clinical psychology forum - british psychological society network… · clinical psychology forum...

ISSN: 1747-5732ISSN: 1747-5732

Clinical PsychologyForumSpecial Issue: The Francis Report

Number 263 November 2014 ISSN: 1747-5732

Guidelines for ContributorsCopyPlease send all copy and correspondence to the coordinating editor, Stephen Weatherhead, c/o SueMaskrey, CPF Administrator, Clinical Psychology Unit, University of Sheffield, Western Bank, Sheffield S102TN; tel: 0114 2226635; e-mail: [email protected]

DCP Notifications editorPlease send all copy to: Stuart Whomsley, [email protected].

Book reviews editorsTony Wainwright (University of Exeter) and Sarah Saqi-Waseem (Compass Wellbeing CIC).Please contact Sue Maskrey (see above) in the first instance if you are interested in reviewing a book for CPF.

AdvertisementsAdvertisements not connected with DCP sponsored events are charged as follows:Full page (20cm x 14cm): £140Half page (10cm x 14cm): £85

All these rates are inclusive of VAT and are subject to a 10 per cent discount for publishers and agencies,and a further 10 per cent discount if the advertisement is placed in four or more issues. DCP events areadvertised free of charge.

The Society’s Terms and Conditions for the acceptance of advertising apply. Copy should be sent to:Mark Wellington, The British Psychological Society, St Andrews House, 48 Princess Road East, Leicester LE1 7DR; tel: 0116 252 9589 (direct line); [email protected].

Publication of advertisements is not an endorsement of the advertiser or the products and services advertised.

Clinical Psychology ForumClinical Psychology Forum is circulated monthly to all members of the Division. It is designed to serve as a discussion forum for any issues of relevance to clinicalpsychologists. The editorial collective welcomes brief articles, reports of events,correspondence, book reviews and announcements.

Clinical Psychology Forum is published monthly and mailed on the penultimate Thursday of the month before the month of publication.

Editorial CollectiveNicola Cogan, Richard Cosway, Jennifer Foley, Garfield Harmon, Jill Jones, Sinclair Lough,Deborah McQuaid, Helen Miles, Paul Moloney, Susan Pooley, Penny Priest, Angela Simcox,Graham Turpin, Jane Vinnicombe, Tony Wainwright, Sarah Saqi-Waseem, HesselWillemsen, Charlotte Wilson

If you have problems reading this document and would like it in adifferent format, please contact us with your specific requirements.

Tel: 0116 252 9523; E-mail: [email protected].

Clinical Psychology Forum 263 – November 2014 1

THE FRANCIS INQUIRY report was published at the beginning oflast year in February 2013 and reported the findings on theinquiry which took place, presided over by Robert Francis QC,

into the causes of the failings of care which occurred within the MidStaffordshire NHS Foundation Trust between 2005 and 2009. The report made 290 recommen-dations, including openness, transparency and candour throughout the healthcare system,together with calls for improved support for compassionate caring, committed caregiving andstronger leadership in healthcare. A similar report, Trusted to Care, was published in Wales in Mayof this year.

Since the publication of those reports, all of us involved in healthcare: psychologists, physi-cians, nurses, allied professionals, social workers, administrators and others, have asked the ques-tions, ‘How did this happen?’, ‘Why did this happen?’ and ‘What must we do to stop it happeningagain?’ Francis laid this out comprehensively. Julie Bailey CBE, in her comprehensive article,acknowledges change but stresses the need for more, particularly in the area of leadership. We arenow adding a discipline-specific offering to the table.

Healthcare is a dangerous business, as those of us who work as clinical psychologists know onlytoo well. And this is also an absolute case of, ‘There, but for the grace of God, go I.’ We are all fal-lible, we are all weak, we are all prone to stress, and we are all human.

But we also all happen to be psychologists, hopefully with particular insights into and under-standings of human suffering – individual, marital, group, corporate and societal.

This special edition of Clinical Psychology Forum draws on those insights, and upon that detailedunderstanding that we, as psychologists, have – overlapping, of course, with the experience, knowl-edge and viewpoints of our fellow professionals. Thus, we have papers in this issue reflecting uponall the things that Francis concerned himself with: stress, compassion, compassionate care, cul-ture, ethics, policy, social issues and the demands of psychological responsibility.

As difficult as the material contained within these pages is, I feel very at home here. Like mostpeople navigating the lengthy course of snakes and ladders that marks the route to clinical psy-chology training, I spent much time as a nursing assistant in acute psychiatric hospitals and chal-lenging behaviour wards in, and later – in company with Rachael Edge – on dementia wards as atrainee. With the benefit of those experiences, it becomes all too easy to imagine how it can bethat stressed and burnt-out staff can end up in situations where they become guilty of, or complicitin, terrible and seemingly unforgivable things. But I learned too, as I developed a specialist inter-est in this area, how psychological interventions in the form of psychoeducation, supervision andBalint groups – akin to the Schwarz Rounds described by Barbara Wren in her piece – can relievestress and burnout, promote job satisfaction and facilitate the development of compassion and thedelivery of compassionate care.

When I became a trainee, Derek Mowbray – who writes in this issue on psychological respon-sibility – was my inspiration and my talisman. He foresaw a world of psychological leadershipwhere consultant psychologists would lead all aspects of health services concerned with psycholog-ical provision, right across the spectrum. Alas, that world was not to be, although he remains myinspiration. The passing years have instead seen the diminution of our profession. Our profes-sional structures have been eroded, badly impacting on numbers, our influence and impact onhealthcare policy, and hence on our power to change things – not just in clinical psychology, but

ForewordJamie Hacker Hughes

2 Clinical Psychology Forum 263 – November 2014

Foreword

across the whole of British psychology. We can change that. We must change that. As these pagesshow, we have – not all the answers – but several of them. We have so much to offer as experts, asclinicians, as leaders. You will find these pages inspiring. I did.

Professor Jamie Hacker HughesClinical Psychologist, Neuropsychologist and British Psychology Society President-Elect

ReferencesAndrews, J. & Butler, M. (2014). Trusted to Care: An independent review of the Princess of Wales Hospital and Neath Port Tal-

bot Hospital at Abertawe Bro Morgannwg University Health Board. Stirling: Dementia Services Development Centre.Francis, R. (Chair) (2013). Mid Staffordshire NHS Foundation Trust Public Inquiry Report. London: The Stationery

Office. Retrieved from www.midstaffspublicinquiry.com.Hacker Hughes, J.G.H. (1994). Caring for the Carers: An approach to supporting Health Care Professionals working in Stress-

ful Clinical Environments. DipClinPsychol thesis. British Psychological Society.Hacker Hughes, J.G.H. (1996). Supervision, Stress and Satisfaction in a Learning Disabilities Service. PsychD dissertation.

University of Surrey.Mowbray, D. (1989). MAS Review of Clinical Psychology Services. Management Advisory Service.

DCP Wales in collaboration with

the Division of Health Psychology and the

Division of Counselling Psychology

Post Francis and Andrews:Psychological Approaches to Advancing

Compassionate Healthcare Delivery in WalesSWALEC Arena, Cardiff CF11 9XRTuesday 4 November 2014, 9.00am

This event is aimed at healthcare managers, policy makers, assembly members and clinicianswith an interest in developing compassionate healthcare systems, including approaches tosupporting a resilient workforce.

There will be presentations from experts in the field of psychological approaches to healthcare aswell as the development of patient informed services. There will be panel discussions and timefor delegate participation. There will be opportunities for delegates to make links with other keyplayers and discuss ways to take forward approaches within local areas.

This is a free event and open to all, but places are limited so please book early.

This event is being financially supported by the DCP Wales Branch, which has invested in it for the benefit of its members.

To register go to:https://response.questback.com/britishpsychologicalsociety/dcpwales041114

All queries, please e-mail [email protected] with ‘Post Francis & Andrews’ in the subject line.


Editorial

Clinical psychology:Keeping the human in healthcareAndrew Hider, Alison Beck & Richard Pemberton

THIS ISSUE of the Clinical Psychology Forum focuses on the learningarising from the reports of Sir Robert Francis and associatedinquiries and responses across the UK. The publication of these

reports in triumvirate and in succession – Winterbourne, Francis,Andrews – are, we feel, an indication that things will not be the sameagain in the UK healthcare system. We believe that clinical psycholo-gists, as senior, highly-trained healthcare professionals, share account-ability with colleagues for addressing the issues contained within theirpages. The key issues are all interconnected – patient safety, leader-ship, governance and staff well-being. Often, diagnosis and even pre-scription can be easy, but delivering effective solutions in complexhealthcare systems is very hard to achieve.

These issues are directly relevant to a range of psychologists, acrossthe divisions and faculties. In order to harness this wealth of experi-ence, we set up a ‘Francis group’ e-mail group. This is a group of inter-ested psychologists, many in senior healthcare positions with wideraccountability for service delivery, who share ideas and practice. Wehave hosted conferences and liaised with divisional leadership,branches and faculties to share learning. This edition represents theculmination of this work. Hopefully, it will provide food for thoughtand, most importantly, a springboard for further debate and discus-sion. Ideally, you will join our Francis e-mail list (contact [email protected] to sign up). It has been a struggle to gain formal BPSsupport and assistance, but we are hopeful that this is about tochange. The new DCP policy officer, when appointed, is going to helpshape the next stage of our work in this area and given Jamie HackerHughes’ foreword to this special issue, we are confident that addi-tional cross-divisional support and BPS resources will be forthcoming.We would like your ideas about what we and the Society as a wholeshould be doing next to take this area of work forward.

In this special issue, we wanted to do three things: Firstly, wewanted to include a mixture of academic theory-driven articles, andpragmatic clinical articles, in order to reflect the profession’s role as apragmatic discipline rooted in empirical science.

Secondly, we wanted to capture the contribution psychologymakes in encouraging a focus on human concerns within modernhealthcare environments that also, necessarily, have to be process,outcomes and resource driven.

Andrew Hider

Alison Beck

Richard Pemberton


Editorial

Thirdly, we wanted to send a message to colleagues that we work alongside, from all disciplines,and to service users and their carers saying: ‘we are here, alongside you’ and ‘we have somethinguseful to offer’. If we are to ensure that future history of UK healthcare is not going to be one ofrepeated scandal due to poor, neglectful or abusive care, inadequate governance, interdisciplinaryconflict and poor staff morale, then we need to do something different.

We have made both the printed and extended versions of this issue freely available to allonline. The articles in the online extended section have no less merit than those in this print ver-sion. We simply did not have space to include everything. We hope you will read and enjoy thesethought provoking papers and that they will support our ongoing endeavours to improve thehealth and social care systems in which we work and, of course, from which we all receive carewhen we are vulnerable or unwell.

Dr Andrew HiderConsultant Clinical & Forensic Psychologist, Ludlow Street Healthcare GroupDr Alison BeckTrust Head of Psychology and Psychotherapy, South London & Maudsley NHS Foundation TrustRichard PembertonChair, Division of Clinical Psychology

Clinical PsychologyForum is now on

Twitter@CPFeditor


IWILL BEGIN this article about profes-sional ethics and the Francis report with myown views about the root causes of poor

standards of care. I have a social model (see,for example, Oliver, 2013; Wolfensberger,1972) that is similar in some ways to the Fran-cis inquiry’s, but with some differences (Fran-cis, 2013). Francis, particularly Volume 3, wasvery close to the mark, when he reports thatthe culture of an organisation is a key issue,but I think he underplays the wider picture ofthe overall culture (including power relation-ships) in which we live and how organisationstend to reflect that wider context – one inwhich some groups and individuals are subjectto powerful forces of social devaluation. Thisis then manifested in different ways, includingpoor standards of care. The inquiry notes:

One true measure of the NHS’s effectiveness indelivering hospital care can be found in howwell the elderly are looked after. They are a vul-nerable group, often unable to assert their rightsand legitimate expectations for themselves, andhave complex needs. It is a measure not just ofour health service but also of our civilisation asa society. (p.1595)

This expresses something of this wider con-text, but maybe misses the point that evencivilised societies will have these devaluingforces at play, placing people at risk. Theseare essentially moral questions and our profes-sional ethical principles and standards can beone route for ensuring these vulnerablegroups are protected.

My personal experience in evaluating service qualityMy learning about these ‘root causes’ of poorcare, and indeed my interest in professionalethics, goes back to the 1980s when I wasinvolved in using a service evaluation instru-ment, Program Analysis of Service Systems(PASS) based on normalisation/social role val-orisation (SRV) principles (Wolfensberger,1972, 1991; Wolfensberger & Thomas, 1983)We were using this as a training tool, in whicha group of participants would be taught thebasic idea that groups and individuals couldsuffer serious harm through social devaluationand that by the same token could be protectedagainst this by occupying valued social roles(Wolfensberger, 1991). Participants then spentsome time in a care setting and rated the qual-ity of its care against 50 standards, the majorityderived from SRV theory. During these evalua-tions we would get to know one or two of thepeople using the service, and try and get a feel-ing for what life was like for them. The majorityof settings were institutions for people withlearning difficulties or mental health problems,or for older adults, and in general the overallpicture was not at all positive. What we experi-enced on the visit to the care setting was verypowerful as it had the effect of ‘unveiling’ ourusual perceptions and allowed us to view itthrough this social lens of devaluation. Twoexperiences come to mind as illustrations.

In one setting for older people, I sat downnext to a few people who were in a room thatwas like an expanded part of the corridor. It wasvery quiet except for the ticking of the clock.

Ethics column

The governance and influence of clinicalpsychology: Professional ethics and theFrancis reportTony Wainwright


Tony Wainwright

I sat there for about an hour. During this timethe things that took place have stayed with me.Every so often there would be the sound of footsteps and then the door would burst open anda staff member would walk in and brightly say acollective hello to everyone and then disappearthrough the other door and after this briefburst of noise it went back to the clock ticking.The only other event during this hour was whena woman was helped in by a staff member andsat down. Her handbag was placed in a chairout of reach. The staff member left. This clearlydistressed the resident. She repeatedly calledout for her bag, but nothing was done. I remainguilty for not fetching her bag, but at the timewas trying to experience the life they had. Even-tually I did fetch it, and then left the setting.

My second memory concerns a learningdisability residential setting on bonfire night.There were no fireworks for the young peoplewho lived there, but they (and we the visitors)all stood in the back garden trying to peerthrough a very thick hedge to see the villagecelebrations. It was very sad that they were sep-arated in this way.

I have to say that I saw many much worseexamples of care, but the above haveremained with me as, while they were not asgraphic, they are just the day-to-day devalua-tions that people in these groups experience.The SRV account of how these things happenmakes good sense to me.

In another role as part of visiting teamswith the Commission for Health Improvementand the Healthcare Commission (Commissionfor Health Improvement, n.d.) in the 2000s,going to mainly large general hospitals I simi-larly witnessed (in addition to excellent care)some very poor care, particularly on older peo-ple’s wards. I recall one staff member saying tome that the decor didn’t really matter, as thepatients were ‘past their sell by date’. Thereports we wrote laid the responsibility for thislargely at the door of the Trust boards for notgetting it right, and this, in some cases,resulted in the resignation of senior staff.While I had some hope that standards mightimprove as a result, I was much less confidentin this analysis than in the one provided bySRV. Wolfensberger’s own recommendedapproach to dealing with poor care that peo-

ple may experience in hospital is for individu-als to voluntarily give their time to support andadvocate for those they care about rather thanhoping that government agencies will do this(Kendrick, 2007; Wolfensberger, 1992).

These societal processes of social devalua-tion have, of course, psychological aspects,and Mike Bender and I summarised some ofthese individual responses to people at risk ofdevaluation in a paper about dementia care:‘So sad to see good care go bad – but is it sur-prising?’ (Bender & Wainwright, 2003). Wewanted to make the point that it is likely thatgroups with these devalued identities willremain at risk and that it is not surprising thatbad things happen to them. The research wequoted was from the social psychology litera-ture (Asch, 1956; Festinger & Carlsmith, 1959;Milgram, 1974) to illustrate that the way webehave could best be understood as part of amuch wider social framework. More recentstudies of how we develop ethical blind spotsare well described in Bazerman and Tenbrun-sel’s work from the field of behavioural ethicsas applied in a business context, which focusesmore on, for example, cognitive biases (Bazer-man & Tenbrunsel, 2011a, 2011b).

Organisational cultureAnother important contextual strand that theinquiry noted was the presence of a bullyingand intimidating culture that they said needsto be challenged. My reading of this, and fromother points made in the report, is that thereis a widespread problem of unethical behav-iour among senior managers, arising fromtheir being put in positions where they feelpressured to cut corners to fulfil contractualtargets. The consequence has been toxic workenvironments where bullying and intimida-tion are not uncommon.

