas of interest and our experience together and you have an interesting and very unusual approach. There's not a simple dichotomy here – often offenders have been abused and even in community settings victims can become abusive in close relationships. We used the word trauma to extend the type of experiences and stress we studied.'

At first the centre was spread across Royal Holloway College and Kingston University where Julia worked, but it became easier to move the whole thing to Kingston. More recently it's moved to Middlesex University 'which is very go-ahead. It's investing in research and research centres. It's a terrific environment to work in at Middlesex. But it has also offered me a change in my career: in addition to co-directing CATS I'm now Head of the Psychology Department as well.'

I suggested this must be quite a big change for Antonia. 'Yes, up until now I haven't gone down a management route. I've been able to be independent and take a rather maverick approach. A year ago my husband died and I felt the need for more stability. The role which includes forensic and health areas in the department – ones I already had an interest in – fit well with what I want to do. I can also work with a much bigger group. So the experience is helping me to see psychology as a discipline more clearly. Like other people who've specialised in social psychology or who have a sociological approach to the discipline, I've not always felt at home in purely psychological environments in the past. That's changing. I think of myself more as a psychologist nowadays and feel I want to help the profession, give something back to it, rather than sit on the periphery. If that means getting involved in administration and some bureaucracy, then so be it.'

Psychology is under threat…but I'm optimistic
Given Antonia's wide experience and new role what's her view of psychology now?  'I think it's under threat as a critical service. There is less recognition of its distinct value in relation to medical or social work, and psychologists in children's services are having a hard time. CBT has, to some extent been farmed out and a lot of provision has moved into the voluntary or private sector.'

'But, despite all that I'm optimistic. Our courses are full. It seems to me that we're raising a generation in a society which is much more psychologically literate than previous ones. Psychologists are very employable and have very good transferable skills. They are excellent methodologists but we need to talk more about the non-quantitative techniques like the narrative interviewing I'm so interested in. One current challenge is finding ways to use technology to assist with this. Psychologists are reflective, they think about what they do. They're also very good at understanding and applying ethics, something employers are crying out for whether employing fully Chartered Psychologists or someone with a first degree in the area. My approach to research demands very high ethical standards as narrative techniques lead you into areas you can't predict. But I'm very much against the wilfully deaf school of ethical thinking which says "Don't ask as it will upset people". You need to respect people and understand that they often need to tell very painful stories.'

And other research? 'I have a database of over 500 life stories resulting from research. In a sense they're a sort of psychological mass observation resource. I'd love to find a way to make these available electronically to other researchers…' 

Becoming a health psychologist – the story so far

Establishing a career in psychology can seem a never-ending process. Belinda Hemingway examines her journey so far to becoming a health psychologist, with all its highs and lows. 

Health psychologists still struggle to be fully understood by those outside the field, so championing and promoting the contribution health psychology can make to a range of services is important.

I currently work as a team leader for two complementary services in Surrey – a mental health promotion service and an IAPT Step 2 service – but my journey started at school when I developed an interest in studying the mind and behaviour. Unfortunately my school decided I didn't meet the entry requirements for psychology A-level but I successfully got onto a BPS recognised honours degree after my A-levels.

The only careers routes mentioned during my degree were clinical, forensic and occasionally occupational psychology. I decided the clinical route would give me an all-round view, enabling me to specialise in the future if I wanted to. I had already gained experience of mental health issues by volunteering at a MIND centre supporting centre users. But, once again, I was diverted by educational advice. A university careers adviser regaled me with tales of students who'd failed to get onto clinical training, and more or less suggested I pursue other options such as HR. This didn't appeal, and I left university not really knowing what to do next.

I spent three years travelling, working in temporary jobs and exploring other training options, including occupational therapy. My sister heard about the new MSc in health psychology from some friends and realised it fitted with my developing interest in applying psychology to physical health. It focused on the promotion and maintenance of health and the prevention of illness, as well as on improving the psychological impact of acute and chronic health conditions. I got a place on the course and completed in a year. Whilst studying, I volunteered for a sexual health promotion project, where I ran the drop-in service, providing students and staff with advice and information on sexual health. This provided me with a focus for my MSc dissertation.

My cohort qualified just before the Stage 2 competencies were introduced and we thought that, as the MSc counted as Stage 1 of the qualification, Stage 2 would involve a similar amount of work. We were shocked to find out it meant doing the equivalent of a PhD!

