I wrote this from Toronto where I was fortunate to have a three year career break from my post as joint head of a child psychology service. This is relevant firstly, because after 20 years in the NHS in a job I am passionate about, my frustrations were such that I leapt at the opportunity to have some time out.
Secondly, I was afforded the space to reflect on 12 years as a manager – something that never felt possible when I was working, despite the best of intentions. Finally, spending time in Canada, I was struck that there may be things we can learn from the culture there.
For the majority of my career I have worked in a child psychology service where the core values have been explicit, and have shaped every aspect of our practice. This predates my leadership role, and indeed, was the incentive to take up the mantle. With such a clear rationale, and the support of an equally passionate job share partner and team, it has been easier perhaps to crystallise those values, and to spot when they come under threat.
The values have remained resolute throughout my experiences of working with highly distressed children and families. This is despite working in a number of core and specialist teams; responding to an evolving evidence base; and throughout all the turbulence, fads and fashions faced by the NHS. They are:
1. that every child is unique
2. that the family and the systems around the child are central to our understanding
3. that the child and their family are the experts on their own experience
4. that children deserve the opportunity to have a normative, contextual, and developmental understanding of their distress
5. that the language we use is very powerful and must be considered with care
6. that the least possible contact with professional services, the more empowering the experience
7. that we are our most important resource, and need to be nurtured if we are to nurture those we work with
8. that we are a scarce resource, and have a responsibility to target our specialist skills to maximal effect
It is my assumption that there is nothing particularly controversial in these values, and they would be commonly held by psychologically minded professionals throughout health. Indeed, in my discussions with the vast majority of multi-disciplinary and managerial colleagues there is generally consensus regarding the above; and they can usually be found embedded in strategic documents that shape our public services.
Despite this, when it comes to service delivery, much of my career has been spent either arguing in their favour, or defending them against attack. Indeed I would characterise the majority of my professional life as a manager as ‘swimming against the tide’, which is perhaps why I felt so ready for a break.
With the privilege of time , I was able to reflect on the mismatch between what people clearly believe, and how it can actually feel on the ground. Maybe my thoughts can offer some insight into why the ‘culture of care’ can feel so vulnerable, despite us knowing that the vast majority of people who work in healthcare do so because they genuinely DO CARE. I will also argue that psychology, because of the nature of our training, is in an advantaged position to be able to offer some potential solutions.
Value 1 – every child is unique
Only the brave would deny this, and yet as clinicians we are constantly put under pressure to conform to standardised formats and ‘one size fits all’ solutions. The rationale is obvious – it is simpler, cheaper, ensures consistency, guards against idiosyncratic practice and reduces negligence claims. The risk of course, is that it has the potential to depersonalise, and even dehumanise the healthcare experience. The alternative prospect, of course, that every user of the NHS requires a completely individualised service, is equally terrifying for us all in health. This is particularly in light of the pressure we are under, and the constant message that demand is only going to grow.
I would argue that Clinical Psychologists are able to adopt a helpful position in respect of this dichotomy. We start and finish with the premise that everyone is unique; but equally we are diligent in our reference to both the evidence base, and clinical experience, to ensure the most efficient interventions are identified. We are trained to anticipate that the journey will be dynamic, requiring constant adjustment. We trust that it is through a relationship that change will be achieved, and we have many skills to help us to achieve this.
It is unrealistic to roll out similar training to all professions but there are some basic principles that can be shared. For example, listening and responding to feedback; and having the confidence to change direction in the middle of a process. Interview questions such as “how will you know if today’s appointment has been helpful?” can facilitate an individualised approach regardless of the endeavour.
Value 2 – the family and the systems around the child are central to our understanding
This is most relevant to children’s services, of course, but it may have a wider utility. The traditional model of healthcare is very individualised – despite often losing sight of the individual. However, as psychologists we are trained to understand that everyone exists within a context, and that this context may be more or less helpful to the healing process. We have the skills to manage multiple perspectives, and frequently deliver interventions indirectly through carers or staff.
These are less familiar concepts within the medical model, and yet they have the potential to be highly relevant. For example, from family myths about illness, to the accessibility of the school toilets, there are an infinite number of factors that can interfere with the effectiveness of treatments.
Questions such as “who is most likely and who is least likely to support you in this?” can help to identify potential barriers; and psychologists can have a role in containing the commonly held fear of ‘opening a can of worms’ when professionals venture beyond the scope of their specific condition or body part.
Value 3 – the child and their family are the experts on their own experience
As psychologists this is a concept that is central to our profession, and it has gained a real momentum in the general healthcare arena. We are well placed, therefore, to support the development of user involvement and methodologies such as co-construction. We can also have a role in containing another common anxiety that this will generate unrealistic demands.