On 14 February 2014 in The Times, RobertFrancis said: ‘A repeat of the Stafford Hospi-tal scandal is still possible and it is “danger-ous” for NHS staff to think otherwise’, andwarned that health chiefs are still ‘bullying’hospitals to hit financial targets at theexpense of patient care, and says that ‘hospi-tals trying to put patients first will soon bedeterred if behaviour like this is not stopped’(Francis, 2014b).


Ethics column

That this is indeed a problem has beenacknowledged for some time (see for exampleresearch on training of medical staff (Paice &Smith, 2009).

Sir Ian Kennedy is another outspokencritic in this area. When Chair of the Health-care Commission, he stated that: ‘A bullyingculture in the NHS is permeating the deliveryof care… One thing that worries me morethan anything else in the NHS is bullying’(Santry, 2009).

This issue is one where ethics can quicklybecome compromised – indeed, bullying itselfis unethical. It leads to people being fearful ofacting in a way that is in conflict with theirmanagement colleagues, and to whistleblow-ing becoming the only option. As a follow onto the Mid Staffordshire inquiry, Robert Fran-cis is now chairing the Freedom to Speak UpReview (Francis, 2014a), described as an inde-pendent review into creating an open andhonest reporting culture in the NHS. The aimis that: ‘Those who speak up when things gowrong in the NHS should be welcomed for thecontribution they can make to patient safety.’

It is a commentary on all the previous ini-tiatives and their surrounding rhetoric thatthis is still needed, and leads me to return tothe point that wider social and political forcesare at play that need to be addressed.

Professional codes of ethics and conduct, clinical psychology and managementSo how can we link this context of culture andvalues to professional ethics and in particularthe British Psychological Society’s (BPS) Codeof Ethics and Conduct? In the introduction tothe Inquiry a central concern is indeed com-pliance with professional codes of ethics andconduct. Francis says of the role of the profes-sions and their compliance with their ownprofessional standards:

As has been frequently pointed out to the inquiry,the primary responsibility for allowing standardsat an acute hospital trust to become unacceptablemust lie with its Board, and the Trust’s profes-sional staff. The system is designed for directorsto lead and manage the provision of serviceswithin its allocated budget but in accordance

with required standards, and for professionalstaff, informed by their ethical standards andcommitment, to serve and protect their patients.If every board succeeded in that challenging task,and if all professional staff complied at alltimes with the ethics of their professions, therewould have been no need for the plethora oforganisations with commissioning and perform-ance management responsibilities. (Page 14,Part 1, Introduction – emphasis added).

As professional psychologists this asks us to con-sider why we might not comply at all times withthe ethics of our profession. It also has implica-tions for the function of the BPS. In the currentregulatory framework, how does the BPS act tosupport its members complying? In what waycould it enhance its current role to promote anethical culture in which professional staff work-ing to their codes of ethics and conduct wouldbe actively promoted by the organisation, witha strong focus on putting the patient first, asFrancis argues in the above quote.

In many Trusts, professional leadershiphas been weakened over the past few years.Perhaps the time has come to use the oppor-tunity created by the inquiry to review this,and for the DCP (and the Leadership andManagement Faculty in particular) to link itsstrategy for strengthening local professionalleadership to the promotion of an ethical cul-ture within the NHS.

This could be linked to another recom-mendation in the inquiry: that all managersshould be signed up to a code of ethics, andperhaps we could see a joint project of sup-porting managers and clinicians in complyingwith these principles. The use of codes ofethics is now widespread and the evidencegenerally support their use (The Center forthe Study of Ethics in the Professions, 2013).

This recommendation fits well with thework of Professor Derek Mowbray, clinicaland organisational psychologist, who has con-sistently argued that implementing a manage-ment code is badly needed and that it isprimarily this implementation aspect that isthe problem. He produced a Code for Managers(Mowbray, 2014) which has now been incor-porated into the Institute of Healthcare Man-agement Code and was formally adopted in


Tony Wainwright

January 2012. An excellent presentation out-lining the rationale for the code and its pur-pose is given in a presentation by Dame CarolBlack (Black, 2012), Expert Adviser on Healthand Work at the Department of Health, at itslaunch. At the end of her talk the last slidesays: ‘Please use the code’. Clearly, unless thecode is used it will not have much impact, andimplementation is going to be key here.

Another body that has taken this on is theProfessional Standards Authority – the regula-tor of regulators. They have published a codewhich sets out standards for members of NHSboards and clinical commissioning groups –the governing bodies in England (Profes-sional Standards Authority, 2013).

It sets out the following principles for man-agers and they have a familiar ring, being verysimilar to the BPS’s Code of Ethics and Conduct:n responsibility;n honesty;n openness;n respect;n professionalism;n leadership; andn integrity.

I have not been able to clarify the mechanismfor these codes to be implemented or howmanagers may be held to account. Whateveremerges in that context, however, we have a

golden opportunity for collaboration betweenour own professional body (whether the DCPor the BPS) to make the NHS a thoroughlyethical place to work and deliver services. Suchcodes, backed by professional bodies like theDCP and the Institute of Healthcare Manage-ment, provide a possible way to resist unethicalpolitical demands. It would suggest that nowwould be a good time for the cultivation of eth-ical communities in NHS organisations acrossall professional groups, including managers,who are often put in situations where their eth-ical standards can be compromised.

ImplementationThis special issue could be a game changer inhow the DCP links practice to action, as theinquiry gives us permission to intervene as pro-fessionals in the cultural landscape of healthand welfare which may have hitherto appearedto be too political for us as a professional body.Francis is very clear: we have an ethical duty toact and this may mean taking on powerfulvested interests and societal value systems if weare to have any real impact on quality of care.

Dr Tony WainwrightSenior Lecturer and Academic Lead, Doctoral Pro-gramme in Clinical Psychology, Washington Singer Lab-oratories, College of Life and Environmental Sciences,University of Exeter; [email protected]

Asch, S.E. (1956). Studies of Independence and Con-formity: 1. A minority of one against a unanimousmajority. Psychological Monographs, 70(9), 1–70.

Bazerman, M. & Tenbrunsel, A. (2011a). Blind Spots:Why we fail to do what's right and what to do about it.Princeton, NJ: Princeton University Press.

Bazerman, M. & Tenbrunsel, A. (2011b). Ethicalbreakdowns. Harvard Business Review, 89(4),58–65, 137.

Bender, M. & Wainwright, T. (2003). It's sad to seegood care go bad, but should we be surprised?[draft]. Journal of Dementia Care, 12(5), 27–28.

Black, C. (2012). Launch of the New Code. Retrievedfrom www.ihm.org.uk/en/about-us/code-of-con-duct/revised-code-of-conduct-launch.cfm

Center for the Study of Ethics in the Professions(2013). Professional Ethical Codes. Retrieved fromhttp://ethics.iit.edu/ecodes/introduction

Commission for Health Improvement (n.d.). Commis-sion Members. Retrieved from tinyurl.com/owopfnr

Festinger, L. & Carlsmith, J.M. (1959). Cognitive con-sequences of forced compliance. The Journal ofAbnormal and Social Psychology, 58(2), 203–210.

Francis, R. (Chair) (2013). Mid Staffordshire NHS FoundationTrust Public Inquiry Report. London: The StationeryOffice. Retrieved from www.midstaffspublicinquiry.com.

Francis, R. (2014a). Freedom to Speak Up Review.Retrieved from www.freedomtospeakup.org.uk.

Francis, R. (2014b). The NHS must not slip back intobad old ways. The Times, 6 February. Retrievedfrom www.thetimes.co.uk/tto/opinion/colum-nists/article3996858.ece

Kendrick, M. (2007). The challenges of authentically get-ting what people actually need on a person-by-per-son basis issue. The Frontline of Learning Disability, 69. Retrieved from www.socialrolevalorization.com/arti-cles/kendrick/challenges-of-authentically-getting-what-people-actually-need.pdf

Milgram, S. (1974). Obedience to Authority. London:Tavistock.

References


Ethics column

Mowbray, D. (2014). Management codes. ManagementAdvisory Service [website]. Retrieved fromwww.mas.org.uk/codes_of_management.html

Oliver, M. (2013). The social model of disability: Thirtyyears on. Disability & Society, 28(7), 1024–1026.DOI: 10.1080/09687599.2013.818773

Paice, E. & Smith, D. (2009). Bullying of trainee doc-tors is a patient safety issue. Clinical Teacher, 6(1),13-17. DOI: 10.1111/j.1743-498X.2008.00251.x

Professional Standards Authority (2013). Updated Stan-dards for Members of NHS Boards and CCG GoverningBodies in England. London: Author.

Santry, C. (2009). Bullying ‘permeating’ patient care,warns Healthcare Commission. Health Service Journal,1 April. Retrieved from www.hsj.co.uk/news/work-force/bullying-permeating-patient-care-warns-healthcare-commission/2007581.article#

Wolfensberger, W. (1972). The Principle of Normalizationin Human Services. Syracuse: Human Policy Press.

Wolfensberger, W. (1991). A Brief Introduction toSocial Role Valorization as a High-Order Concept forStructuring Human Services. Syracuse, NY: SyracuseUniversity.

Wolfensberger, W. (1992). A Guideline on Protectingthe Health and Lives of Patients in Hospitals, Espe-cially If the Patient is a Member of a Societally Deval-ued Class. Syracuse, NY: Training Institute forHuman Service Planning, Leadership andChange Agentry.

Wolfensberger, W. & Thomas, S. (1983). PASSING: Pro-gram Analysis of Service Systems’ Implementation of Nor-malization Goals: Normalization criteria and ratingsmanual. Downsview, ON: National Institute onMental Retardation.

Faculty of Psychosis & Complex Mental Health

Psychosis & Complex Mental Health Faculty Conference & AGM

Developing the Narrative 2: Putting the New Narrative into PracticeBPS London Office, 30 Tabernacle Street, London EC2A 4UE

Tuesday 4 November 2014, 9.00am–5.00pmBuilding on last year’s successful gathering of allies, we are taking the process a step forward withan opportunity to engage with the challenge of embedding the new narrative into everydayclinical practice. Real life examples of how this can be done will be provided by Lucy Johnstone(Formulation in teams), Russell Razzaque (Open Dialogue project in the UK), Spiritual CrisisNetwork (a completely different take on psychosis), along with workshops focused on innovativeresearch and practice.

The New Paradigm AllianceTaking forward last year’s themes of building alliances and creating visibility for a new approach tomental health in the public sphere, we will be introducing and discussing the New Paradigm Alliance.

Free event for Faculty of Psychosis & Complex Mental Health members only.

This event is being financially supported by the Faculty of Psychosis & Complex Mental HealthMembers, which has invested in it for the benefit of its members.

The PCMH AGM will be at the end of the day at 4.30pm.

To book go to:https://response.questback.com/britishpsychologicalsociety/pcmhannual14

All queries, please e-mail [email protected] with ‘PCMH narrative 2’ in the subject line.


THE EXPERIENCES of patients reportedby their families in the Mid Staffordshireinquiry were shocking, disturbing and

bewildering. It is difficult to hear and believethat people were not given food or water,and were allowed to lie in their own filth.These experiences were reported secondhand by patients’ families. What if it hadbeen you? Or me?

Well, as it happens, one time on admissionto a psychiatric ward, having been a vegetarianfor a decade and not having eaten for sometime, I was given liver at mealtime. There wereno other options. No-one seemed to know orcare that I was a vegetarian. I ate the liver andthat was the end of my vegetarianism, alongwith my belief that I had the same rights aspeople outside the hospital.

I am not comparing this experience to thatof those at Mid Staffordshire, but each timeI was in a psychiatric hospital there were manyoccasions where myself and my fellow patientswere treated in ways that suggested we were ofless value than others.

Francis witnessed descriptions of ‘badcare, denials of dignity, unnecessary suffer-ing’, and advocates that ‘people must alwayscome before numbers’. He said that theprovider Trust board ‘…did not listen suffi-ciently to its patients and staff’.

For many people, listening is a straightfor-ward thing – you either are or you’re not. Psy-chologists know that it is more complicatedthan that. Listening occurs within power rela-tionships. Some are more powerful than oth-ers. How welcoming is a nurse of a patient’sreflection on their care? How likely is a patientto express their opinion to the carer they aredependent on and at the mercy of? How pos-sible is it for a nurse to talk to their managerabout how easy it is to deliver care within the

current system? What about the managers? Dothey find board members eager to hear goodand bad news? Psychologists can help tounderstand these relationships and how theyrelate to effective communication. At theheart of it must always be how the system putspatients first.

Francis advocated openness, transparencyand candour. There is no point in being hon-est and open if there are negative repercus-sions as a result of it. The great irony is, do wetrust the NHS Trusts? Do the employees trusttheir managers and the board? It is only asgreater trust develops that these workplaceswill become stronger and more effective at tol-erating truth. Would there be some way ofusing the lessons of the truth and reconcilia-tion commission in South Africa?

We cannot complacently scapegoat MidStaffordshire and leave it at that. This scandalcame on the heels of Winterbourne View, thelatest of a long list of services for people withintellectual disabilities where there were seri-ous problems. As I talk to people who haveused services I hear stories of people whoselives have been saved by fantastic services.I also look at the psychiatric ward wherepatients hover outside the staff door waitingfor someone to speak to, with eight staff in theoffice ignoring them; many patients on thisward no longer having the courage to evenknock on the door, others driven by frustra-tion to walk right in. The system seems puz-zling and unhelpful.

There is a worrying tendency where thosewho are not part of systems are described asexhibiting ‘challenging behaviour’. Is thisterm now being misapplied in mental healthcare with the meaning becoming pejorative?A nurse on a general ward recently describedhow they have many patients with ‘challeng-

DCP Experts by Experience Column

Courage to tackle the real issuesJoanne Hemmingfield


DCP Experts by Experience Column

ing behaviour’. If the way the system relates tome causes me to feel frustrated and I expressthat, then am I labelled as showing ‘challeng-ing behaviour’? Then what? Has psychologygiven this expression to nurses, to schools tothe world? What sort of responsibility goeswith this?

As psychology departments have beenreduced it has become increasingly difficultfor clinical psychologists to feel that they aresupported by like-minded colleagues. There isan opportunity, by engaging with the DCPright now, to ensure that you are supported,to have your voice heard, and to ensure thepeople who use your services and the staff yousupport have their voices heard too.

It is essential that we do not get side-tracked by the red-herrings of the intellectu-ally fascinating or the areas that we feel mostcomfortable with as we grapple with thethorny issues raised by Francis. Yes, there is arole for looking at leadership – providing thatthere is a clear link with how this improvespatient reported experience. Yes, there is arole for looking at values and culture in organ-isations – providing, again it can be demon-strated that this indeed improves patientreported experience.

Where is the consideration for how wehear the patient voice, how we ensure thatwe know what sort of experiences patients

are having? The British Psychological Soci-ety’s work on Francis needs to be knittedtogether with our strategy for connecting anetwork of people who have used our serv-ices, in a hub and spoke model. In Englandthese networks will be focused around theregional branches (the spokes) and thenfrom this there will be potential candidatesto sit on the hub committee, which will workalongside the DCP Executive Committee.This model will ensure that the DCP is ableto take Francis and other crucial work for-ward in a way that we may stand a chance ofpreventing further tragedies in the futureand create services that we are truly proudof. If there is one lesson to be learnt, I sug-gest it is that people must always comebefore numbers. It is the individual experi-ences that lie behind statistics, benchmarksand action plans that really matter, and thatis what must never be forgotten when poli-cies are being made and implemented.

Joanne HemmingfieldDCP Lead for Service User and Carer Involvementin England

ReferenceFrancis, R. (Chair) (2013). Mid Staffordshire NHS Foundation

Trust Public Inquiry Report. London: The StationeryOffice. Retrieved from www.midstaffspublicinquiry.com.

Organisers of a wide range of workshops, seminars,conferences and events

For full details of our service and the events we organise visit:www.bps.org.uk/conferences

Tel: 0116 252 9555

E-mail: [email protected]


THIS IS A REFLECTIVE piece on my expe-rience as a trainee clinical psychologistworking on an in-patient dementia ward.

I consider my process of adapting to thisplacement, and the challenges psychologistsface in dementia wards.

I recently completed a placement involv-ing one day a week on an in-patient dementiaward, which was a completely new experiencefor me. I hope that my reflections on thisexperience are useful for others working withthis client group. This account, whilst subjec-tive, may be relevant for others who find them-selves on an in-patient ward, whether as staff,patient or visitor. Consideration of the chal-lenges in providing psychologically-based careto these clients may also be of benefit to thosecurrently working in this setting.

