‘We’re in threat mode’

Towards the end of our interview, I asked Sula about the big issues in health psychology since her transition from the NHS to private work in December. 'Of course, long Covid is a catch-all umbrella: it may show itself in blood changes, for instance, or still feeling very tired after you've tested negative for a long time. But it's an example of how recovering from an illness is something we often ignore. Recurring symptoms – feeling better then feeling worse – are really worrying and there's a tendency to ignore them. This is a real health psychology issue at the moment.'

Sula raises another trend. 'Post Covid we're beginning to see people reacting to the local and global situation: the economic climate, the war and climate change. Media, the arts, and personal conversations continually reinforce that we're facing impending doom and the situation is out of control. We're in threat mode. We're seeing more evidence of learned helplessness, cognitive dissonance and difficulty in concentrating. People are looking to find comfort and reassurance in certain activities: binge-watching their favourite TV programmes is a common example. More generally, many people have become glued to screens and devices. These were often the only outlet under pandemic restrictions, but now they're becoming more like mental prisons. We're beginning to see evidence of anhedonia: the inability to feel pleasure in normally pleasurable activities. As yet these are not major issues but they may well become stronger and more prevalent over the winter.'

I was interested to understand how Sula's move had changed her work, particularly in a period when, as she stresses, health psychology services are becoming increasingly important. 'There are real differences between the two environments. When working for the NHS, there are short-term targets and a particular number of patients you have to discharge within a given period of time. Therapy is therefore short-term in primary care mental health services, which is not enough for people with complex presentations, particularly where health is involved. In contrast, there is the potential to have longer courses of therapy in private practice. However, for some, the financial expenditure means there may be an impatience to see change and add to the burden of worry about "doing the right thing" for their health. But how the NHS works depends on the particular service you work in; certainly, the treatment of physical health often takes a more integrated approach. It has to be said that private work can be a lot less pressured.'

A typical day

Sula described a typical day in her relatively new way of working, highlighting this difference. 'From Monday to Wednesday I focus on client work and supervision, but I keep the mornings free to prepare. I then do clinical work in the afternoon and evening. This arrangement is driven by my NHS experience where you often saw clients back-to-back with little time for preparation or reflection. I use Thursday and Friday for a mix of research, supervision, and consulting with companies on health psychology issues.' How did the transition come about and how hard was it? 'The biggest factor was that my husband was going round the world and I couldn't do my job from a distance, navigating different time zones. The plan was to move to the US but that didn't happen and we found ourselves "stuck" in London.' 

Sula thought about going back to the NHS, 'but working privately feels less like being at the end of my resources the whole time and the increased demands and trauma resulting from Covid clearly affected me. I was lucky that I'd been working for four days a week during my last seven to eight months in the NHS and during that time I'd had a number of private patients referred to me.' Is that still how she contacts clients? 'I receive referrals from other health professionals through my website and through my Instagram page. The idea was to, in the end, match my NHS salary but offer more specialised and intensive services, create a work-life balance, and have time to pursue my interest in gynaecological and pelvic health disorders. I think I've achieved that.'

'I'm spending my first year as a private psychologist trying to get the balance right between my work and the rest of my life, and within my work. I'm also going to continue my existing work on projects allowing people more access to health psychology at lower or no cost. This has been a major aim of mine since I finished my degree. Digital technology in particular offers hopes of improved access to a more diverse group of people.' There has been some criticism of offering distant services via Zoom and other systems. 'Well, it makes things easier for people with physical difficulties or who are anxious about travelling because of their physical condition. Whether digital therapy and other services work well depends on a number of things, not least whether they're warm and human in the way they're designed. 

The format matters hugely. Having group chat or meet-up elements – some sort of person-to-person element, not just person-to-screen interaction – helps here. We underestimate the need for social interaction and its power. There is a political element in my commitment to this… Systemic structures – and health care services are very important examples – exhibit unconscious bias. Women's illnesses in particular are minimised or disregarded, resulting in many very bad experiences despite the July, ten-year Women's Health Strategy. So, some of my work will be to address these issues for health psychology by creating new access.'

'I felt like a burden'

Sula's parents worked in the health system (her Dad a psychiatrist, her Mum a nurse). They split up when she was young. 'I became an observer, analysing how people fitted in with each other. I also learnt how to teach myself since my college hadn't got a good track record at A-level. I took film studies, psychology, law, and English, then spent a very unhappy year at Leeds University studying law. My attraction to that subject was that I could "fight for justice", but pay for criminal barristers is lower than I thought and the work requires hugely long hours. I felt like an outsider, given my lack of interest in corporate law and prestigious firms. I switched to psychology but, if I'm honest, found the first year boring. Now I'd probably be more interested in the topics we looked at and it certainly predisposed me to use CBT. In the second year, I got fascinated by health and social psychology as well as psychopathology. Understanding how physical and psychological processes affect each other was the real engine of my later career.'

Sula took a marketing job in a small company while doing her undergraduate degree and it's helped her in her later career. 'It taught me a lot about how people make decisions.' Sula's own health experiences have informed her later interests. 'Around about then I had severe urinary tract infections. I'd had some when younger but these were very painful and uncomfortable. The company weren't very sensitive in handling these issues, adding to the anxiety and worry. I felt like a burden, avoided socialising and my work suffered. I began to experience migraines. My father's partner was a clinical psychologist who suggested mindfulness as a way of coping with chronic pain. At first, I was slightly insulted that someone thought it could address what I was experiencing, but it helped. I began to understand how pain and worry impact our immune system and that addressing your mental landscape gave you choices and hope. Of course, the symptoms didn't disappear but I had space to recover.'

A need for identity

Sula moved to London and her links with Kings College, starting with her MSC and PhD, have continued since then, with teaching, training, research, and development work. In parallel, she worked with South London and Maudsley NHS Trust in CBT and IAPT services.

Given the growing importance of health psychology in facing the new challenges she has raised so eloquently, I finally asked Sula about its future. 'It is a broad profession. It can be about a variety of things from behaviour-change to mind-body interaction. This makes it very rich but does, for instance, create difficulties when you want to recruit a health psychologist. The training is so varied so you're never sure what you're going to get. The reasons for this are varied but I really believe health psychology needs more of an identity in the future so that people understand where it can contribute.'