Careers: Psychology in the community

A while ago, Midlands Psychology advertised in The Psychologist for a Clinical Psychologist to work in South Staffordshire and I briefly interviewed Angela Southall, their Director of Services, when we made this a 'featured job'. But I was left wanting to know more about the delivery of psychology in a social enterprise, working for and in the community.

'I just pick up the phone…'

How did you get involved in psychology? 'My interest in children. Even as a child I thought about the nature vs. nurture debate, though I didn't know that that's what it was. I used to ask "What makes us tick?" all the time. I became a mother at quite a young age and that only increased the fascination. My partner had had an unhappy childhood, and I began to ask "How can I make a difference?"'

Angela left school without A-levels but took them at college and then went to Aston University to take a degree in Human Psychology (graduating with a first and the university prize in psychology). Like many people of my and Angela's generation she was the first person from her family to go to university. 'I worked in a busy community mental health service during my sandwich year, and two things struck me about working in the NHS – they've informed much of what I've done since. First, it's very difficult to apply psychological ideas where people don't understand or value them and who may view psychologists as interlopers – you have to find new places and new ways to deliver. Second, professional infighting and border disputes can get in the way. It can be a very difficult environment to work in. A wonderful clinical psychologist called Barbara Baxter saved me – but her modelling of clinical psychology practice was also a major contribution in making me a workaholic!. She also gave me the idea that you can do psychology anywhere and that, if you wanted something done or the funding and resources to do it, you picked up the phone or visited people until you got them. By the time I qualified as a clinical psychologist, I had already started to gain the reputation of someone who got things done'.

'A tube of green paint'

After graduating, Angela went back to working as an assistant psychologist, then took her MSc in Clinical Psychology in Birmingham. Her first job was in Coventry. 'I found myself working with hard-to-reach families that no one else wanted to work with. My entire "kit" for working with children seemed to consist of a tube of green paint – no toys, books, pencils or other equipment! So I looked at my referrals, worked out where the "hot spots" were, and rang the local health centres to see if they would have me. They were incredibly welcoming, actually. I'd learned a lot about working in the community as an assistant psychologist but that was the start of my journey into community psychology. The work was in very deprived areas, and it was clear that the only way of offering any kind of meaningful help to people was to get together with other professionals to create an integrated approach. As an enthusiastic, newly-qualified psychologist, I also had the idea that this was the way you started to shape services.'

Angela worked in a number of principal and senior clinical and clinical child roles – shaping services – before moving back to Staffordshire, where she'd grown up. It struck me that Angela's interest in community psychology is linked to the fact that she has stayed in one location, the Midlands, for most of her career. It seems that, for her, an in-depth understanding of the area you're working in is as important as knowledge of psychological theory and techniques.

I suggested that Angela's approach and interests come from her own experiences: she had a third child while taking her master's, and it's very clear from talking to her that she has seen life from the other side of the 'desk'. 'That's interesting. I've certainly had a very good apprenticeship in how to survive as a psychologist. Being able to be creative and resourceful has stood me in good stead. From the very beginning I had experience of setting up new services – by default, as it happened, because there were so few facilities out there. Without exception, these were partnership services – for example, joining up health and education services to provide focused support for teachers and children. Quite often this involved very complex funding streams – psychologists need to be able to find, win and manage these sort of financial resources if they want to innovate. I led a children's community mental health team which took a unique psychosocial approach in an area with few resources and quite a lot of social problems. We got through a huge waiting list very quickly and effectively and, what's more, continued to operate the service successfully without a waiting list.

This shows what can be done when psychologists are able to innovate and professionals work together.'

'I'm absolutely committed to the social model of health provision'

Leaving the NHS after over 20 years to set up Midlands Psychology was obviously a wrench. 'I don't want to go into my reasons too deeply – they're complicated and difficult. Some of the background issues are discussed in my book The Other Side of ADHD and in a couple of papers I wrote around that time. I'm absolutely committed to the social model of health provision and to the NHS. But I'm also committed to psychology, and there comes a point at which further compromise just isn't possible. My experience has been a bit ironic in that I have had to leave the NHS in order to contract back in again (Midlands Psychology is now an NHS provider). Importantly, though, we are able to contract in on different terms.'

Angela set up Midlands Psychology in 2008 with 'a group of great people with similar ideas and the same values'. 'We're not planning for Midlands Psychology to be a huge, geographically widespread organisation but one that focuses on its local community and the people in it.