My initial expectations of the ward wereshaped by various factors, including mediarepresentations (fictional and factual), storiesfrom my colleagues in training, and my ownpersonal values around safety, mental healthand involuntary hospitalisation. I felt appre-hensive – uncertain I could feel comfortablein a ward environment, yet also enthusiasticabout working with this client group, forwhom I feel a great sense of compassion.

Chaos and anguishMy first experience of the ward was an unfairrepresentation of ward life. It confirmed myfears of a chaotic environment steeped in dis-tress where I would feel unsafe and helpless tohelp others. Intending to ‘ease me in’, mysupervisor invited me to the ward multidisci-plinary meeting (MDM). During the fourhour meeting, I was shocked by the shoutingand commotion occurring outside – chaos

leaking into the meeting through the distressof family members who attended, crying andshouting at one another. I had expected dis-tress but not to this extent! The other profes-sionals did not overtly respond to this anguish,so following suit, neither did I.

Trainees often gain a privileged insightinto placement environments; their ‘outsider’perspective, combined with curiosity andreflexivity developed through clinical train-ing, enable observations of systems which maybe unseen by those within. During the MDM,it appeared that staff must contain a great dealof the distress of others, in order to make dif-ficult decisions and provide care, while copingwith this distress themselves.

I wondered what strategies staff used tocope with the emotional impact of turmoiland distress, which may become ‘the norm’for them. Kitwood (1990) describes some ofthe detrimental strategies that staff use whenworking with people with dementia, such asdetachment – losing touch with the person asa human, potentially causing objectification.Staying attuned and empathetic in an environ-ment where there appears to be so much dis-tress may therefore be a challenge. It seemsimportant that staff are supported in copingwith the emotional impact of their work, par-ticularly those who may have received lesstraining and feel less a part of the staff team,such as agency staff.

A multifarious existenceMy second visit to the ward revealed a verydifferent aspect to ward life. The woman whohad been at the centre of much of the com-motion days earlier was now quiet and sub-dued, appearing pensive as she waited for

DCP Pre-Qualification Group Column

Seeing an in-patient dementia ward throughcurious eyes – A trainee’s experienceRachael Edge


DCP Pre-Qualification Group Column

her husband’s visit. The gentleman whosefamily had been so conflicted during theMDM was being doted on by the same familymembers, their disagreements replaced bytenderness and love. Another gentlemanovercame language barriers to joke with staff,miming and smiling.

Over the coming months, I noticed thiscontrast between chaos and harmony, frustra-tion and moving moments of poignancy.Safety had been a concern for me, yet I wasable to notice when the ward felt ‘charged’,often after a difficult morning for a patient,and which indicated further distress was likely.On days when the ward was quiet and calm,staff feared jinxing this fortune – scolding,‘don’t say that!’ when I highlighted the quiet-ness. Staff appeared to believe that calm daysoccurred through luck, not through their ownattunement and empathy for their patients’needs. Perhaps downplaying their own impacton the ward environment made it easier forstaff to tolerate distress when it did emerge –this being ‘bad luck’ rather than anythingwithin their control. My curiosity as a traineeencouraged staff to reflect on how theiractions may have contributed to ‘good days’,emphasising the positive impact they couldhave. The ‘good times’ seemed important forstaff to keep the person behind the ‘dementiapatient’ in mind, and in helping staff to copewhen things weren’t going so well.

Each time I left the ward, I felt acutely con-scious of my freedom compared to those inhospital under the Mental Health Act. I won-dered how it would feel to leave one of my par-ents there, particularly during times when theenvironment was highly emotional or‘charged’. These reflections diminished thelonger I worked on the ward, and I supposethose working there daily rarely think of this.Yet it strikes me that these are the things wemust hold in mind if we are to retain the per-son behind the ‘dementia patient’ we walkaway from at the end of each day. This empa-thy was sometimes difficult to spot, but atother times, it shimmered behind heartfeltconversations between staff who consideredhow they would feel if they were in the posi-tion of their patients’ loved ones, or what theywould be like if they had dementia.

A process of cultural adjustment occurredfor me. I learned to tolerate chaotic momentson the ward by keeping in mind the personfeeling distressed and using the informationI gathered to make recommendations. I wasable to acknowledge the distress that could beheard during MDMs in a contained manner,that I felt comfortable with, by making sympa-thetic utterances, and noticed others doingthis as well. These responses involved remain-ing in touch with the person, rather than dis-tancing from them.

When my placement ended, I felt confi-dent, competent and valued – inspired to‘bring the person back’ when talking withstaff, writing reports and contributing tomeetings. This is a strength of clinical psy-chology within acute dementia, where indi-viduals can be viewed as challenging orhopeless. Trainees especially can curiouslyexplore established organisational attitudesand practices, encouraging reflection andperspective taking.

Context and climateI became aware of some ambivalence towardsclinical psychology input, which had unfortu-nately been limited at times, with periods ofno psychologist due to staffing and organisa-tional changes. This is a common occurrencenationally within the current climate of auster-ity; limited budgets mean NHS resources arestretched, including clinical psychology withinacute care (DCP, 2012). Indeed, once myplacement ended, there would be no psychol-ogist on the ward for a time. Coupled with thistransience of psychology, was the inevitableinconsistency in staff collaboration due tochanging shifts. I visited the ward twiceweekly, but it was likely that any one staffmember would not see me for longer than aweek. It was no surprise then, when one staffmember commented, ‘We’ve coped withoutpsychology before’, and while this is likely tobe true, ‘coping’ may involve tolerance andstasis, rather than empathy and improvement.

NICE (2006) recommends psychologicalapproaches when addressing challengingbehaviour in dementia; such approaches canimprove quality of life for those who arereliant on others to provide this. While ward


Rachael Edge

staff appreciated psychological recommenda-tions, applying interventions consistently andin a sustained manner was difficult due to thechallenge of doing this across staff shifts andstaff members, which often included agencystaff. Effective intervention arises from collab-orative formulation of difficulties, with staffownership of interventions – it can thereforebe difficult to consistently apply ideas thatsome staff may not have had the opportunityto collaborate with, and which may seemimposed, rather than helpful.

Psychology on in-patient wards may oftenbe viewed as secondary to patients’ physicalneeds, and as something which there fre-quently isn’t time for. Paradoxically, the timeswhen psychology began to have an impactappears to be when psychologists had agreater and sustained presence on the ward,This perhaps highlights the need for psychol-ogy resources within some ward teams, inorder for effectiveness in collaborative psycho-logical interventions. At present, however, psy-chologists may be seen as visitors, as they arenot based within ward teams and are oftensplit between services – appearing an ‘add-on’to the essential in-house ward service.

Mutual benefitsThe complexity of ward environments mayinitially be overwhelming for trainees; how-

ever, exploring this system with curiosity, sup-ported by supervision, can enable reflectionson personal and systemic levels, benefitingboth trainees and placements. Regular, fre-quent, and sustained psychology input, whichis supported and enhanced by key ward staff,may increase the effectiveness of interven-tions, improving both patient conditions andstaff morale.

Rachael EdgeTrainee Clinical Psychologist, South Staffordshireand Shropshire NHS Foundation Trust;[email protected]

AcknowledgementWith thanks to Angela Young, ConsultantClinical Psychologist (South Staffordshire &Shropshire NHS Foundation Trust) for assis-tance with the development of this article.

ReferencesDivision of Clinical Psychology (2012). Commissioning

and Delivering Clinical Psychology in Acute Adult Men-tal Health Care. Leicester: British PsychologicalSociety.

Kitwood, T. (1990). The dialectics of dementia: Withparticular reference to Alzheimer’s disease. Ageingand Society, 10, 177–196.

NICE (2006). Supporting People with Dementia and TheirCarers in Health and Social Care. CG42. Manchester:Author.

Research DigestBlogging on brain and behaviour

Subscribe by RSS or e-mailwww.researchdigext.org.uk/blog

Become a fanwww.facebook.com/researchdigest

Follow the Digest editor atwww.twitter.com/researchdigest


LIKE MOST people in the UK, I wasbrought up to believe in the NHS. Hospi-tals are safe places where doctors and

nurses will be there to care and make us bet-ter, if they can. All that was shattered for meafter spending eight weeks on Ward 11 at MidStaffs in 2007.

What I saw during those weeks still hauntsmy dreams today and I suspect always will.I had no idea that a hospital ward could be sounsafe and so uncaring and I had no idea thatMid Staffs wasn’t an isolated case, and that Iwasn’t alone in my search for answers.

On this anniversary we must remember thatmany people were harmed at Mid Staffs andfamilies have been left devastated by how theirloved one suffered. Further damage was causedby how the NHS treated them afterwards whenthey complained about poor treatment.

Much has changed in the NHS since MidStaffs and the subsequent Francis inquiry.Things are changing for the better and theNHS is more transparent with its perform-ance, but the culture of denial identified bySir David Nicolson when he gave evidence tothe Public Accounts Committee in 2013 issadly still thriving.

Our group, Cure the NHS, helps thosewho believe they or their loved ones havebeen harmed unnecessary within the NHS.It’s disappointing that this culture of denialstill exists, but it does. Families want to knowthat when a mistake has been made, lessonshave been learnt and it won’t happen again.Organisations still fear litigation instead ofpromoting candour.

A sudden unexpected death is hardenough to deal with, but when you feel thatthe truth hasn’t been told it adds to the tor-ture. My mum was 86 years old and expectedto die, but that didn’t make it any easier. It wasthe way she died and the denial afterwardsthat has made grieving difficult.

Sir Liam Donaldson said as far back as2009 that: ‘To err is human, to cover up isunforgivable, to fail to learn is inexcusable’.This still challenges facing the NHS today andI deal daily with the consequences.

One woman who I assist has actually beento prison for wanting answers to her hus-band’s death (Daily Mail, 2012). She is stillsearching for answers many years later; stillturning events over and over in her head, try-ing to make sense of what happened. I hearfrom many in a similar position, stuck in astage of the grieving process unable to moveforward. Damaged by people they had somuch trust in and were socialised to.

We give little thought to those who havemade a mistake and harmed a patient.Danielle Ofri, writing about the emotionalside of medicine, rightly points out that wespend time creating new system approaches,relabelling medication, and so forth, to dealwith medical errors, but instead we need tobring them out in the open and talk aboutthem (Ofri, 2013).

How difficult is it for a clinician/nursewhen they fear admitting a mistake has beenmade? An admission that isn’t easy in the firstplace, but even harder when the values withinthe organisation don’t welcome candour.

At the Mid Staffordshire Public Inquiry weheard that speaking up and out about errors was-n’t encouraged. Also highlighted recently byRobert Francis, who is chairing the review Free-dom to Speak Up (www.freedomtospeakup.org.uk)to ensure those that raise concerns within theNHS around patients safety can do so safely.

Creating a safe learning environment is aleader’s role within the NHS. Where errorscan be made and talked about and learntfrom to ensure they don’t happen again, thepublic expect nothing less.

Until the NHS creates this leadership andenvironment, I will continue to hear from

Cure the NHSJulie Bailey


Julie Bailey

poor souls who struggle to find answers andtorture themselves trying to do so.

We don’t go away, some will continue tosearch for answers, possibly forever. Others,like myself, can help to work towards a saferNHS. I have Cure the NHS and my family tothank for giving me the support and strengthto do that; others haven’t that luxury. I havefound the system offers little in the way ofsupport for the public or its staff, and thatmust change.

I hope a safer NHS for patients and staffwill one day be the Mid Staffs legacy. Where toerr happens, covering up doesn’t and notlearning from a mistake is a never event.

AuthorJulie Bailey CBE, Founder, Cure the NHS;[email protected]

ReferencesNarain, J. (2012). Widow, 74, who stalked hospital

chief executive and bombarded her with late-night calls over her husband's 'poor care' is jailed.Daily Mail, 6 September. Retrieved from www.dai-lymail.co.uk/news/article-2199137/Widow-74-stalked-hospital-chief-executive-bombarded-late-night-calls-husbands-poor-care-jailed.html

Donaldson, L. (2004). To err is human, to cover up isunforgivable, and to fail to learn is inexcusable. Speechto the World Alliance for Patient Safety in Wash-ington DC.


Nicholson, D. (2013). Evidence Presented to the CommonsSelect Committee on Health, 5 March. Retrieved fromwww.publications.parliament.uk/pa/cm201314/cmselect/cmhealth/657/130305.htm

Ofri, D. (2013). What Doctors Feel: How emotions affect thepractice of medicine. Boston, MA: Beacon.

Cure the NHSJulie Bailey is founder of Cure the NHS, a group she established in December 2007 after thedeath of her mother in Mid Staffs Foundation Trust Hospital. The group successfully campaignedfor a public inquiry into the failings at the hospital and the wider NHS.

Cure the NHS offers support and advice to people throughout the country who have beenharmed within the NHS and the group has recently become a small charity.

Julie speaks to a wide range of audiences and has been working with leaders from England,Scotland and Wales. Her book From Ward to Whitehall: The disaster at Mid Staffs captures thestruggle she had to be heard to help to expose systemic failings within the NHS.

Julie was awarded a CBE in the New Year’s Honours list for her services to older people. Shewas recently awarded 2nd place in the Woman’s Hour Power List 2014, as one of the top gamechangers operating in the UK today. The group continues to campaign for a safer NHS forpatients and its staff.

Back issues available onlineDCP members can download recent issuesof Clinical Psychology Forum free of chargefrom the BPS Shop:

www.bpsshop.org.uk


OVER THE PAST few years many organi-sations have been exposed as havingserious issues around culture, leader-

ship, whistleblowing, the interface with cus-tomers, clients and patients, the behaviour ofstaff with each other, the disengagement ofthe workforce from work and their employers,and the disconnection between staff and man-agers. This adds up to concerns about theworkforce and raises questions about itscapacity to provide high quality and effectiveservices in the context of such discontent.

Engagement between a person, others, theirwork and their employing organisation is knownto improve performance. Social engagement,also known as affective engagement, is charac-terised by vigour, dedication and absorption,and is a feature of positive working cultures,good leadership, good workingenvironment and resilient people.Social engagement is a goal worthaiming for, not only because ofimproved performance, butbecause the processes of attainingthis form of engagement involvesthe reduction of psycho-presen-teeism – people being present atwork in body but not in mind – and the associ-ated costs, normally between one and a half andtwo times the combined costs associated withsickness, absence and attrition attributable topsychological distress. The Organisation for Eco-nomic Co-operation and Development (OECD,2014) calculated the total cost of mental healthissues including presenteeism in the UK to be£70 billion per annum.

Calls for a change in culture are now fre-quent, with the most recent being that fromthe Public Administration Select Committeein April 2014, over the public sector handlingof complaints from the public.

Recommendations on how to change cul-ture and transform the public sector havecome from various sources, including (with

respect to the NHS) the Mid Staffordshire NHSFoundation Trust Public Inquiry Report, followedby a A Promise to Learn – A Commitment to Act:Report on improving the safety of patients in Eng-land, both published in 2013 and both ofwhich identified the catastrophic conse-quences of dis-engagement.

The impact of challenges facing the work-force in the NHS had been brewing for anumber of years preceding these reports, asshown in the NHS annual staff surveys andother major inquiries.

Amongst several initiatives to change andtransform the NHS into a positive working cul-ture that predate these reports was the publica-tion of the Code of Conduct for Managers in Healthand Social Care, based on the work of theauthor, launched by Dame Carol Black in Jan-

uary 2012 on behalf of The Insti-tute of Healthcare Management.This code set out behaviours toachieve commitment, trust andengagement between managersand the workforce, leading to a cul-ture based on psychological well-being and performance. It was apiece of work that involved all the

major professional organisations, including theBPS, trade unions and representatives of theWelsh Government and the Department ofHealth. Efforts to promulgate this code as theNHS code have been thwarted (probably as aresult of being caught up in the discussionsabout manager regulation and licensing), giv-ing rise to speculation about the commitmentof senior people in the NHS to genuine cultureand leadership change, as this was the focus ofthe code.

Psychological responsibilityAs part of his continuing development ofapproaches to transforming cultures, theauthor has brought together under a singleframework (the WellBeing and Performance

Psychological responsibilityDerek Mowbray

Socialengagement is a goal worthaiming for…


Derek Mowbray

Agenda) the behaviours and actions that areknown to trigger responses that can lead toindividual and corporate peak performance asa consequence of embedding psychologicalwell-being in the workforce. One of the mainpillars of this framework is social engagement.The WellBeing and Performance Agendadepends on the workforce adopting behav-iours that trigger trust, commitment, engage-ment and kinship in others, as these areevidenced as being the behaviours that reducethe risk of psycho-presenteeism and encour-age psychological well-being.