This reminds me of my own experience of an admission to a medical ward 15 years ago. The general hygiene levels were very poor, people were left in soiled beds, and I overheard conversations between staff about ‘difficult patients’. After I had been discharged I mentioned my concerns to a doctor from a different organisation. Despite being one of the most caring and diligent physicians I know, the response was that it was “a hospital and not a hotel”. The comment was fuelled, of course, by feeling defensive on behalf of overstretched nursing and medical colleagues, and overwhelmed regarding where the line gets drawn. Again I believe that psychology has something to offer this dichotomy. We are trained to search out solutions in ‘all or nothing’ situations, trusting that a middle ground can be found.
Value 4 – children deserve the opportunity to have a normative, contextual, and developmental understanding of their distress and
Value 5 – the language we use is very powerful and must be considered with care
These values are perhaps most relevant to mental health services. However, again I am minded of a story that suggests a much wider application. I worked with a boy referred because of ‘extreme behavioural difficulties’. His mother was the victim of severe domestic violence, often witnessed by the boy. I saw my role as acknowledging to the mother that her son was presenting her with a challenge, but at the same time helping her to understand how his experiences were relevant to his behaviour. This inevitably implies that choices in her life may have been a contributing factor – a devastating prospect. It is tricky terrain, but common ground for child psychologists, and we were making tentative progress.
In the meantime, in a desperate attempt to help a desperate situation the G.P. had written a number of referrals . The mother duly attended a paediatric clinic with her son, and he was diagnosed with ‘conduct disorder’. This diagnosis simply confirms that the child has significant behavioural difficulties. However, for the mother a ‘disorder’ implied that the problem lay within her child after all; and no doubt relieved that what he had experienced was not ‘to blame’, she cancelled future appointments with me. The paediatrician also discharged the boy, unaware of the impact of the diagnosis on the mother’s understanding of her sons behaviour. Sadly, I met the boy again a few years later in foster care, placed there he told me, because he had a “behaviour disorder”.
This story illustrates a number of points that do not need to be hammered home. The intention, rather, is to suggest that the NHS itself (that’s us), may perpetuate some of its (our) own problems. The model of care can create expectations that, in turn, we feel obliged to fulfil. As psychologists I am certain we have our blind spots too. However, we do bring a systemic understanding that can be particularly useful in unpicking some of these tangles. Indeed, we can often be of most use to the teams and services we are not a part of, as we have the opportunity to adopt a meta-perspective, looking at them through fresh eyes.
Value 6 – the least possible contact with professional services, the more empowering the experience
I would suggest that this value runs counter to the dominant model of ‘care’ in health. As psychologists we are trained to see that the lightest touch necessary results in the most effective interventions because they empower people to take control of their own lives. I often observe the opposite in healthcare professionals, who often report ‘feeling guilty’ if they haven’t ‘done something’, especially when waiting lists are long. If we could help in shifting this, then we would go a long way towards changing the culture of dependency that is currently crippling the NHS. Sharing our frameworks for psychological consultation; along with therapeutic models such as motivational interviewing and solution focused approaches are powerful tools in this process. Indeed I have seen more and more of this beginning to happen, with a notable shift following my return from Canada.
Value 7 – we are our most important resource, and need to be nurtured if we are to nurture those we work with
This is clearly something that the health service wants to believe in, and yet time and time again staff feel undervalued. Training budgets were the first to be cut; posts are held vacant to ‘save’ the financial bottom line; and staff feel under constant pressure to achieve more with less. As psychologists we certainly have the tools to help in this area, but there really has to be some investment here if staff are to experience it as anything other than tokenism.
Value 8 – we are a scarce resource, and have a responsibility to target our specialist skills to maximal effect
This too is an area where I would suggest psychology has something to offer the general healthcare landscape. Stepped care, consultation and training are all models of service provision that we embrace; alongside ongoing evaluations to ensure our interventions are targeted effectively. We are passionate about early intervention, and have a track record in developing ‘spend to save’ models of care. We always endeavour to look upstream to seek to understand how problems develop, and therefore how they could be avoided.
Now to Canada, and why my experiences there feel relevant despite no contact, as yet, with health services. It certainly seems to be a softer, warmer and more patient society. Even the large metropolis that is Toronto sees itself as a city of neighbourhoods that care. Reference is often made to Canadian values, and there is a strong sense of identity that includes tolerance and citizenship. I am sure it is not perfect, of course, but it is both palpable, and impressive given the enormity and diversity of the country.
At the heart of this paper is the concept that if the NHS adopts the right core values, then decision making, regardless of the size and nature of the task, becomes clearer and more coherent. If, as citizens and employees, we were able to identify the values we are all prepared to sign up to I am certain that common ground would emerge; and with that a template for a model of health care we could all feel proud of.
Dr Liz Gregory
Consultant Clinical Psychologist