'The contract for children with autism was advertised in 2009. We were awarded it after a competitive tendering process and started delivering last October. Our users are involved in everything we do. They helped put together the service specification, they work alongside us within the service and are represented at board level. Without them we simply can't know what the issues for users are so their input is crucial. Transforming delivery is also critical – sessions take place in church halls, community centres, sports clubs, schools. Wherever possible, users don't come to us, we go to them.'

Flexibility and delivery are also key. After starting with a three-year waiting list, clients are now guaranteed a meeting within eight weeks. 'Psychologists and other professionals who offer services to children are often wonderful people with huge knowledge but are constrained by "a way of doing things". We don't have a "house approach". We concentrate on the people in front of us and their particular social and environmental situation. Our relationships are reflexive – two-way. This has helped us make a difference quickly and begin to win trust. So, we're now offering services to people who've never had psychological services before, and welcome them. But this is only a start. Ultimately our activities should impact on the community as a whole.'

When I talk to her, Angela is working at her desk. Is that what she does most of the time? 'No. As I say, we're a small organisation, we want to innovate and we don't believe in waiting lists, so we are all involved in delivering direct services. I do two to three clinics a week. This week I've been involved in advisory groups – I'm putting together a children's advisory group, which is a challenge since the members keep growing up! In any case, sitting at a desk runs counter to everything I know about doing psychology in this way. Networking, picking up the phone and creating community relationships underlie everything we do.

'I would love to think that some of these ideas might find their way back into public sector working, where they originated. My own experience is that the pervasiveness of the medical model in the NHS and the policy thinking shaped by it, has had a major influence on how clinical psychology services have developed. This should not be the taboo subject that it is, and, as psychologists, we should be able to have a grown-up debate about it'.

Eckart Winzen, a Dutch entrepreneur developed and applied 'cell theory', the idea that if organisations are to stay energetic and innovative they mustn't get too big. Whenever one of his companies grew beyond 50 people, he split it up. It seems to me that Midlands Psychology is putting this into practice and, along with other community psychologists, creating new ways of delivering therapy that will affect 'mainstream' practice.

- For more information on the organisation's work, see www.midlandspsychology.co.uk

Working with demanding clientele

Robel Iyassu on the challenges of working with complex clinical profiles

Learning about behaviour theorists in undergraduate psychology was an incredibly stimulating period for me as a student. Our lecturers taught us about token economies and other ways of applying classical and operant conditioning in real life, but it was working in clinical settings that allowed me to see this fantastic theory at work. Little did I know it, but learning about reinforcement, aversion and punishment was fundamental preparation for the road ahead.

Fast forward four years and welcome to the world of working with people with learning disabilities, a challenging area of psychology. Such a client group calls for resilience on the therapist's behalf due to the complex nature of clients' clinical profile. The busy southwest London service I currently work in provides treatment for a broad range of clients, but our team has particular criteria for referrals – a client must have a serious mental health problem with a learning disability or challenging behaviour. Typically, referrals from allied mental health professionals can ask for psychological assistance in the form of consultation or brief interventions.

The structure of the service means you can come across some quite harrowing cases; for example, a client who has treatment-resistant psychosis, autism and a moderate learning disability with extremely challenging behaviour. We can be seen as a complementary service to the community mental health team (CMHT) in that we provide treatment for people with a learning disability and effectively become a community mental health learning disability team (CMHLDT). At first glance, work in this field can come across as quite intense and challenging, but this makes it all the more rewarding.

Therapeutic input in mental health settings commonly involves the use of cognitive behaviour therapy (CBT), a treatment that explores negative thoughts and their influence on feelings and behaviour. Recent models of cognitive therapy have extended it to psychosis work and the learning disability population. This is not to take away from the efficacious work of psychodynamic psychotherapy or systemic approaches, rather that time and resource constraints do not always permit their use.

The challenge our practitioners face is deciding which therapeutic technique to adopt while considering the low cognitive functioning some of our clients. Due to the complex nature of our clients' presentation, the concepts of CBT may be too challenging to grasp. CBT 'homework' could prove difficult for service users who may possess a chaotic lifestyle and lack the planning/executive functioning skills to carry out this task. It is also quite common for our service to have clients on our caseload who are non-verbal. This adds to the excitement of our work and challenges us to use alternative communication techniques such as Makaton.