Introducing into organisations the ideathat everyone needs to behave in certain waysis a substantial challenge requiring changes inattitude by managers towards the workforce.The change needed is from approaches thatexploit to approaches that nurture.

The global project to encourage organisa-tions to adopt ‘social responsibility’ (a respon-sibility for their impact on the environment)has had a major impact on the way businessesand services have changed theirattitude towards their engage-ment with local communities.Those businesses and services thathave adopted social responsibilityare amongst the most successful inthe world.

The idea of social responsibil-ity has spawned in the author theidea of psychological responsibilitywhich aims to encourage everyoneat work (and elsewhere) to change attitudestowards themselves and others with whom theyengage. The ultimate aim is to attenuate therisk of psycho-presenteeism, improve socialengagement and provide the opportunity forimproved or enhanced personal performance.

Encouraging everyone to adopt psycholog-ical responsibility is a process that requirespeople to think about themselves and theirimpact on others. It is also a process of devel-oping a psychological culture, one that has theinterests and well-being of people at its centre.

The slogan that accompanies the psycholog-ical responsibility headline relates directly tothe behaviours needed to enhance the opportu-nity of the workforce to achieve output behav-iours of commitment, trust, social engagement

and kinship at work. These output behaviours,when people are encouraged to focus on workusing motivation and provoking concentration,produce high level performance:n Think independently is linked to

Attentiveness and Intellectual flexibility.n Be attentive to others links to

attentiveness and encouragement.n Act with humanity links to attentiveness,

reliability, conflict resolution andencouragement.

Responsibility is how people feel. People takeit upon themselves to feel responsible fortheir own actions by being accountable tothemselves for them. Therefore, people whotake psychological responsibility need to feelaccountable to themselves for their own psy-chological welfare as well as being account-able for their impact on others.

This has been shown to be a powerful tech-nique in encouraging people to think beforethey act and behave. Simply talking about psy-

chological responsibility makespeople more aware of their ownbehaviour and the behaviour ofothers. It is the beginning of aprocess to bring a cultural shifttowards nurturing the workforceas opposed to exploiting it. Nur-turing people enhances their psy-chological well-being. The processinvolves triggering key featuressuch as, for example, attentive-

ness, challenges, encouragement, career pro-gression, involvement and openness.

People who feel psychologically well per-form better than those who don’t. Feelingexploited, however, does the opposite. If a per-son feels exploited this plays to negative influ-ences on attitude, on being personally valued,on self-esteem and self-worth. For those organ-isations seeking to perform at their peak,exploitation is to be avoided. In the NHS, thecurrent excess squeeze on money, and theincreased demand for more from less, com-bined with the reshaping of jobs and grades,gives rise to a sense of exploitation.

The idea of psychological responsibility alsohelps to counterbalance the emergence of theisolation, frenetic experiences, quick fixes and

A cultural shift towardsnurturing theworkforce asopposed toexploiting it.


Psychological responsibility

the impact of social media on relationships byencouraging individuals to think about otherpeople, about the impact we have on eachother, and how this impacts on our psychologi-cal well-being as well as that of others.

Psychological responsibility has a link tomindfulness, which is about being in the pres-ent. Mindfulness is also about taking responsi-bility for your own thoughts and feelings inthe present. Used as a means of delaying reac-tions to events and other people, mindfulnessacts as a moderator for behaviour and cancalm people down in the face of a challengingevent or difficult behaviour.

In the workplace, when everyone adopts psy-chological responsibility they start the processesof being attentive to others; the processes of cre-ating and sustaining trust, commitment andengagement. These behaviours play to psycho-logical well-being and the reduction of psycho-presenteeism. The benefits that arise includeimproved performance, the prevention of psy-cho-presenteeism, a reduction in costs associ-ated with psycho-presenteeism, sickness,absence and attrition, and the creation of a cul-ture that provokes social engagement, with theconsequences of vibrancy, innovation, adaptabil-ity, corporate resilience and peak performance.

Psychological responsibility on its ownisn’t sufficient to bring the cultural and lead-ership changes the NHS needs. Embeddingpsychological responsibility in organisationsrequires the implementation of The WellBe-ing and Performance Agenda. This agenda isdesigned to enable organisations to achievepeak performance by sustaining psychologicalwell-being in the workforce.

The WellBeing and Performance AgendaThe WellBeing and Performance Agendatransforms first level behaviours – attentive-ness, reliability, intellectual flexibility, conflictresolution and encouragement (psychologicalresponsibility) – into second level outputbehaviours (commitment, trust, engagement,kinship, motivation and concentration).

The overall process is shown in Figure 1.It involves introducing input behaviours intoorganisations using the WellBeing and Perform-ance Agenda to produce the output behavioursthat provoke commitment, trust, engagement,kinship, motivation and concentration. Theresult is the potential for peak performancefrom individuals and the organisation.

The underlying principle of the WellBeingand Performance Agenda is ‘sharing responsi-

Figure 1: WellBeing and Performance Development Framework


Derek Mowbray

bility for the future success of the organisa-tion’. This is the focus for each of the ele-ments of the agenda.

The elements are: adaptive culture, adap-tive leadership, adaptive working environ-ment, and the adaptive and resilient person.Each element has specific activities andactions to be put in place that reinforce theutility of the psychological responsibilitybehaviours in achieving psychological well-being and performance. These are shown inthe figure.

Adaptive leadership, for example, is basedon ‘sharing responsibility for the futuresuccess of the organisation, and is a processthat ensures that all members of the work-force have the organisation and its future astheir focus, not the requirements of man-agers. The ingredients that make this happeninclude:n independent judgment is expected;n elephants in the room are raised

and dealt with; n reflective and continuous learning

is institutionalised; andn leadership capacity is extended.

A distinction is drawn between technical chal-lenges for which solutions are known andadaptive challenges for which solutions arespeculative.

As so many organisational challenges areadaptive, the need to capture the combinedintelligence of the workforce is an essentialingredient to reaching decisions which reduceand limit their ambiguity. Adaptive leadershipprocesses eliminate the need for people towhistleblow.

The role of managers becomes that of aconductor of a choir, ensuring that all partscontribute effectively, whilst allowing eachperson to interpret the music and critique thecontributions of others if they are felt not tobe contributing to the overall success of thepiece. In effect, each member of the choir actsas though they are the conductor, whilstrecognising that one person has the oversightand needs to bring everything together.

There are certain behaviours needed tomake this happen without everyone descend-ing into chaos.

Psychological responsibility behavioursThe behaviours are those that provoke com-mitment, trust and engagement in others.

Attentiveness – Arguably the most impor-tant behaviour to demonstrate. If someone isattentive to you, and you feel they are beingattentive, it is almost impossible not to recip-rocate and to be attentive in return. This isthe essence of successful interaction, butrequires considerable skill, concentrationand practice. Clinicians will argue that atten-tiveness is essential in the clinical setting toensure appropriate assessment and treat-ment. Managers, however, tend to find atten-tiveness more difficult to achieve, as they areoften more concerned about putting overtheir point to others than considering thethoughts and feelings of those with whomthey interact. This can apply to others in theworkforce whose consideration of others maynot be at the top of their own personalagenda in interaction.

Reliability – Strongly linked to trust,which is derived from reliability. Trust is theabsence of second guessing the motivation ofothers. Trust occurs when we take people atface value and expend virtually no resourcesin working out the persons’ motivations foractions and what they say. We rely on peoplewe trust. Reliability, leading to trust, isdemonstrated by consistency of opennessand transparency.

Intellectual flexibility – A capacity to‘think on your feet’. This requires being ableto think independently and respond to any sit-uation by demonstrating thoughtful responseswhich are not obviously aligned to a knownagenda. When this occurs, it is also a sign thatthose engaged in an interaction are ‘free’ tothink independently.

Conflict resolution – The capacity to nego-tiate in an interaction and, where necessary,arrive at a compromise when a conflict is antic-ipated. This requires considerable skill, con-centration and practice, as well as attentivenessand understanding the self-interest of others.

Encouragement – The support providedfrom one to the other in interaction to say anddo things.

All the behaviours add up to humanity –Tending and befriending others, in an envi-


Psychological responsibility

ronment of reciprocal kinship which con-tributes to mutual psychological well-being.

ImplementationThe words ‘psychological responsibility’ con-jures up many possible interpretations, and inmany ways this doesn’t matter. Introducingthe words into everyday discussion at work hasan impact and makes people stop to thinkabout what it means.

To date, the implementation of this ideahas been part of the implementation of TheWellBeing and Performance Agenda. Thisinvolves three stages of implementation – rais-ing awareness of all the challenges and possi-ble solutions using the agenda (for example,by presentations and workshops; implement-ing the agenda which follows the strategy ofconviction and uses action research and learn-ing methods; and mentoring internal champi-ons for change and coaching in behaviours –e.g. instead of saying ‘I am going to talk toMiss Smith’, say ‘I am going to listen to MissSmith’). The third stage is embedding theagenda, which uses methods to reinforcechange, such as ensuring the elements of theagenda are regularly reviewed by managerswith their teams.

However, there is no reason why the imple-mentation of psychological responsibilityshould not be a stand-alone project. Whilst itwill not transform culture and leadership onits own, it starts the process of change. Thiscould involve the introduction of cards as away forward with the slogan for psychologicalresponsibility conveying its meaning. If everymember of staff had a card with psychologicalresponsibility and the slogan printed on it, itwould provide a physical reminder of what isexpected in practice. Implementing the ideaalso requires articles to be written in newslet-ters and elsewhere, so that it becomes a com-mon phrase. It requires managers to placepsychological responsibility on the agenda fortheir meetings with staff, and to encouragediscussion about where the idea has made adifference to relationships between staff andbetween staff and their clients or patients.

Psychological responsibility could alsobecome a unifying feature for applied psychol-ogists. Adopting the words could become a uni-

fying purpose for applied psychologists work-ing inside organisations and other communi-ties – a purpose that is ultimately intended tochange attitudes towards people and raise thelevel of consciousness about the importance ofattentive and humane interactions.

ConclusionPsychological responsibility is an idea to assistwith transforming culture in organisationsfrom one of exploitation to one of nurturingand social engagement. This is achievable inany organisation if people think about theirinteractions with others.

Such an approach has an impact on theworkforce, and in conjunction with imple-menting The WellBeing and PerformanceAgenda, would have reduced the risks ofbehaviours highlighted in recent inquiries inthe NHS.

AuthorDr Derek Mowbray, Applied Psychologist;Chair, WellBeing and Performance Group;Director, Management Advisory Service;Director, Organisation Health; Director,National Centre for Applied Psychology; Visit-ing Professor of Psychology, NorthumbriaUniversity; Tutor, MSc in Wellbeing and Per-formance, Applied Psychology Centre, Uni-versity of Gloucestershire; Vice President,International Stress Management Association;[email protected]

ReferencesBerwick, D. (2013). A Promise to Learn, a Commitment to

Act: The Berwick review into patient safety. London:Department of Health.

Francis, R. (Chair) (2013). Mid Staffordshire NHS FoundationTrust Public Inquiry Report. London: The StationeryOffice. Retrieved from www.midstaffspublicinquiry.com

Institute of Healthcare Management (2012). IHMManagement Code. London: Author. Retrieved fromwww.ihm.org.uk/en/about-us/management-code/index.cfm

Organisation for Economic Co-operation and Develop-ment (2014). Making Mental Health Count: The socialand economic costs of neglecting mental health care. Paris:OECD Publishing. DOI: 10.1787/9789264208445-en

Public Administration Select Committee (2014). MoreComplaints Please! and Time for a People's OmbudsmanService. Third Special Report. London: Her Majesty’sStationery Office.


STAFF EXPERIENCE is at the heart oforganisational culture in the NHS andintimately related to patient experience

(Maben, 2010). The drive to improve organi-sational culture derives to a great extent fromthe concern that patients have suffered need-lessly and their clinical outcomes been com-promised while using healthcare services(Francis, 2013). National data from staff sur-veys and other sources tell us that staff are suf-fering too (Berwick, 2013; Ballat & Camping,2011). Constant change, job cuts, insecurityand increasing work volume are creating highlevels of anxiety in healthcareorganisations. Anxiety is managedthrough various means, somemore functional than others, thatcan be broadly categorised interms of creating defences and/orcreating meaning (i.e. creating adistance between oneself andwhat is difficult, or making senseof what is happening). This hap-pens at both an individual and anorganisational level (Obholzer &Roberts, 1994). It is through helping organisa-tions to understand the impact of this anxietyand manage it in a reality-based way that psy-chologists can make the greatest impact onorganisational culture. Schwartz Rounds arean organisational intervention in which themanagement of anxiety and the managementof meaning come together in a group explo-ration of the psychological impact of work andof organisational culture on both troublingand rewarding staff experiences.

Schwartz Center Rounds (The SchwartzCenter, n.d.) originated in the US and pro-vide a forum for healthcare staff to come

together once a month to explore togetherthe non-clinical aspects of caring for patients– the psychological, social and emotional chal-lenges. They were piloted in two UK sites (theRoyal Free London NHS Foundation Trustand Cheltenham and Gloucester FoundationNHS Trust) and more than four years later arestill running successfully in both hospitals.

Each Schwartz Round lasts for one hourand includes a presentation of a patient expe-rience by a multidisciplinary panel who go onto describe the impact that the patient experi-ence has had on them. A typical panel will

include 3 or 4 staff, all involved ina case, who will each describe theirunique experience of it. Occasion-ally, Rounds are theme ratherthan case based. For example,‘A patient I’ll never forget’, wheneach presenter describes a patientfrom their past and why they hadsuch an impact on them. Once thepanel have presented, a facilitatorand a medical lead (who jointlyfacilitate the Round) help the

audience to make a connection between thestories they have just heard and similar experi-ences of their own. The Round then becomesa group reflection on work experience withthe facilitators creating links between the sto-ries that are shared, and drawing out per-sonal, professional and organisational themesthat emerge.

The implementation of Schwartz Roundshas been recommended in the Department ofHealth’s response to the Francis inquiry. ThePoint of Care Foundation (www.pointofcare-foundation.org.uk) is now rolling outSchwartz Rounds across the UK and provides

Schwartz Rounds: An intervention withpotential to simultaneously improve staffexperience and organisational cultureBarbara Wren

…understandthe impact of this anxiety

and manage it in a reality-based way.


Schwartz Rounds: An intervention with potential

support, mentoring and training to neworganisations starting Schwartz Rounds. Theauthor works with the Point of Care Founda-tion as Lead Mentor and Psychologist, and hasdeveloped the training and mentoring modelthat is provided to healthcare organisations tosupport successful implementation ofSchwartz Rounds (see Wren, 2012, for a fur-ther discussion of these points).

Schwartz Rounds at the Royal FreeThe Rounds take place once a month in aneutral setting, a large meeting room wherehigh profile meetings are held. The day of theweek is varied to increase their accessibility tostaff on different shifts. While the Roundstarts at 1.00pm, lunch is available for stafffrom 12.30pm and has been shown to be animportant part of the experience of theRounds, highly valued by staff andproviding an opportunity for dis-cussion, support and reflection onthe Rounds. The Rounds wereintroduced as part of a pro-gramme to improve organisationalculture and began at a time whenthere was a commitment fromexecutive level to look at a rangeof ways to improve staff experi-ence. They were launched with thefull and visible support of theTrust Board. The support that the Roundsreceived at all levels of the organisation andthe way in which staff engaged with them sug-gested that there was a state of organisationalreadiness for new ways of talking about theimpact of patient experience and just what itis like working in a healthcare organisation.This experience has been repeated again andagain throughout the country in organisationswhich have started the Rounds, where theyhave been found to be highly appealing tostaff and very well regarded and supported.

From the start, Royal Free Rounds havebeen very well attended and powerfully mov-ing, and staff have participated fully, openlyand honestly. The evaluation consistentlyshows that staff highly value them, and the wayin which they have been responded to sug-gests that they meet an important need.Rounds are restorative and allow staff to con-

structively process difficult work experience,and gain reassurance and support. They equipstaff with new ways of thinking about diffi-culty, reduce isolation, develop community,and role model coping with difficult emotions(Goodrich, 2011). Staff also report that thepresence of the Rounds makes them feelproud to work for their organisation andreconnected to the values that first broughtthem into healthcare (Wren, 2012). Four anda half years later between 60 and 140 staffattend the Royal Free Rounds each monthand the evaluation data shows that they areconsistently highly rated and valued by staff.

