‘I focus on the iceberg below the waterline'

Amanda has played both hockey and squash to a national level, and still plays National League and international masters hockey. 'In my Birmingham University days, where I did my degree, Master's and PhD,' she says, 'I played squash with Matt Hammond, who now works in wheelchair tennis. He helped create a clinical psychology post in the Loughborough centre of the English Institute of Sport (EIS) and suggested I might be interested in it. I hadn't thought about applying clinical psychology to sport but applied for and got the post, which involved working about four hours a week in addition to my NHS role.'

'Clinical psychology has something significant to offer to elite sport with a specific focus on mental health. It was important to be clear about that from the beginning: this was a new area and Matt was a trailblazer. Between 2008 and 2012 at EIS, I received referrals for athletes across all Olympic and Paralympic sports. I worked closely with sports physicians and Sports Performance Psychologists and would often be asked to provide clinical psychological advice to other professionals working in elite sport. After a small role with Team GB at London 2012, supporting athletes' mental health – especially post-competition – I left the EIS to focus on my new Chief Psychologist role in Birmingham. The awareness of and focus on mental health in elite sport had increased and my four hours a week wasn't enough to meet growing demand.'

Late in 2018 Amanda re-joined EIS as one of three practitioners providing a mental health expert panel, funded though UK Sport, providing clinical consultation and guidance to elite athletes, again across all Olympic and Paralympic sports. 'I am the only Clinical Psychologist on the panel, alongside two experienced Sports Psychiatrists. We have endeavoured to operate where possible as a mini-MDT, offering strategic and clinical advice. We don't have the capacity to see athletes directly, but are creating a network of private practitioners who can be supported by us to learn how best to apply their therapies to elite athletes and can access support in learning more about the context of elite sport. We also focus on supporting national sports governing bodies to develop mental health strategies and raise awareness amongst staff and athletes. The panel is my main involvement in elite sport, although I have also been recruited as mental health practitioner for the Paralympics GB squad, to provide preparation and games time support for staff and athletes for the 2020 games. I was due to have been in Tokyo for the Paralympics in Summer 2020 and hope that the games will go ahead as proposed in 2021.'

I mentioned to Amanda that I was a big cricket fan. 'When I worked at the EIS in Loughborough I worked alongside Dr Nick Peirce, who was also the chief medical officer at the England and Wales Cricket Board (ECB)', she replied. 'The board took me on for a few hours a month to support them in developing their mental health strategy. There were a number of high-profile issues around mental health in cricket: two or three England players were in the media for struggling with mental health. There's now some interesting data suggesting cricketers are particularly vulnerable in certain areas.'

Addressing the issue in a different way

I asked Amanda about the role of a Clinical Psychologist in sport in comparison with sports, exercise, or performance psychologists. 'The image of an iceberg is useful. The volume above water is the domain of sports psychologists. They assume a reasonable level of functioning for their athletes and teams and work on improving or enhancing that. As a Clinical Psychologist I focus on the iceberg below the waterline. Here normal functioning may be impaired, possibly by mental health issues, and that affects basic functioning or performance. So in my first EIS period I focused on athletes' clinical and mental health difficulties that sports performance psychologists were not trained to address. In the past these difficulties might have been treated medically or by a psychiatrist: areas such as eating disorders, depression, anxiety. Practically, I worked closely with sports psychologists where their approach wasn't working, I would get involved to address the issue in a different way.'

Is clinical psychology accepted in sports environments? 'Yes, there is much better understanding of what it does. It is better able to explain itself. The biggest challenge is the stigma for athletes around acknowledging mental health difficulties, as this raises all sorts of anxieties regarding selection and appearing "weak", in addition to the stigma anyone may encounter.'