We provide psychology input to the Trust's unique learning disability ward; our team can provide consultation, assessment and intervention which support psychiatric nurses in managing challenging behaviour. This can often be down to changes in the environment/ward personnel; this does not warrant an increase medication but an analysis of the surroundings. Communicating this to the multidisciplinary team calls upon the interpersonal skills psychology as a profession possesses.

This stage of psychological work on the ward is investigatory and can include introducing 'ABC charts' to the staff. These charts capture the events preceding behaviour and the consequence of it. A major challenge here is that ward staff who are best placed to fill these charts in are already busy with observations, personal care to clients and existing paperwork. Getting around this obstacle has meant thinking of alternative ways to collect data from the ward. We have thought of looking at incident forms and case notes entries and retrospectively filling in the charts based on the information in these. We have also met with ward staff to fill them in. This has worked well.

By far the most powerful way of working has been collaboratively. By helping with data collection, the ward staff enable us to start our analysis process and eventually make suggestions on behaviour management. Therefore, collaboratively we are able to put these strategies in place that can reduce challenging behaviour, improve the clients' quality of life and make the ward environment more safe and pleasant for staff to work in.

Some clients have poor executive functioning and verbal fluency alongside challenging behaviour, and this has been my favourite work. This kind of presentation excludes the use of 'talking therapies': the principles of both can be used for a systemic intervention, but direct client work will need the practitioner to 'think outside the box'. It can be very stressful working with a client who cannot articulate except for grunts and groans, with their primary form of communication being sporadic bodily movements. Staff on inpatient wards can often feel burnt out and bruised (emotionally and physically). We have found solace in using Intensive Interaction – a form of communication for non-verbal clients. This technique involves mirroring the client's actions (motor and verbal) in an attempt to allow communication that is meaningful for the client. In our service, we have formulated that challenging behaviour can occur due to the client being bored and under-stimulated. By using this intervention you allow a significant interaction between the client and staff to give the client the daily communication they need and appreciate.

It's important that working with people with learning disabilities involves working with carers and families. A lot of the time, a client's chronic disturbed behaviour can be transformed by working with carers and hospital staff. Researching the nature of the behaviour and circumstances in which it occurs will allow psychologists to support nursing teams to alter their environment in a bid to induce settled behaviour. It is quite common for challenging behaviour to be treated with medical interventions, but more often than not the challenging behaviours (e.g. attributed to severe autism) do not cease. This is when psychologists can come in and conduct functional analyses to understand the behaviour. Ideally, a move away from punishment used in typical operant conditioning is more productive.

Educational psychologists have used positive behaviour support (PBS) to manage difficult behaviour. The PBS intervention involves taking a proactive stance and reinforcing positive behaviour with the hope of undesired behaviour slowly fading away. By viewing undesired and challenging behaviour as a form of communication, our team works to tentatively make suggestions to carers in behaviour management strategies. Following full data collection and analysis we may construct guidelines for behaviour management and review the guidelines periodically.

One common issue in this client group is diagnostic overshadowing – when the presenting problem is misinterpreted and attributed to a learning disability but could be due to some other disorder. Commonly, the medical model may use antipsychotic medication to treat behavioural problems in clients with challenging behaviours. Psychology is in a strong position to offer support in understanding these behaviours and their antecedents so that a proactive method of support can be given to the client that aims to reduce these behaviours.

In contrast to some of this work, my last role involved working with people who had a learning disability in a forensic setting. This work involved much more exposure to personality disorders and interesting observations of client presentations. Most riveting was our clients' desire to have spiritual encounters and their requesting the services of pastoral staff.

What struck me were the categorical differences in people with learning disabilities. With mild, moderate and severe presentation being commonly distinguished in people with learning disabilities, I often needed to adapt my communication style when conversing with clients of different severity.

You get to experience a broad range of clinical presentations in such a setting, and see clients recover from quite serious mental health problems. Unfortunately at times we worked with only a single psychologist for 14 clients. This can be very demanding and the atmosphere could be intense and volatile. Work in this forensic setting involved offender work (relapse prevention), but most interventions were unfortunately psychopharmacological.

I hope these reflections have helped you to understand the role of psychology in healthcare settings, and the scope of work in this branch of psychology. CBT may be a common therapy, but it is not possible with every client. Adopting a different approach to treatment and intervention, and involving carers and families, can make for a varied and stimulating career.