How do Schwartz Rounds work?There are a number of psychological mecha-nisms by which Schwartz rounds may be hav-ing an impact on staff experience and

organisational culture. Researchon supervision highlights theimportance of reflective space indetoxifying the impact of emo-tional labour and providing spaceto think and remain effectivewhile staying engaged with theemotional content of work. Rolemodelling is also an importantpart of a Schwartz interventionand there are many benefits forjunior staff in witnessing senior

staff role discussing their own human frailtyand vulnerability. It is proposed that the fol-lowing mechanisms are all at work in aSchwartz Round.

An opportunity to witness and a sense of communityThe creation of resonance that occurs inSchwartz Rounds, that is developed throughauthentic storytelling, draws colleaguestogether and creates a sense of belonging.Witnessing increases the group’s appreciationof colleagues and the tough work they do.Both experiences create a sense of shared pur-pose and community.

A reduction in isolationHealthcare workers have poorer mentalhealth (Wren & Michie, 2003). Rounds helpstaff realise they are not alone, that feelings of

…reconnectedto the

values that first broughtthem into

healthcare…


Barbara Wren

incompetence and helplessness are common(and not necessarily related to actual perform-ance), and that vulnerability is acceptable andcan be acknowledged. This provides opportu-nities for profound relief.

A sense of coherence – an antidote to fragmentationA sense of coherence (Antonovsky, 1987)helps people to stay well and even able toimprove their health despite stressful experi-ences and situation. Regular attendance atRounds may provide a sense of coherencethrough the following three elements of theRounds experience:(i) increasing comprehensibility of difficult

work experience;(ii) enhancing a sense of manageability; and(iii) restoring meaningfulness.

An increase in compassion and inunderstanding the cost of doing healthcare workHealthcare staff have been shown to be proneto self-criticism and perfectionism (Firth-Coz-ens, 2001) and the extent to which the processof attending Rounds may influence how staffrelate to their own inner experience of doubt,self-criticism and anxiety is a fruitful one forexploration. Attenders at Schwartz Rounds areoften very moved by the stories they hear theircolleagues tell and the effort they have putinto their work. Over time it is likely that thismay increase their compassion for themselvesas they see repeated acknowledgement in theRound of how tough healthcare work is andhow vulnerable all staff can feel regardless oftheir role or their position in the organisation.

Coming to terms with ‘a failure to repair’Rounds provide opportunities for attenders toconsider their relationship to themselves,their chosen healthcare role and the feelingsthey have about the extent to which theirorganisation supports them in achieving theobjectives of their role. Their motivation totake up this role will stem from conscious andunconscious personal and professional quali-ties and goals (Obholzer & Roberts, 1994).Achieving these complex goals is healing,enriching and rewarding. Being frustrated in

the achievement of these goals is stressful,damaging and can cause significant ill-healthand relationship breakdown at work. ManySchwartz Rounds are concerned with caseswhere the healthcare professional was unableto ‘make it better’. Attenders are often movedby the openness with which panellists describetheir sense of failure in relation to difficultcases, and over time Rounds discussions havetackled this difficult experience and sup-ported and contributed to an understandingof staff who have expressed it.

Coming to terms with inadequatecontainment by healthcare organisationsAside from the difficulties posed by the natureof the work, healthcare contexts are becomingtougher and tougher places to be. While agen-das around staff well-being are espoused,healthcare work can expose staff to harm, andhealthcare management style and constantchange increasingly does. Rounds discussionsoften contain an underlying hope that some-where there is a policy or strategy that will dealwith this and that the organisation ‘must’ beable to protect them. Over time the Roundshelp the community of staff to digest the factthat maybe there isn’t, it can’t, and to reflecton and appreciate how they are withstandingpainful situations – and surviving in caseswhere it would be difficult to thrive.

A reconnection to the values that motivatedthe decision to enter health careBy reaching for the story of their experienceof a patient, staff connect to the values thatmotivate them – this is an affirming experi-ence that can help staff to withstand the ongo-ing worry that these values are being erodedin the current climate. Schwartz Rounds mayhelp staff to hold fast to these values, espe-cially when they can feel that they are notbeing held safely anywhere else.

A performance – a peek behind the curtainBusy staff can experience a silo version of theirorganisation – feedback from the Rounds isthat attenders really enjoy hearing about otherpeople’s work and feelings. Everyone is curi-ous about ‘other people’s business’. Roundssatisfy that curiosity. In this way, perhaps they


Schwartz Rounds: An intervention with potential

also have an opportunity to reduce mispercep-tions, clarify mysteries and bring darker areasout into the open – and in a legitimate way.

A consideration of the personal with theprofessional – Giving permission for stories oflove, hate, hope, loss, satisfaction and regretSchwartz rounds reveal the person in the pro-fessional role – the person who has beenaffected by their work – the person who madea connection to a patient to improve theirexperience. The experience of doing this andobserving other people do it gives permissionto reveal the deeply personal aspects of self thatmotivate staff in their work, and the relation-ships through which they carry out they work.

Levelling the playing fieldEveryone in the hospital is invited to the Round– a recognition that all staff contribute to thecommunity of this organisation – and areaffected by its work. Rounds discussions createequality, model democracy, and allow staff tohear and understand the experiences of col-leagues they would not normally have access to.

New consideration of how to negotiate relationshipsSchwartz rounds are not just individual storiesbut involve a team ‘performing’ a story – thedelicate negotiations and adjustments that areinvolved in the relationships that created thatpatient experience and also created that story,are both explicitly and implicitly exposed in

the storytelling. Panellists sometimes describetheir awareness of the impact they were hav-ing on each other and how it grew in prepar-ing the Round. This creates opportunities inthe Round to discuss how relationships arenegotiated, to consider how different health-care roles position people, to reflect on thedifficulty of challenging colleagues, and toappreciate the pleasure of teamwork.

ConclusionTelling stories, and building and maintainingattachments and connections help with themanagement of anxiety and meaning, as dostaying connected to values and having space tomake sense of and process experience.Schwartz Rounds create a space in which allthese activities and processes are possible, whileproviding a cumulative and sustaining sharedorganisational experience that difficulty andcomplexity can be named and withstood, evenif circumstances cannot be changed. In thisway, healthcare organisations and their staffcan be helped to be more reality based in theirunderstanding of problems, and in the mainte-nance of compassion for patients, but maybemore importantly, for themselves.

AuthorBarbara Wren, CPsychol, AFBPsS, ConsultantPsychologist and Schwartz Round Lead, RoyalFree London NHS Foundation Trust; LeadMentor and Psychologist, The Point of CareFoundation; [email protected]

Antonovsky, A. (1987). Unraveling the Mystery of Health:How people manage stress and stay well. San Francisco:Jossey-Bass Publishers.

Ballat, J. & Campling, P. (2011). Intelligent Kindness:Reforming the culture of healthcare. London: RCPsychPublications.

Berwick, D. (2013). A Promise to Learn, a Commitment toAct: The Berwick review into patient safety. London:Department of Health.

Firth-Cozens, J. (2001). Interventions to improve physi-cians’ well-being and patient care. Social Science andMedicine, 52, 215–222.


Goodrich, J. (2011). Schwartz Center Rounds: Evaluationof the UK pilot. London: Kings Fund.

Maben, J. (2010). The feelgood factor: Evidencefor a link between staff well-being and the qual-ity of patient care. Nursing Standard, 24(30),70–71.

Obholzer, A. & Roberts, V.Z. (Eds.) (1994). The Uncon-scious at Work. London: Routledge.

Schwartz Center (n.d.). Schwartz Center Rounds.Retrieved from www.theschwartzcenter.org/View-Page.aspx?pageId=20

Wren, B. (2012). Schwartz Rounds: Creating new spacesand having new conversations in healthcare organisa-tions. Paper Presented at OPUS International Con-ference, London, November.

Wren, B. & Michie, S. (2003). Staff Experience of theHealth Care System. In Llewellyn, S. & Kennedy, P.(Eds.) (2003). Handbook of Clinical Health Psychol-ogy. Oxford: Wiley.

References


SCHWARTZ ROUNDS originated in theUS and were initially piloted by theKing’s Fund (renamed The Point of Care

Foundation (PCF) in 2013) in the UK in 2009following recognition of their positive out-comes for staff (which ultimately benefitedpatients; Goodrich, 2011). ThePCF has been involved in thedevelopment of Rounds in theUK since then. The main aim ofRounds is to provide a forum forstaff from all disciplines to cometogether to explore and discussthe emotional challenges thattheir work can create for them.Schwartz Rounds adhere to astructured process which isdescribed by the PCF (2013).

In our Welsh health board (Abertawe BroMorgannwg University Health Board (ABM)),due to a growing awareness of the strains onNHS staff accompanied by some negativemedia coverage about poor patient experi-ence, a direct request from the CEO was madeto introduce Schwartz into the organisation.ABM provides a full range of services along acentral section of the South Wales corridor fora population of 500,000 and employs 16,500staff with a budget of £1.3 billion. The ABM isthe first organisation to launch SchwartzRounds in Wales.

A steering group was formed and a subse-quent planning committee created frominterested individuals, including representa-tion from Senior Nursing, Nurse Education,Clinical Psychology, Chaplaincy, allied healthprofessions, and medicine, including pallia-

tive and anaesthetic services. The authors ofthis article were chosen as the initial Roundfacilitators and duly attended PCF Schwartztraining in London. Part of the Schwartzlicence includes mentorship from a moreestablished site, which in our case is from

Cheltenham & Gloucester NHSTrust and for whose support wecontinue to be immensely grate-ful. Due to the size of our healthboard it was decided that wewould start small by piloting theRounds in one site.

We have run three Rounds todate, and in the style of Schwartz,would like to share some of thechallenges in getting this off theground, plus aspects which have

been easier than anticipated – both of whichmay be of interest to other organisations con-templating introducing Schwartz.

As is often the case with new initiativesthat are competing for time with everyone’s‘day job’, attendance at the Planning Com-mittee has varied and numbers have dwin-dled, meaning that the work has fallen ontothe shoulders of a committed few, which isfrustrating. The work involved is bigger thanjust attending the Round (particularly if inthe Facilitator role) and includes needing tofind potential panellists and helping themprepare their story. Other essential tasksinclude advertising the Round, organisingthe venue and refreshments, analysing thedata from each Round and attending Plan-ning Committee meetings. Of particular noteis the flexibility required to meet with panel-

Introducing Schwartz Center Rounds into a Welsh NHS Health Board: Six months in –A reflection on the process and experienceto dateDebbie Rees-Adams & Louise Hughes

…the work has fallen onto the

shoulders of a committed

few…


Introducing Schwartz Center Rounds into a Welsh NHS Health Board

lists who may be limited in their availability.We have since asked managers from other dis-ciplines (e.g. Estates and Housekeeping) tojoin the Planning Committee in order toincrease the acceptability of Schwartz anddiminish any assumption that it is only rele-vant to clinicians.

Despite only being three rounds in, wehave already had to cope with late changesto the panel due to accident and have usedmembers of the Planning Committee as lastminute stand-ins (endorsing the PCF’s rec-ommendation of having an emergencyRound ‘up your sleeve’ for such eventuali-ties). We have an ongoing practi-cal issue with booking suitablevenues, which has interruptedthe flow of the Rounds andreflects the reality of Schwartzcompeting with other healthboard activities. We have hadsome perceived negative feed-back about staff returning totheir workplace seemingly dis-tressed. We have taken this tomean that the Rounds have hadtheir intended (i.e. emotional) effect andgiven reassurance that this is the organisa-tion getting used to this as a longer-termintervention, that it is normal (and positive)for the emotional cogs to keep whirringafter a Round, and that the Staff CounsellingService has not seen an increase in referralsbecause of Schwartz. Another challenge hasbeen managing our own anxiety about whatis largely an organic group process but onewhich feels very visible, both in the momentand as a new organisational intervention.

Aspects which have been easier thanexpected, include good attendance, and theaudience quickly understanding the Roundspurpose and process. To date, we have had54, 72 and 48 participants in our Rounds andhave had little need to steer the discussionaway from problem solving. The honesty ofpanellists in what they chose to share hasbeen inspiring. Our third Round felt particu-larly cathartic as staff discussed the theme‘A Patient I’ll Never Forget’ and both posi-tive and negative feelings towards patientswere exposed, such as working with patients

we may dislike and how to care compassion-ately for them despite our human reaction.There is not space here to discuss the evalua-tion data in any detail but in the main it hasbeen a positive experience for participants.The discussions at times have been uncom-fortable (and we are under no illusions thatcertain topics will be more emotive), but instriving for transparency, this feels like aworthwhile undertaking.

We are pleased to have recently heardthat funding has been granted to train a fur-ther four facilitators, which will enable us toexpand the delivery of Rounds across four

main sites within the AMB on abi-monthly basis. We also intendto try to target those professionalgroups who have had the lowestattendances to date, whilst under-standing that this is likely to beabout release of staff, which is acompeting issue.

In summary, the introductionof Schwartz has been both per-sonally and organisationally anx-iety provoking but it appears

that the post-Francis climate is such that thetime may never be better to shine a spot-light into deeper crevices of the healthboard, and our organisation currentlyappears willing to hear and listen.

AuthorsDr Debbie Rees-Adams, Clinical Psychologist,Occupational Health & Employee Well-beingService, Princess of Wales Hospital, Bridgend,Abertawe Bro Morgannwg University HealthBoard; [email protected]; LouiseHughes, Nurse Education Lead, Singleton Hos-pital, Swansea, Abertawe Bro Morgannwg Uni-versity Health Board

ReferencesGoodrich, J. (2011). Schwartz Center Rounds: Evaluation

of the UK Pilots. London: King’s Fund.Goodrich, J. (2012). Supporting hospital staff to pro-

vide compassionate care: Do Schwartz CenterRounds work in English hospitals? Journal of theRoyal Society of Medicine, 105, 117–122. [Not in text]

Point of Care Foundation (2013). Setting up and run-ning Schwartz Center Rounds. London: LongridgePrint.

…carecompassionately

for them despite our

humanreaction…


THE FRANCIS REPORT (2013) has, in thespace of a year, thoroughly penetratedthe discourse and practice of healthcare

in the UK, and the widespread reaction to ithas to an extent reinvigorated an establishednarrative, which proceeds something like this:The NHS (and, arguably, all healthcare organ-isations) is characterised by the presence oftwo groups of people – the ‘hard working’staff on the ‘front line’ of healthcare (oftendeified as ‘angels’), and the ‘managers andpen pushers’, ignorant and detached from the‘front line’ and, worse, motivated by ‘savings’and ‘targets’. Said managers, ignorant of real-ity ‘on the ground’, blindly drive services toruin by prioritising processes over people,money over compassion. These two, mutuallyantagonistic, groups, fight as if at war. It is nosurprise that healthcare attracts militarymetaphors – fear and emotional arousalaccompany all human endeavours that placepeople at close proximity to death, suffering,and in the case of mental health, madness.

The reality, however, is more nuancedand in this paper it will be argued that thereis a significant risk that simplistic accounts ofthe challenges facing mental health care inparticular will eclipse the psychologicallyand behaviourally complex issues thatobtain in the leadership, management andeffective operation of such systems. It isargued that a psychological understandingof human systems needs to be prioritisedrather than seen as an accessory to the solu-

tion. In particular, two relevant areas will bediscussed. Firstly, deriving from the work ofZimbardo (2007), it will be argued thatattention needs to be paid constantly to thepsychological processes in psychiatric sys-tems that, left unchecked, can allow poorand abusive practice to flourish. Secondly,deriving from the work of Bloom (2004), itwill be argued that the unhelpful theoreticaland epistemological battles in mental healthcare stem from a failure to recognise the psy-chological limitations we have that preventus from truly understanding the clinicalproblems we try to ‘treat’.

The tactical reality of the battlefieldWe think that we are nice, but often we are notPsychologists need no introduction to theidea that good people can do bad things. Thehistory of organised human society is one ofviolence and the forcible acquisition of prop-erty, as much as it is of altruism and sharedeffort. We know (Milgram, 1974) that socialindicators of power exert significant effects onbehaviour, to the extent that people are pre-pared to cause harm on the instruction of per-ceived powerful others. We also know that thedesire to be accepted by a social group (andthus avoiding the depression inducing experi-ence of social rejection) can influence behav-iour (Asch, 1951). Recent findings inneuroscience have indicated that group influ-ence even influences the perception of reality,

Military metaphors and mental health –Francis and psychiatric systemsAndrew Hider

‘The vast majority of front-line staff, who are consistently hard-working, conscientious and compassionate, haveto understand that criticism of poor and unacceptable practice is not aimed at them but is part of a struggle tosupport everything they stand for.’ Robert Francis QC, The Francis Report: One year on – The responseof acute trusts in England, February 2014, p.4

‘…what we need now, to fight the health problems that threaten the future of the NHS, is an army that’s fit tofight a war’. Christina Patterson, The Guardian, August 2014


Military metaphors and mental health

and that nonconformity induces a fearresponse marked by increased amygdala acti-vation (Berns, 2005). Generally, people dowhat those in power tell them to do, and whenone is established in a group, nonconformityis stressful and even emotionally painful.

