‘I tend to deal with unconventional clients’

Since we were talking via Skype, during lockdown, I began by wondering how Lindsay's therapeutic approach translated onto screen.

'I've been doing sessions online for some while: one reason is that accessing dialectical behaviour therapists is always exceedingly difficult so people have been making enquiries from some distance.' Do you notice any difference in distant therapy? 'It's more exhausting: concentrating on your client is more of a challenge on screen. Deciphering body language is difficult. Overall you have to be very explicit about things, checking understanding and summarising. I find myself talking about process and content more than in a face-to-face sessions. You also have to be aware of your own emotions during the lockdown: a lot of these are unconscious but communicated to the client. You have to focus on the fact that you are as much part of the present, unusual situation as the person on the screen.'

'I've lost some clients. There are definitely more texts and emails inbetween sessions. I suppose all in all it is more stressful. You can't hold people emotionally and they can just cut off without giving you a reason. I've found myself checking up more on clients. Older clients, in particular, can find the whole technical aspect of the sessions difficult – and I think psychologists need to ensure they're comfortable with whatever system they're using.'

The motivation to continue learning
I asked Lindsay about her path into psychology. 'I grew up in Warminster, an army town in a quiet part of the world and was desperate to leave. I was very musical growing up and played the clarinet semi-professionally in three orchestras, but an illness when I was 16 prevented me from playing the clarinet.'

Lindsay completed a BSc in psychology at Sussex. 'I originally wanted to be a doctor but my health wasn't great so I probably wasn't physically up to the demands of the process. An interest in psychiatry led me to psychology, which seemed exciting.' Lindsay was not particularly enthused by social psychology. She had taken science A-levels so 'the biological aspects of the subject really fascinated me and, when we got on to it, I became interested in abnormal psychology'.

But experiences outside her course influenced her. 'In the middle of my course I took a sabbatical. For a year I worked as the Union's Vice President for Welfare and got involved in campaigns and political issues. This strengthened my interest in people.'

Lindsay had decided she wanted to specialise in clinical work in her second year. 'Lecturers tried to put me off. I was told how difficult it was to become a clinical psychologist – as students often are when they express that preference. But I was also a difficult student in my final year: I didn't go to lectures, preferring to read in the library. I was an autodidact who loved learning and went back to papers and primary sources rather than course books: I like to form my own opinions. This motivation to continue learning becomes particularly important in private practice when CPD is not provided automatically by your employer. You don't have access to libraries and CPD becomes expensive. That is why a number of us who left the NHS at about the same time have formed a local support group, swapping articles and offering each other supervision. But I'm getting ahead of myself!'

Lindsay spent two years doing assistant psychology jobs. 'I'd volunteered in a rape crisis centre and a Headway home during my final year and then worked in an eating disorder clinic for the summer – which I left quickly. I finally got on to a three-year course in Southampton and became even more interested in complex cases – in trauma and PTSD, which link to personality disorders. There isn't enough training in personality disorders during clinical courses.'

'It reminded me why I became a psychologist'
Lindsay describes her first job as 'a great training ground in engaging people from quite different backgrounds while having no formal authority. It was created for me. Fifty per cent of my time was spent on an acute in-patient ward. I had no office and the existing staff did not really want me there at first, but I had to train and supervise a diverse team. The other half of my job was in an assertive outreach team – trying to engage people who had dropped out of traditional service and were at risk. The role really taught me a lot about engagement skills and motivational interviewing – that has stood me in good stead ever since. In both jobs there were no other psychologists.'

Within a year of this Lindsay trained for and helped set up a dialectical  therapy service within a community health team. She worked there for seven years. I had noticed that Lindsay's website listed a range of therapeutic approaches. She did not seem to be wedded to one. 'Yes, I believe you should formulate in one model (in my case a cognitive one) then have a toolbox of different therapeutic approaches. I tend to deal with unconventional clients and in each case need to find an individual model or technique that will engage that person. That's the nature of working in personality disorders.'

Moving North with her husband – 'we wanted a different lifestyle' – Lindsay worked in a dangerous and severe personality disorder service pilot project. 'There was a lot of emphasis on these at the time.

It was extremely interesting and it was here that I learnt about legal aspects of client cases, a knowledge base I still use. The clients were difficult to engage so my earlier experience was critical here.'

Five years ago Lindsay got ill with rheumatoid arthritis and, after a couple of years, she made a change. 'Setting up in private practice was the best decision I've ever made. I work two to three days a week and can look after myself. It reminded me why I became a psychologist in the first place: to help people get better.

Her clients are a mix of self-referral cases – 'people not coping or reporting self harm for instance. They have very rarely been diagnosed with personality disorders. It's almost impossible to get diagnosed in the NHS and people look at my website and say, "that looks like me". There are some GP and psychiatrist referrals. Insurance referrals tend to be for conditions such as depression. I do some civil court work as well.'

Have you any advice for people moving into private practice? 'I think getting NHS experience first is really helpful in working with other professionals. It is important to decide very clearly what your goals are then look at issues like supervision and, especially, ethics. What do you do if someone cannot pay or would struggle with your usual fee? What happens if someone wants to continue your sessions but you genuinely consider you're not helping? And, as I have mentioned, arranging for proper CPD is a priority.'

You have mentioned in passing that the NHS has not been able to help in certain areas. 'It's been stripped bare and mental health services have been treated as the poor relation. Even before the lockdown I was seeing a lot of stress issues. Longer hours and zero hours contracts, poverty and other social factors were causing increasing mental health problems. But personality disorders are there all the time. They're a constant.'

At the end of our interview, I asked Lindsay if her interest in and focus on complex, often unconventional clients reflected the fact that she was unconventional. 'Some people might think so. Some of my hobbies include roaring around on a motorbike, firing cannons and taking part in historical re-enactments, which I suppose aren't that conventional.'