Building up work experience

Faced with this obstacle, I decided to build up my work experience. I temped in local hospitals for several months and in 2002 gained valuable experience of working with multidisciplinary teams on a variety of projects through a temporary role in a clinical audit team. After six months I began working as a permanent research fellow in cancer care within a large research and development department. I managed two sizeable projects focusing on the assessment and alleviation of symptoms and problems in cancer. I also volunteered to help run a cognitive behavioural therapy course for adults experiencing anxiety, depression and low self-esteem. These experiences re-inspired me to pursue a psychology qualification.

I thought about the Stage 2 route, but it still felt like a lot of investment for not much gain, so once again I abandoned the idea.

I wanted to explore how health psychology could help in cancer and other life-threatening conditions. The new graduate primary care mental health worker roles seemed a great opportunity to gain both experience and a qualification in primary care mental health, plus a chance to increase my knowledge and skills in therapeutic work. I secured one of these roles, but it wasn't for me. The patient work had little structure and I felt GPs didn't use our expertise well.

A new position in the same department built up my experience in health promotion by developing, delivering and evaluating health projects in partnership with local agencies, to improve health and reduce inequalities for young people. Over three years, I worked in schools and youth centres, created and delivered training for professionals, and championed young people's participation in service delivery. This was followed by a year spent developing and delivering a range of behaviour-change programmes for a children and young people's healthy living and obesity prevention organisation. I then had a lucky break when I was offered an NHS maternity cover position in health promotion strategy. This experience in health promotion, behaviour change, training delivery and project management to improve health outcomes, re-confirmed my passion for health psychology.

Health psychology's contribution
My current role (see above) has enabled me to put everything that I have learnt on my journey so far into practice. It involves leadership, clinical supervision and coordinating the work of the teams to ensure the effective running of both services. I work alongside a counselling psychologist, occupational therapists, psychology graduates and social care professionals. As part of the mental health promotion service, I contribute to and advise on the development, implementation and evaluation of evidence-based health improvement programmes and resources promoting self-management. Then as part of the IAPT service, I provide specialist assessment, formulation and one-to-one or group cognitive behaviour therapy-based interventions for patients with mild/moderate mental health and emotional difficulties. My role also specifically leads on projects relating  to the interaction between physical and mental health, such as rehabilitation programmes and psychoeducational groups. This is where health psychology can play a part. During my time in this role and 10 years after completing my MSc, I began my Stage 2 training in health psychology by gaining a place on the professional doctorate at City University London.

I have heard people say that they can't really see how health psychology is relevant in mental health, but working psychologically in this way with those presenting with physical health problems, can make a big difference – think of managing the emotional impact of diabetes, heart disease, chronic pain, HIV and respiratory disease. As an example of this, a couple of years ago I was contacted by a respiratory physiotherapist requesting psychological input into their rolling pulmonary rehabilitation programmes for patients with chronic obstructive pulmonary disease (COPD). COPD is still the fifth biggest cause of mortality in the UK. It's also associated with other conditions: about 40 per cent of people with COPD also have heart disease, and significant numbers have depression and/or an anxiety disorder. Key issues for this particular programme were helping with the adjustment to chronic respiratory disease and providing strategies to manage stress and anxiety. We developed a one-hour session based on health psychology theory, delivered in a cognitive behavioural therapy format, to identify factors that help or hinder the management of stress and anxiety, using motivational interviewing techniques to explore patients' own personal motivations for change.

Patients have fed back that the sessions gave them permission to listen and talk about emotions, to talk to someone who understands, let them know it was quite normal to be anxious with a lung disease, informed them what to do to relieve stress, therefore helping them to overcome anxieties and frustrations and to find where difficulties arise, discovering that they are not alone in their struggles to manage their condition and its impact.

The current health agenda is somewhat dominated by a mental health focus, but there is also recognition of the interdependence between mental and physical health, as well as an undercurrent of prevention, early intervention and health promotion. Health psychology isn't explicitly on the agenda, but health psychologists are in an excellent position to develop the current focus.

What I've learnt about getting qualified
Anyone wanting to become chartered as any kind of psychologist must keep resilient, motivated and creative in building their experience, especially in health psychology. It takes a minimum of six years to qualify as a health psychologist and most people take longer than this. This is similar in other areas of psychology, so getting chartered as a psychologist is akin to training in medicine. I hadn't appreciated that when I started.

Improved vocational guidance at school and university might have made me more focused on achieving a professional qualification at the start. If I were to do anything differently, I would have pursued the professional qualification earlier. I am still certain however that this is the career for me, and it's been worth the challenges. I hope my role will continue to enable me to support the development of my two services into new and exciting areas of work that are key to the current health agenda. I also look forward to qualifying within a year and finally becoming a Chartered Psychologist!