Zimbardo, in The Lucifer Effect (2007) con-siders findings gained from observationalaccounts of organised inhumanity and experi-mental studies and refers to two principal fac-tors – deindividuation and dehumanisation –that need to occur in social groups in orderfor them to act inhumanely (and can there-fore be engineered and encouraged by thoseso inclined).

Deindividuation This happens when systems are set up in sucha way as to ensure that people easily seethemselves as acting in the interests of agroup with little cognitive control over theirindividual decisions. In common speech, theterm ‘the madness of crowds’describes this process. Zimbardostates that in order for this to hap-pen one needs to encourage twodistinct processes – reducing thecues of social accountability andreducing the concern for self-evaluation. Social accountabilitycan be reduced by using anymechanism that protects individ-uals from the risk of social shame.This can be done either by allow-ing for anonymity (e.g. when riot-ers wear masks), or by associatinga social cue (such as a uniform) with permis-sion to use behaviours otherwise consideredunacceptable. Concern for self-evaluation isinversely related to cognitive control, so anyintervention that encourages actors to actunder direct stimulus control, with littleregard for past or future, can reduce it.Examples include the administration of alco-hol or drugs, or exposure to highly arousingemotional experiences. Those militaries thathave needed soldiers to commit crimesagainst humanity, such as the Nazi regime,used these principles very effectively to facili-tate behaviours that people (military or oth-erwise) would not normally do.

DehumanisationWith the possible exception of people with pro-nounced impairments in the ability toempathise, it is generally aversive for us tocause harm to other human beings, so leadersthat wish to cause widespread suffering arerequired to consciously encourage the dehu-manisation of victims. Dehumanisation occurswhenever someone is excluded from the‘moral order of persons’ – from this pointonwards excluded individuals tend to be seenas objects. Bandura et. al. (1996) refer to this‘moral disengagement’ as a social psychologi-cal process characterised by four stages: Firstly,the redefinition of immoral behaviour as ‘hon-ourable’ by citing compatibility with societalvalues or using sanitising language to describethe behaviour (e.g. ‘collateral damage’). Sec-ondly, the diffusion or displacement of per-sonal responsibility (e.g. giving away agency toauthority). Thirdly, changing the way we thinkabout the actual harm we have done through

cognitive distortion, minimisationand/or denials. And fourthly,blaming the victim of our abuse bysaying that they deserved it becausethey are not a ‘person’.

In systems, therefore, thesimultaneous presence of de-indi-viduated actors (who see them-selves as essentially acting in theinterests of a group) and a dehu-manised outgroup, the interac-tions between which are overseenby a powerful hierarchy thatencourages innate tendencies

towards obedience and conformity, representsa potent recipe for harm. Zimbardo thereforeargues that all social structures where onegroup intervenes onto another through themedium of power (particularly statutorypower) should be ‘reverse engineered’ to pre-vent these natural tendencies from emergingin the system.

The mental health system can traumatise its staff and its usersNobody would wish to compare the mentalhealth system to a battlefield, but for staff andservice users it can sometimes feel like it.There is a reason that we refer to staff ‘on the

…a powerfulhierarchy thatencourages

innatetendenciestowards

obedience andconformity…


Andrew Hider

ground’ or ‘on the front line’. Many of thepeople we try to help have fallen victim toappalling abuse (Spataro et al., 2004). The‘awfulness’ of the behaviour that can occur inmany in-patient psychiatric units is testamentto the awfulness of experience that oftencauses it. Sometimes it is easier to hold on tothe idea that we are fighting blind disease,inflicted by solely nature, than enter into thereality that the past has been for many of thepeople we try to help (Winnicott, 1949). Onoccasion, the resort to technological explana-tions of distress can ‘turn off’ our emotionalresponses and protect us from engaging withsuffering (Shapiro, 2008). Using a phrasesuch as ‘complex trauma with dissociation’ iseasier than using language that accuratelydescribes the events in the life of the person infront of us. We can be poor at holding bothperspectives together, so we switch betweentechnical medical or psychological explana-tions that can distance us and human interac-tions that can help alleviatesuffering but can cause us signifi-cant vicarious distress. These‘switching’ processes may be hardwired in humans (see below).None of us wishes to suffer, so wesometimes protect ourselves withtechnical language.

Thus, in mental health prac-tice, the desire to avoid trauma canlead to accounts of people that canbe lacking in humanity or, at worst,dehumanising. In particular, the noble aspira-tion of clinicians working in physical health-care to ‘battle against disease’ can beproblematic when applied to mental health,since if the ‘disease’ is identified as being theperson, clinicians can end up engaged in fruit-less battles with service users, all the whilebelieving that they are in fact ‘treating’ them(witness the impact of poor clinical manage-ment of people diagnosed with personality dis-order). Further, psychiatric in-patientenvironments, often characterised by high lev-els of emotional arousal, can encourage dein-dividuation, and occasionally the language weuse can encourage this (e.g. physical interven-tion ‘response teams’ and protocols of variouskinds). In such settings, where one group of

human beings controls the movements, libertyand bodily integrity of another, the presenceof factors that can encourage deindividuation,and language and technical accounts that canencourage dehumanisation, needs to be con-tinually in the minds of clinical leaders and allthose attempting to shape the behaviour of the system.

The Theatre of WarIdeological battles encourageinterdisciplinary warfighting in the clinicalarena of a mental health system that lacks an adequate understanding of psychopathologyThe Francis report discusses profoundissues with the culture of healthcare, with aprincipal focus on physical healthcare sys-tems. In such systems, there is an accept-ance that pathophysiology underpinsphysical diseases that are visible andtestable. In mental health there is no such

consensus, with the exception ofsome disorders in the areas oflearning disability/autism serv-ices and dementia care. The aeti-ology of, and appropriatetreatment for, the majority ofproblems described as mental ill-ness or personality disorderremains far from settled, and istherefore a fertile ground forrhetoric and for political andclinical division. For the pur-

poses of illustrating this final point in prac-tice, the best course of action is to refer torecent highly public ‘battles’ between psy-chology and psychiatry, such as the Observerarticle of May 2013, with the headline ‘Psy-chiatrists under fire in mental health battle– British Psychological Society to declarewar on rival profession’. These battle linesdrawn within clinical teams are the deathknell of effective multidisciplinary working.

As psychologists, we should constantly bereflecting on our own tendency towardsfalling victim to ingroup conformity, whichfor us, can on occasion be characterised by atendency to ‘dehumanise’ outgroups whooperate within a different epistemologicalframework (principally psychiatrists).

…fertile groundfor rhetoric

and for political and

clinicaldivision…



Human psychology may hinder thedevelopment of an adequate, integratedunderstanding of psychopathologyAccording to Bloom (2004), when it is facedwith the task of constructing a causal explana-tion for an event, the mind has available twocognitive modules – the biological, reductive,‘stuff’ explaining module, and the psychologi-cal, intentional/phenomenal, mind explain-ing one. In the case of ‘clinician minds’, bothof these modules have access to informationof both a considerable quantity and depth(e.g. the huge body of literature surroundingpsychotic experience), thereby making it acognitively effortful task to survey the fieldfrom even one of these standpoints. Further,it seems that the mind struggles with itselfwhen trying to simultaneously process ‘men-tal’ and ‘material’ causal explanations of phe-nomena. It wants a single explanation when itsees things, and it may have what Bloom refersto as ‘inbuilt dualism’ between mind andbody, person and system when approachingthe world and how it operates.

Little surprise then that we see in practicethe existence of two groups of practitioners,the minds of one of which have plumped prin-cipally for the former and the minds of theothers, the latter. Of course we need special-ists whose job it is to explore one field indepth and understand each blade of grasswithin it. It is evolutionarily parsimonious forcooperative human societies to have devel-oped in this way – just as cognitive modularisa-tion and anatomical specialisation in the brainseems to be the most efficient way of process-ing information in individual terms, divisionof cognitive labour seems most efficient forsocieties – in other words, I do not care if myheart surgeon has read Jaspers (1913), but I’dlike my psychiatrist to have done so, and I maynot be concerned if my psychologist has an indepth technical knowledge of serotoninreceptors, if that’s not what I need from her.

However, in clinical practice, as the clichégoes, if system as a whole adopts one mode ofcausal explanation, or even privileges oneover the other, we end up with either a brain-less or a mindless practice that does not ben-efit service users. How often is it that peopleare continued on medical treatment to little

effect, despite severe negative side effects,without referral for psychological interven-tion. Or that psychologists resent medicaloversight, even when the presentation sug-gests that it is needed? The argument here isthat these practitioners may have renderedthemselves psychologically unable to see thingsfrom a different perspective because of theirsedimented views, which in themselves are areflection of the type of explanations theirminds (and training) have caused them tofavour, rather than, per se, ‘the truth’. Per-haps we need a new subdiscipline of‘metapsychopathology’, focused on the psy-chological and neurocognitive factors thatinfluence our attempts to understand ourown psychological afflictions?

Unless we are careful, theoretical conflictscan be acted out in clinical practice, causingsystem-wide breakdowns in relationshipsbetween clinical leaders which fomentingroup/outgroup divisions within clinicalteams, which in turn cause the real underlyingproblems of the system to remain inade-quately addressed. While we remain far from asettled view regarding the aetiology andappropriate interventions for mental healthproblems, any professional group that pro-nounces with certainty on the causes of orsolutions to complex clinical issues that wework with will, quite rightly, be regarded withsuspicion and suspected of professionallymotivated self promotion. Some of our recentpronouncements have made us look as if weare more concerned about being right whatdoesn’t work than about dedicating our effortstrying to make the system work as well as itcould. This is unedifying and inappropriatefor the highly educated, rigorously trainedand clinically skilled profession that we areand wish to represent ourselves as.

So, if there is a ‘truth to tell’, it is that val-ues-based principles should supersede all oth-ers in healthcare systems, regardless of thescientific positions of the clinicians workingin them. We should be very careful not tomake the assumption that the substitution ofpsychological formulation for diagnosis andpsychologists for psychiatrists in mentalhealth settings would automatically and radi-cally change the behaviour of these systems,


Andrew Hider

absent consideration of the powerful socialpsychological processes operating in them.All professionals are capable of understand-ing these processes, and of taking steps toensure that they do not go unfettered, caus-ing poor (or abusive) service user experience.We should not make the changes in cultureof care that we all know are required in themental health system contingent upon us win-ning a theoretical war.

Conclusion – Towards disarmamentAs psychologists we should be relentlesslyreminding people of these inbuilt weaknessesin the mental health system, and working to‘reverse engineer’ out these natural, if unfor-tunate, group behaviours. Certainly, retreatinto oppositionality and militancy is unlikelyto help – the mental health system isrequired. Some people requiremedication, and some peopleneed to be admitted to hospital,and sometimes against their will.The challenge is to shape the sys-tem so that those characteristics ithas with battle and division areminimised. Firstly, as Francis says,the principals and practices ofclinical governance need to beadhered to continually by all serv-ices. However, there is a risk that governancebecomes characterised by quantitative dis-course alone. Tracking metrics is obviouslyimportant, but these need to be supple-mented by active processes of ‘stakeholdergovernance’ – meaning high levels of serviceuser power and external scrutiny, particularlyover the use of preferred descriptive terms todescribe psychiatric problems, in order tominimise any perceived message that onceyou become a mental health service user, youbecome a marginalised and powerless victimof a potentially hostile and powerful group-ing (clinicians). In mental health, particularlyforensic settings, this can be difficult – how-ever, significant progress has been made inthis area by bodies such as the NationalRecovery Outcomes Group in Secure MentalHealth – a Department of Health fundedbody – and this should continue (seeCallaghan, 2014). These processes, which

bring service users alongside clinicians aspowerful agents, reduce and minimise therisk of dehumanisation and also hold up serv-ice user bodies as groups to which cliniciansare publically answerable, thus increasingtheir social accountability. Clinical Psychol-ogy should increasingly and explicitly adopt ashared leadership role here, influencing andsupporting the multidisciplinary team from aposition informed by scientific experimentalpsychology, particularly social psychology.

Secondly, while Francis talks about cultureof care and the importance of compassion,this paper suggests that both the processes ofthe mental health system and the nature ofthe problems that it treats can induce psycho-logical states that reduce compassion, eitherby encouraging an overemphasis on techno-logical reductionism and/or by exposing staff

and service users to the kind ofemotional arousal and groupdynamic that encourages deindi-viduation. As such, exhortationsto compassion through the mediaof leaflet campaigns and lecturesare unlikely to work alone. Morelikely to be effective are constantand strategically visible reinforce-ment of ‘pro-cultural’ behaviourssuch as basic kindness by staff at

all levels, high quality clinical supervision, andconscious reward and modelling of suchbehaviours by clinical leaders, particularlythose nursing staff at ward level. As such,supervision and support of clinical leaders(as opposed to targeting and blaming) is criti-cal. Clinical psychologists are well positionedto support all these interventions, should pri-oritise them, and in many areas are doing so.Clinical psychologists, it goes without saying,should physically be on wards as much as pos-sible, working alongside nursing colleagues tosupport this modelling.

Thirdly, the mental health professionsneed to engage in honest debate about theirideological and theoretical struggles and do soin an adult and psychologically informed way.Simplistic accounts of ‘the medical model’ or‘the psychological model’ are unhelpful and atworst can encourage sedimentation of inflexi-ble positions by psychologists and psychiatrists

…hold upservice userbodies as groups to

which cliniciansare publicallyanswerable…



Asch, S.E. (1951). Effects of group pressure upon themodification and distortion of judgment. In H.Guetzkow (Ed.) Groups, Leadership and Men. Pitts-burgh, PA: Carnegie Press.

Bandura, A., Barbaranelli, C., Caprara, G.V. & Pas-torelli, C. (1996). Mechanisms of moral disengage-ment in the exercise of moral agency. Journal ofPersonality and Social Psychology, 71(2), 364–374.

Berns, G.S., Chappelow, J., Zin, C.F., Pagnonini, G.,Martin-Skurski, M.E. & Richards, J. (2005). Neuro-biological correlates of social conformity and inde-pendence during mental rotation. BiologicalPsychiatry 58(3), 245–253.

Bloom, P. (2004). Descartes’ Baby: How the science of childdevelopment explains what makes us human. New York:Basic Books.

Callaghan, I. (2014). Putting recovery first in secure care.Rethink Mental Illness, 18 July 2014. Retrieved fromwww.rethink.org/news-views/2014/07/putting-recovery-first-in-secure-care

Doward, J. (2013). Psychiatrists under fire in mentalhealth battle: British Psychological Society tolaunch attack on rival profession, casting doubt onbiomedical model of mental illness. The Observer,12 May. Retrieved from www.theguardian.com/society/2013/may/12/psychiatrists-under-fire-mental-health


Jaspers, K. (1913, 1997). General Psychopathology - Vol-umes 1 & 2 [translated by J. Hoenig & Marian W.Hamilton]. Baltimore and London: Johns HopkinsUniversity Press.

Milgram, S. (1974). Obedience to Authority: An experimen-tal view. New York: Harper & Row.

Shapiro, J. (2008). Walking a mile in their patients'shoes: Empathy and othering in medical students'education. Philosophy, Ethics and Humanities in Med-icine, 3–10.

Spataro, J., Mullen P.E., Burgess P.M., Wells D.L.,Moss S.A. (2004). Impact of child sexual abuse onmental health: Prospective study in males andfemales. British Journal of Psychiatry, 184(5),416–421.

Thorlby, R., Smith, J., Williams, S. & Dayan, M. (2014).The Francis Report: One year on – The response of acutetrusts in England. Research report. London:Nuffield Trust.

Winnicott, D.W. (1949). Hate in the counter-transfer-ence. International Journal of Psychoanalysis, 30,69–74.

Zimbardo, P. (2007). The Lucifer Effect. New York: TheRandom House.

References

who feel attacked because of their views andnaturally retreat into defence, thus reinforcing‘natural dualism’ and preventing the furtherdevelopment of an integrated understandingof mental distress. For clinical psychology thisis particularly important because of our lack ofrelative power and therefore vulnerability tomarginalisation if we are perceived as predom-inantly obstructive, oppositional, and prioritis-ing theoretical concerns over the practicaloperational demands of running hospitals andclinical services. At least, a settled view on thegeneral principles of good mental healthcare,that can be pragmatically applied to its gover-nance, independent of privileged adherence

to epistemological models, is urgentlyrequired if we are to free ourselves from war-like engagement with service users and eachother, and focus our efforts on remediatingthose aspects of the mental health system thatwe should all agree need to change. In otherwords, we, all of us, psychologist or not, needto be clear about what we stand for, so that wecan struggle for it.