Was it important for Amanda to have experience of playing sports to get accepted? 'Initially, yes I think it was. There is something about being credible in a sporting environment and to athletes. I think understanding sport was initially more important for me than psychology knowledge. At your first meeting a client often judges you by your knowledge of their sector and how you come across in general since they cannot really assess your psychological knowledge. This is true in a number of sectors including elite high-performance sports, the military and business. Using the right language and asking the right questions is a good way of creating a connection and building trust based on being able to show that you have some knowledge of their world.'

'I learnt most from hugely capable clinical leads'

As I've suggested, Amanda's working life is far wider than her sports involvement. Coming from a medical family, she bucked the trend and chose to study psychology. 'After my degree I worked in research, initially on taste perception, and then went on to what became my PhD research funded by the Department of Health (DoH). My PhD focused primarily on quality of life for adults with learning disabilities who were being moved out of long stay hospitals and into much smaller community residential homes. I worked in the hospitals and then in the homes as part of the staff team whilst also collecting data (quantitative and observational) on the experience for both residents and staff.'

Amanda says that while it was helpful to complete her PhD on this research, she has always felt that the experience of working shifts as part of the care assistant team was of even more benefit. 'I always advise those wishing to pursue a career in clinical or applied psychology to spend some time working in a very hands-on carer role initially: it is very fulfilling, gives you the very basic skills to just "be" with people, and the confidence to undertake very personal tasks with compassion and respect. Since I started working as a Clinical Psychologist, I have gained an unusually wide range of experience. I started as a child/adolescent psychologist then moved into adult mental health. Working in adult services I trained in neuropsychology and in my last clinical role got involved in Primary Care Mental Health and IAPT services. I have also been fortunate to have part time secondments into academic and research posts, as well as some regional roles focusing on national developments such as IAPT and most recently Psychological Therapies for Severe Mental Illness (PT-SMI).'

Amanda's present NHS role is 'very much a senior professional leadership one, and my variety of experience has helped me hugely there'. Did she train formally in leadership? 'I regularly refer back to a course that I took on organisational dynamics at the Tavistock Clinic. But I have learnt mostly from some hugely capable clinical leads and managers that I worked alongside especially during my formative years in Warwickshire. I recognise that being a very senior leader who is a psychologist places a set of responsibilities on me to retain and apply psychological thinking to my role… It's important to "walk the walk" so to speak. This is incredibly important in the NHS, which is a difficult, pressurised and at times uncertain environment.'

One of the biggest challenges, Amanda tells me, is to help mental health providers embrace different ways of thinking about service user needs. 'Mental health services in the NHS are dominated by the disease model and I take responsibility for supporting and enabling psychological professions colleagues to introduce other ways of thinking about mental health, and how to apply them. During the pandemic one of my main roles has been to focus on developing a model for psychological staff support, and we were very quick off the mark here in Birmingham to put something in place for over 20,000 staff working in our local acute trust. I have found it helpful to apply clinical psychological principles to support and advise in both my NHS and elite sports roles, especially in relation to resilience and psychological growth. Some of the pressures have been similar, such as the challenges of not being able to control and predict your environment to create success… a challenge for frontline clinicians as well as for athletes and those supporting them. Talking about "failure" is anathema in both areas. We know that resilience and growth will be more substantial if individuals can acknowledge and express their anxieties and their sense of loss. Whilst the world of intensive and acute care medicine and elite sports cannot be directly compared, there is certainly some synergy in relation to how the Covid-19 pandemic has impacted upon individuals who work within those two worlds.'  

Amanda feels her role as a Clinical Psychologist has 'in some ways crystallised over these past few months', recognising that basic guidance based on solid theoretical understanding is what is most needed during such a crisis. 'Encouraging people to be open and honest about their feelings by providing them with a psychologically safe and supportive environment is at the centre of this advice. There is still a long way to go within both health care and elite sport before mental health is approached with a parity of esteem to physical health. However, I have seen significant change in the culture over the past few months, and if we continue to create the right environment in its broadest sense, I am confident that progress will continue in the coming years.'