AuthorDr Andrew Hider, Consultant Clinical,Forensic Psychologist & Clinical ServicesDirector, Ludlow Street Healthcare Group;[email protected]

The Division of Clinical Psychology is on

Twitter@DCPinfo


THE EVIDENCE is convincing that workrelated stress is extremely damaging,not just to the staff that experience it,

but also to their relationships with patientsand to the experiences patients have of thecare provided by the NHS (Westet al., 2011). There is also a sub-stantial literature demonstratingthat service redesigns and otherchanges in the NHS place staff atparticular risk of stress and disen-gagement. NHS changes oftenleave staff with a lowered sense ofpersonal effectiveness, moreprone to emotional exhaustion,more likely to make errors(which are again a source ofmore stress), more likely to be self-critical,and more likely to lack of compassiontowards self and patients (Gilbert, 2009). Sowhy are we in the NHS constantly involved inchange? Let’s consider a number ofhypotheses…

1. The public are not happy with the NHSThere is very little evidence that the publicare dissatisfied with NHS. The British SocialAttitudes Survey published by the King’sFund found that, in 2012, 61 per cent of peo-ple were satisfied with the NHS, comparedwith 58 per cent in 2011 and 70 per cent in2010 (King’s Fund, 2012a). The WorldHealth Organisation published its rankingsof 190 of the world’s healthcare systems in2000 and ranked the UK at 15th in Europe(World Health Organization, 2000). Manypeople feel that universal free healthcare atthe point of delivery is an extraordinaryachievement. In fact, we are so proud of ourNHS that it has come to represent somethingabout us as a nation – who we are – and some-thing we are proud to showcase at ourOlympic opening ceremony.

2. Universal healthcare is unworkableUniversal healthcare is not, of course, a purelyBritish phenomenon. Outside the USA virtu-ally every developed country provides compre-hensive universal healthcare so there is no

evidence that it is unworkable. Infact, some European countriesprovide greater coverage than theNHS; for example, including opti-cian and dentistry services andlong-term nursing care.

The UK has a very high level ofpublic funding (World HealthOrganization, 2000), but there aremany other systems paid for out oftaxation (like ours), whilst othersare funded through compulsory

insurance, or a mixture of both. In the UK, theonly additional payment people are asked tomake from their own pockets is the prescriptionfee (currently £8.05), while most other countriesrequire a contribution towards the cost of care.In some countries the state is the main providerof care and in other countries private and volun-tary agencies provide the bulk of services.

The NHS ‘brand’ makes it easy for us toattach to, and become sentimental about, ourhealthcare. Perhaps this is why the NHS is soembedded in our sense of identity. Manyhealthcare professionals (such as psycholo-gists, doctors and nurses) are trained ‘in’ theNHS and identify themselves with it. The tasksof the NHS (saving lives, relieving sufferingetc.) are heroic and often invoke gratitudeand affection from patients, and the singlebrand encourages focus and loyalty. But ofcourse the NHS is not one thing; some aspectsof healthcare are more effective and efficient,than others – some are frankly outdated andpotentially unsafe.

There is no evidence that universal health-care is unworkable, but how should we payattention to and address those aspects of the

Staff stress, change and the NHSAlison Beck

…the NHS is so

embedded inour sense

of identity…


Staff stress, change and the NHS

NHS which are not working well whilst retain-ing the bits that are? This is the wicked prob-lem which is driving us to make changes inthe NHS.

3. The NHS is inefficient, inaccessible and poor qualityThere is good evidence that the NHS is veryefficient. A study by Davis et al. (2014) for theCommonwealth Fund compared the healthsystems in Australia, Canada, France, Ger-many, the Netherlands, New Zealand, Norway,Sweden, Switzerland, the UK and the US. TheUS was consistently the most expensive healthcare system and amongst the worst in terms ofaccess, efficiency and equity; however, the UKhealthcare system was consistentlyranked first on all these aspects. Ofcourse, it all depends on how qual-ity, efficiency, equity and accessibil-ity are measured. In the UK, wehave fewer doctors per capita(Ingleby et al., 2012).

Before we conclude that if the NHS ranksfirst amongst all these countries change (or atleast the current pace of change) is not neces-sary, it is worth noting that the same studyDavis et al. (2014) found that the UK was poor(relative to other countries) in terms of healthoutcomes as measured by ‘mortality amenableto medical care, infant mortality, and healthylife expectancy at age 60’.

4. The NHS is unaffordableIt is a universal problem not confined to theUK that healthcare costs are growing expo-nentially. It is not simply a matter of fact thatwe are living longer and receiving healthcarefor longer (and more of us are doing that),but also that we expect more from our health-care providers in terms of what constitutes‘good health’. It is now possible to treat condi-tions which even a decade ago we could notand we all expect to benefit from these costlynew treatments, techniques and other devel-opments (which continue emerge). In otherwords, the NHS is extremely successful, and asa result extremely expensive.

Clearly there must be a limit to these esca-lating costs or the NHS will be unaffordable,but the question really is ‘what are we, as a

society, prepared to spend on our health?’There is also a question about who decideswhat the priorities are. Most people considertheir health and that of their loved ones a pri-ority; if that is the case then the healthcarespend needs to cover all the costs that peoplewith sufficient resources would choose tospend on their health – and that is ‘a greatdeal’. And costs are rising. If the public doesnot accept these rising costs, then we will needto decide which costs we are willing to bearand which we are not – and we currently haveno equitable mechanism for doing this.

A recent BBC news report highlights thepoint. On 10 August, Nick Triggle reportedthat a pioneering new breast cancer treatment

will not be routinely available inEngland and Wales. The drug –Kadcyla – adds six months of lifeon average to women dying withan aggressive form of breast can-cer; however, it costs £90,000 perpatient. Whether this is a price

worth paying (considering what £90,000 canbuy) may depend on whether you or yourloved one has this form of cancer. This is dif-ficult enough but most cost decisions are notso straightforward.

5. Decisions about healthcare are influenced by powerIf decisions about who should and who shouldnot receive healthcare are not carefullyreviewed against principles of equity then thepeople who lose out are those who do nothave a strong voice or for whom treatmentsare complex, expensive and relatively new.The absence of access by people with mentalhealth problems to psychological therapiesmight be a case in point. Decisions to fundthese therapies have generally been left tolocal commissioners to decide whether or notto fund; however, setting national targets (e.g.for treatments or process standards) and com-missioning principles can also skew services,exacerbate stress and curtail autonomy to pro-vide the services local people need (King’sFund, 2012b).

Involving clinicians in the changesrequired in the NHS has come to be under-stood as a key mechanism of change. Clini-

…who decideswhat the

priorities are?


Alison Beck

cians are the experts in health care and areassumed to be motivated primarily by the goodof the patients. Of course the gremlin of per-sonal profiteering is a concern and the argu-ments about privatisation in the NHS havepartly consisted of concerns that clinicians’ pri-mary motivation might become one of greedrather than altruistic concern for others.

Furthermore, supporting clinician auton-omy does not always result in the best evi-denced decisions and leads to high levels ofclinical variation. A well-known US studyshowed that, in such circumstances, patientsonly received half the interventions theyshould have (McGlynn et al., 2003). Clinicalvariation is one of the biggest causes of wastein the NHS, but setting standards is alsofraught with problems as lack of clinicalautonomy exacerbates staff stress.

6. The NHS does not achieve the best health outcomesWe have seen evidence (Davis et al., 2014)that health outcomes in the UK are not goodcompared to other health systems. One driverfor all the change in the NHS must be toachieve better outcomes – and there is evi-dence that this can be done cost-effectively.Derek Wanless in 2002 identified the impor-tance of individuals taking more responsibilityfor their health; however, the challenge ofpersuading people of lifestyle changes has notbeen easy. Campaigns to improve the nation'sdiet, reduce obesity, increase exercise, stopsmoking, etc. have had limited success andhealth inequalities are increasing with awidening health gap between rich and poor(Pickett & Wilkinson, 2013).

Despite almost unanimous agreementabout these health challenges there seem tobe no easy answers. Attempts to link healthresponsibility with access to healthcare havebeen controversial; for example, some Trustsrefused non-emergency treatments to patientsuntil they changed their eating and smokinghabits (Smith, 2010). More challenging mightbe to embrace the robust evidence that equal-ity is better for everyone, and not just be poor(Wilkinson & Pickett, 2010), but so far thehealthcare design which will achieve this hasnot been realised!

Nigel Crisp (2010) in Turning the WorldUpside Down provided numerous examplesfrom less wealthy countries which could (andon occasion have) brought significant cost sav-ings and health gains in the UK. However, totruly realise these benefits the professionalpower bases (most notably medicine, but wecannot ignore the implications for psychol-ogy) would need to be in support.

7. Is there an argument raging about the ideology underpinning the NHS?There have been many arguments about theHealth and Social Care Act. In NHS SOS(Tallis & Davis, 2013), several major critics ofthe bill have argued that the recent changes inthe NHS represent a battle of ideologies andthat the bill is fuelled by a will to privatise theNHS and turn health care into a profit-mak-ing industry. However, this view is far fromuniversally supported and Roger Taylor(2013), for example, argues forcefully for thealternative position that there is an ‘alarmingdegree of consensus across the political spec-trum’ about the challenges facing the NHSand the complexity of the possible solutions.

8. We lack the information we need to get the NHS right Healthcare is a huge undertaking. Measuringhealth outcomes (e.g. hospital deaths) is agood way of understanding the impact ofhealth care provision; however, outcomes arehard to measure and even harder to manage.Often we simply do not know which factorscontribute to particular outcomes. For exam-ple, when Mid Staffordshire hospital was try-ing to understand their elevated death rates agroup of clinicians reviewed patient case notesand found that 34 out of 35 deaths wereentirely ‘predictable’. The scale of the infor-mation challenge is well described by RogerTaylor (2013) and his conclusion that theNHS will continue to change, as we clumsilyiterate towards the kind of healthcare webelieve best meets our needs, is convincing.

ConclusionThe NHS is a national institution and onewith which we are generally happy. It is effi-cient, accessible, and provides high quality


Staff stress, change and the NHS

care; however, our health outcomes do notcompare favourably with other similar coun-tries. Furthermore, healthcare costs are risingexponentially and we have no clear mecha-nism for deciding what should be funded andwhat should not – so it is likely that we will getthings wrong and need to change them.There are all sorts of problems plaguing ourability to design the best healthcare. In men-tal health we have seen years of low invest-ment (relative to physical health) and therecent acknowledgement that we need ‘parityof esteem’ is welcome but inevitably willrequire more changes – and of course thereare many other health inequalities whichneed to be addressed.

It is tempting to think that leaving theNHS in the hands of clinicians would solveour problems, and of course it is importantthat clinicians are entrusted and enabled torespond to the needs of the patients they workwith. However, high levels of clinical auton-omy are associated with high levels of clinicalvariation and this leads to both wasteful serv-

ices and patients not receiving the best evi-denced interventions.

The Wanless Report (2002) was crucialin terms of recognising the importance ofpatients being in the driving seat of healthcare provision and taking responsibility fortheir health. Unfortunately, progress hasbeen slow and the need for more change iswidely recognised. Therefore it seems thatfurther change in the NHS is needed, butthis will inevitably lead to high levels of staffstress, and the risks for patient care (and tostaff themselves) are well known. We needto develop mechanisms to build staffresilience and enable people to remainemotionally engaged and behaviourally flex-ible enough to function effectively in thecontext of change.

AuthorDr Alison Beck, Trust Head of Psychologyand Psychotherapy at South London andthe Maudsley NHS Foundation Trust; [email protected]

Crisp, N. (2010). Turning the World Upside Down: Thesearch for global health in the 21st century. London:CRC Press.

Davis, K., Stremikis, K., Squires, D. & Schoen, C. (2014).Mirror, Mirror on the Wall: How the performance of the UShealth care system compares internationally. WashingtonDC: The Commonwealth Fund. Retrieved fromwww.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

Gilbert, P. (2009). The Compassionate Mind: A newapproach to life’s challenges. London: Constable &Robinson.

Ingleby, D., McKee, M., Mladovsky, P. & Bernd., R.(2012). How the NHS Measures up to OtherHealth Systems. British Medical Journal, 344, 1079.DOI: 10.1136/bmj.e1079

King’s Fund (2012a). British Social Attitudes Survey 2012:Public satisfaction with the NHS and its services.Retrieved from www.kingsfund.org.uk/projects/bsa-survey-2012

King’s Fund (2012b). Leadership and Engagement forImprovement in the NHS: Together we can. Retrieved from www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/leadership-for-engage-ment-improvement-nhs-final-review2012.pdf

McGlynn, E.A., Asch, S.M., Adams, J., Keesey, J., Hicks,J., DeCristofaro, A. & Kerr, E.A. (2003). The qual-ity of health care delivered to adults in the US. NewEngland Journal of Medicine, 348, 2635–2645.

Pickett, K. & Wilkinson, R. (2013). Health inequality isblighting the UK. The Independent. Retrieved fromwww.independent.co.uk/voices/comment/health-inequality-is-blighting-the-uk-8904398.html

Smith, R. (2010). Patients denied treatment as NHSmakes cutbacks, Telegraph can disclose. The Tele-graph, 17 December. Retrieved from www.tele-graph.co.uk/health/healthnews/8208958/Patients-denied-treatment-as-NHS-makes-cutbacks-Tele-graph-can-disclose.html

Tallis, R. & Davis, J. (2013). NHS SOS: How the NHS wasbetrayed – and how we can save it. London: OneworldPublications.

Taylor. R. (2013). God bless the NHS: The truth behind thecurrent crisis. London: Faber & Faber.

Wanless, D. (2002). Securing Our Future Health: Taking along-term view. Final report. London: HM Treasury.

West. M., Dawson, J., Admasachew, L. & Topakas, A.(2011). NHS Staff Management and Health ServiceQuality: Results from the NHS staff survey and relateddata. Retrieved from www.gov.uk/government/uploads/system/uploads/attachment_data/file/215455/dh_129656.pdf

Wilkinson, R. & Pickett, K. (2010). The Spirit Level: Whyequality is better for everyone. London: Penguin.

World Health Organization (2000). The World HealthReport 2000 – Health systems: Improving performance.Geneva: Author. Retrieved from www.who.int/whr/2000/en/whr00_en.pdf

References


IHAVE BEEN actively involved in nationalmental health policy since 2005; less sosince taking on further responsibility within

my NHS role in 2012. I am grateful, if at thesame time a bit regretful, for having taken solong to have been persuaded to share my viewson how the Division of Clinical Psychology andthe British Psychological Society (BPS) as awhole can increase its political and profes-sional influence in national policy. I have littleto offer beyond my on-the-ground experience,largely following trial-and-error and gutinstinct. I very much hope that sharing the fol-lowing anecdotes, and derived principles, willhelp others to take our mission forward.

I was, at the beginning, nudged forward intopolicy arenas by others (willingly, looking for away to contribute politically as well as clinically)-- by the end, I was undertaking a fair bit of thenudging of others, overtly and at times decidedlybehind the scenes. If not clearlyimplicit below, I should here makeit explicit that especially three indi-viduals within the DCP Executive atthe time supported and joined inwith my efforts from start to finish: Peter Kinder-man, Jenny Taylor and David Murphy -- I oweeach a debt of gratitude for their collaboration.

Psychologist, know thyselfI have been described variously, in leadershipterminology, as a ‘fox’, a ‘stalking horse’ and‘a Marine commando operating on his ownrecognizance’ (the latter by someone higherup in the BPS who was both impressed by andannoyed with me at the time). I am not sureabout what any of these terms really mean,even after googling them; I came to learn thatI preferred to stay backstage, that I am betterat writing than speaking, that I am camera-and tape recorder-shy and that I tend to waitfor ‘greatness’ (such as it might be) to be

thrust upon me rather than seek it (certainlynot born to it!). Once you accept who you areand how you operate in policy, you canbecome quite effective by playing to yourstrengths rather than trying to step into thebig shoes of predecessors.

Keep it clear and simpleI have followed, in particular, one key objec-tive: to work toward parity in the delivery ofevidence-based treatments between medicinesand psychological interventions, and thusensure that service users, as elsewhere in theNHS, can access the full range of effectivetreatments which, in combination, producethe best outcomes. I began my policy careerrepresenting the British Psychological Societywithin the development of Accreditation forIn-patient Mental Health Services (AIMS),commenced within the Royal College of Psy-

chiatrists. Citing numerous stud-ies by Mind, Rethink and otherservice user representative organi-sations alongside NICE guidance(see below), the DCP’s efforts

within AIMS over several years has producedmandatory minimum standards of training forand provision of evidence-based psychologicalinterventions on all AIMS-accredited wards.As a result, hundreds of psychologist/psycho-logical therapist posts serving thousands ofpatients have come into being on AIMS-accredited wards.

Triangulate where possibleTriangulating between commissioning, regu-lation and/or national guidance, professionalstandards and unmet service user needs hasproved an effective strategy time and again --one in which initial detractors can be drawninto an aligned position, removing obstaclesto progress.

DCP political influence: Strategy and tacticsto influence national policyJohn Hanna

Psychologist,know thyself…


DCP political influence: Strategy and tactics

During the same period as my initial AIMSwork, I successfully lobbied the National Col-laborating Centre for Mental Health withinNICE to ensure that guidance was clarifiedwith respect to commencing recommendedpsychological therapies in the acute phase ofillness. Various heads of psychology aroundthe country had targeted clinical resourcesmainly (at times exclusively) toward commu-nity patients, as it was argued that in-patientwork was less important given the time framerecommended by NICE could not be accom-modated by the typical in-patient length ofstay. As a result of this intervention, NICEguidance updates for schizophrenia anddepression, with more to follow, have givennew emphasis to the goal of commencing psy-chological treatment for patients in acute dis-tress, a further lever of assurance thatpsychology will increasingly be there for thosemost at risk and in need. I then worked toensure that the DCP set out its own guidance,directly to heads of psychology, instructingthem to adhere to the revised NICE recom-mendations and facilitate commissioning ofacute in-patient and crisis psychology.

Lastly, I have worked directly asa DCP/BPS representative withthe Care Quality Commission(CQC) over many years and overseveral iterations of expert refer-ence groups and regulator-profes-sional interface working parties. Asvirtually a last vestige of my policyrole, I remain closely involved in the CQC’sevolution in regulating mental health services,taking part as the BPS representative in itsMental Health Expert Reference Group byinvitation. I am excited to see that my efforts,alongside representatives of the National Col-laborating Centre for Mental Health, theDepartment of Health and service user groups,are now promised to result in CQC regulationof access to psychological interventions acrossservices, starting with those which carry themost risk, including acute.

When I began, with a vision in mind as apotential outcome, very little attention waspaid to the psychological needs of the acutelydistressed. Now the shared concerns of serviceusers, professional groups and regulators are

marrying up to re-shaped national guidanceon evidence-based practice and enhancedstandards of access. The under-served positionof the acutely distressed is difficult for com-missioners to ignore, and clear to see howprogress in increasing access to evidence-based psychological therapies must go for-ward. It is also clear to all involved thatleadership, training, supervision, and provi-sion for the most complex and risky presenta-tions would predominantly fit the skill set ofclinical psychologists.

Do not take your placards and go home – find compromiseMy policy work began to take off when I wasinvited, by the BPS’ Division of Clinical Psy-chology, into internal and external debatesaround proposals for an expansion of profes-sions eligible for statutory roles under whatwas to become the new Mental Health Act(2007). I was asked to take part in a debate inthe House of Lords, and ultimately wrote sec-tions of implementation guidance publishedby the government on role implementation.The direction of travel in the debates did not

proceed the way I had initiallyhoped, and I was tempted to walkaway. But I was invited to stay onwithin the DCP’s Mental HealthAct Working Party as pretty mucha ‘critical friend’, ultimately influ-encing the government’s imple-mentation guidance to mitigate

against risks ultimately agreed but initiallyunforeseen by working party members whohad, just months previously, been adversaries.What I learned here, thankfully early on, isthat if a policy initiative produces discomfortor discord, abandonment will produce a lesswell-resolved result – we owe a duty of care toservice users and to our profession to stayinvolved and hammer out the best compro-mise solution possible. We must keep true toour ideals, but at the same time, grasp therealpolitik of the day.

Seek information, and ask the rightquestions at the right timeInitially, I felt I needed to demonstrate thatI knew enough about what others, more

…stay involvedand hammer out the best

compromise …


John Hanna

established and experienced, were talkingabout – especially in the higher echelons ofpower. I never really changed that perspec-tive, but I became increasingly adept at ask-ing the right (kind and trustworthy) peoplefor further details, so that I could actuallyfeel that I knew enough.

I also, initially, felt I must always ask aquestion, or raise a point, in policy forums, atleast one question and more if I could comeup with them. I later came to feel morerelaxed about this; we need to be visible, andactive, but not necessarily always front-rowwith our hand waving in the air. The rightquestion or point at the right time will havethe most resonance.

Get your own house in orderAfter assuming the elected role of DCP PolicyDirector, in 2009, I helped to lead the WeNeed to Talk (WNTT) campaign to retaincentral Improving Access to PsychologicalTherapy (IAPT) funding and to extend accessof evidence-based psychological interventionsto all who would benefit; the leaders of allthree main political parties signed up to apromise to achieve this during what is now thecurrent parliamentary administration. Thecampaign was instrumental in notonly maintaining funding forIAPT for primary care, but alsofor creating IAPT programmesfor severe mental illness, olderadults, children and young peo-ple, and long term needs/med-ically unexplained symptoms.

A significant part of keepingthe WNTT coalition together wasthe need, immediately apparentat the outset, to decide whetherto back a position of increasing access of allevidence-based, NICE-recommended psycho-logical therapies, or as others advocated,increasing access to all psychological thera-pies, regardless of status with NICE. It wasdifficult to reconcile, as the former wouldinvariably lead to the decommissioning ofthe latter. My pitch, that we need to considerpublic money spend on public health serv-ices, that every other component part of theNHS broadly implemented NICE guidance

where this had yet to be accomplished inmental health services and we could notstand by to allow this to continue, provedincomplete. Resistance remained within theDCP and within the New Savoy Partnershipalike – expanding choice to include orienta-tions yet to be recommended by NICE wasalso essential, but how to represent whatappeared to be polar opposite positions?

I proposed that we prioritise increasedaccess to NICE-recommended psychologicalinterventions, while also: (i) arranging sec-ondary access to other valued interventionswhen evidence-based approaches had notproved successful; and (ii) campaigning forset-aside research funding to promote thesystematic evaluation of therapies yet to berecommended by NICE for lack of RCT-levelevidence. This stance was helpful in bring-ing about consensus and consequent for-ward movement.

Brinksmanship--as a last resortWithout going into detail, the DCP faced a fewsituations at the highest level of policy forma-tion where it appeared that certain vestedinterests were set to exclude the BPS, or min-imise our role and function within the group,

or to fold the BPS into a superordi-nate grouping consisting of abroad umbrella of psychologicaltherapy representative groups. Itwas vital to be in a position to pres-ent the legitimacy of the DCP/BPSto lead the field, often drawing onleadership roles held within theNHS and on our orientationtoward evidence-based practiceover and above particular modesof therapy. At difficult times,

brinksmanship came into the negotiatingprocess, sometimes using the bulldog-retriever approach where someone in higherauthority, typically the Chair of the DCP Exec-utive, would mandate inclusion while threat-ening public withdrawal of DCP/BPSendorsement (the bulldog) and then typicallythe Policy Director (the retriever, me at thetime) working toward a reconciled, andincluded, position. Uncomfortable, but neces-sary, and effective.

The rightquestion or point at the right time

will have themost resonance.


DCP political influence: Strategy and tactics

Be helpful beyond your brief in putting service users firstI found being helpful wherever feasible, notjust where directly advantageous, repeatedlygained ground. When the Royal College ofGPs opted to retire the unmanageable QualityOutcome Framework (QOF) indicators fordepression, I was asked by the National Clini-cal Director for Mental Health to help. I insti-gated and led a campaign with policycolleagues across mental health to persuadethe Royal College of GPs to revise rather thanretire the standards. After very tactful negotia-tions, the QOF standards were revised andretained and QOF-led referrals from primarycare to IAPT were safeguarded. This was goodfor psychology and for the DCP, but betterstill for service users and the field at large.Leading on this paid dividends for quite awhile afterwards in the form of greater proac-tive inclusion in national policy formation.

Keep your friends close, and makefriends with your would-be rivalsFollowing Peter Kinderman’s instigation,I helped to co-found the Inter-professional Col-laborative for Mental Health, comprised of pol-icy leads for clinical psychology, psychiatry,nursing, social work and occupational therapyworking together as a multidisciplinary teamon mutual concerns in the field. I also, along-side particularly David Murphy, worked tonegotiate a collaborative approach with theNew Savoy Partnership. It would be clear toeach of these organisations as it should be to usthat conflict among component parts of themental health field has re-directed politicalattention (as acknowledged by one Minister forMental Health and Social Care, who describedthe rancour over the last draft Mental HealthBill as ‘a nightmare’) and research funds (avery senior figure in health research noted that‘no one fights in the cancer field; cancer getsthe research funds’). There is more that bindsus than divides us. I did all I could to allowpeace to break out; I hope this can continue.

Volunteer, delegate and develop emerging talentI secured an invitation for BPS representa-tion on the Joint Commissioning Panel for

Mental Health, a joint venture led by theRoyal College of Psychiatrists (RCPsych)and the Royal College of GPs. It felt vital tocontribute as far shoulder-to-shoulder aspossible with psychiatry in guiding commis-sioners toward exemplar service modelsdelivering a balance between evidence-based medicine and psychological interven-tions; I was determined to ensure that aspecialist psychologist was assigned to eachJCP-MH commissioning guidance workingparty and took a co-lead on the acute careand the community mental health guid-ance. Via the DCP leadership, I got in touchwith each relevant Faculty and persuadednational committees to find a way to putsomeone with reasonably deep experienceand expertise forward for service area-spe-cific guidance – we placed someone excep-tional in each descriptor group.

We all know that most of the work com-ing out of the DCP is taken forward by vol-unteers; if each of us from mid-careeronward (while bringing along promisingjunior colleagues) can place themselveswithin a national workstream, not only dowe achieve a great deal together but eachclinician and their sponsoring Trust gainsadvantage from direct and timely access topolicy formation.

Be nice, and be discreet when needing to be constructiveThis really does not hurt, and helps consider-ably. Copy in loads of colleagues when deliver-ing kudos; save the brickbats for face-to-faceor at least telephone (not teleconference)contact. This goes for back-filled posts as well,but especially for voluntary efforts, especiallywhen you want a return, if sometimes slightlyrevised, performance.

The policy initiatives I co-led or led weremany and varied, ranging from commission-ing, to Payment-by-Results, to regulation.I accepted invitations to present on a widerange of policy topics to a diverse policyaudience, including the RCPsych’s annualconference, the New Savoy Partnership,committees led by the National Director forMental Health and to many DCP strategygroups and faculties.


John Hanna

Communicate to members and to the public This is something at which I did not excel,relying on others to blow our collective trum-pet, which consequently did not often sound,and I am afraid a lot of what at the time scoredpoints for us did not register on the score-board. Sometimes emergent success seemedtoo fragile to publicly reveal; too sensitive tobe seen to crow about -- sometimes I just feltmore comfortable chalking it up and movingon to the next project, personally feelingmore relaxed when out of the spotlight. I didnot feel drawn to the media spotlight, espe-cially. Where valuable work was successfullytelegraphed, a consistent media/communica-

tions function mirrored policy interventionsas separate, complementary roles; this is possi-ble within DCP/BPS structures and I shouldhave, in hindsight, valued this more.

I have, at least, communicated subse-quently, with this tardy briefing! I hope, asabove, that these reflections will be useful toothers picking up the baton (I have not ruledout re-entering the race, but perhaps more onthat another time…).

AuthorDr John Hanna, Consultant Clinical Psycholo-gist, Camden and Islington NHS FoundationTrust; former DCP Policy Director (England);[email protected]

Standing up & speaking out: Clinical Psychology and Social ContextIncluding:� Leadership & Management Faculty � Faculty for Addictions

Con1rmed Keynote Speakers� Professor Alexander Haslam� Professor Mary Boyle� Professor Michelle Ryan� Professor Paul Gilbert

DCP Members Day – 3 December‘Across the lifespan’, incorporating the DCP AGM

Open public event: � Professor Michelle Ryan University of Exeter

RegistrationReduced conference rates: prices starting at £55 forsingle day attendance or £69 for full 3-day attendance

DCP Annual Conference 20143–5 DecemberThe Radisson Blu Hotel, Glasgow

For full details including how to make a submission and how to register visitwww.bps.org.uk/dcp2014


THE OCCUPATIONAL PSYCHOLOGY inPublic Policy (OPIPP) working group, partof the Division of Occupational Psychology

is releasing a report this November titled, Imple-menting NHS Culture Change: Contributions fromoccupational psychology. The report aims toaddress the issue of how to implement the rec-ommendations for culture change within NHShospital trusts, as detailed within the Francisreport and subsequent Berwick review.

OPIPP’s report aims not to rehearse thevaluable analyses that have been produced bya wide range of organisations in response tothe Francis report, including health thinktanks and the Health Select Committee, but toshed light on the utility of employ-ing psychological evidence andexpertise when embarking on thepractical implementation of NHSculture change. Indeed, the needto move the discussion on at thisstage from what needs to be doneand on to ‘how’ to make NHS cul-ture change a reality has beenwidely recognised in policy circles,including by The King’s Fund,which has reflected that, ‘…thereal challenge is not in the diagnosis and pre-scription for the problem, it is ensuring thatthe remedy is administered effectively’. Like-wise, the Royal College of Nursing remarkedin its response to the Francis report that,‘Robert Francis has set out a clear directionfor the future of the health service; the onus isnow on all of us to make sure we follow it.’

OPIPP aims to contribute to these objec-tives by providing an occupational psychologyperspective on the practical steps required todeliver organisational culture change withinthe NHS. The Berwick review highlighted thefact that ‘good people can fail to meet

patients’ needs when their working conditionsdo not provide them with the conditions forsuccess’, and argued that in pursuing a posi-tive NHS culture, a ‘measured and balancedresponse, anchored in science and evidence,serves the nation well’. Occupational Psychol-ogy as a discipline is concerned with the per-formance of people at work and with howindividuals, small groups and organisationsbehave and function. Its aim is to increase theeffectiveness of the organisation and improvethe job satisfaction of individuals. Therefore,occupational psychologists, as scientists ofpeople at work and with practical experienceof intervening in a range of organisational

contexts, can offer NHS hospitaltrusts valuable insights into howthe working conditions for successcan be created and sustained.

Whilst the Francis reportmakes a total of 290 recommenda-tions, OPIPP has chosen to focusits report on a smaller number ofcore recommendations for NHSculture change which relateclosely to some of the key knowl-edge areas of occupational psy-

chology. These include ensuring that staff areengaged and supported to deliver compas-sionate care, creating stronger healthcareleaders and developing a climate of trans-parency, openness and candour. It has alsobeen recognised by the Berwick review that anew organisational culture, one devoted tocontinual learning, must take root in orderfor patient experience to be improved. In linewith these recommendations, the report isdivided into three sections. Section oneincludes overview chapters on the key pointsto consider when undertaking a journey oforganisational culture change; section two

Implementing NHS culture change:Contributions from occupational psychologyGrace Everest, Joanna Fitzgerald & Louisa Tate

…a neworganisationalculture, onedevoted tocontinuallearning…


Grace Everest, Joanna Fitzgerald & Louisa Tate

explores the role of leaders in implementingculture change at a broad level and inenabling staff well-being; and the final sectiondetails the steps required to recruit the beststaff and create working conditions that areconducive to the delivery of compassionate,safe care. In line with OPIPP’s aim to ensurethat the evidence base of psychology is utilisedduring the public policy process, all of thereport’s chapters feature case studies withclear ‘how to’ recommendations for policy-makers and healthcare leaders to adopt, andwhich are also likely to be of relevance toother public service organisations.

An overarching theme, tying together thedifferent chapter recommendations, con-cerns the importance of moving beyondcommand and control hierarchies andtowards collective and participative leader-ship in the NHS, with an emphasis on theneed for hospital trusts to develop more col-laborative relationships between healthcareleaders and their staff. For example, MichalTombs-Katz’s chapter on ‘Fostering a contin-uous learning culture in the NHS: The roleof leadership’, stresses that senior leaders atall levels in the NHS should approach a con-tinuous learning culture as not only a func-tion of top-down strategy and formaltraining, but as the product of a work envi-ronment built on empowerment,open communication and bot-tom-up processes of co-produc-tion. Her discussion of effectiveelectronic workbook develop-ment advocates that hospitalteams should be ‘empowered toexpress their own way of doingthings and to influence practice’,with the autonomy to customise their ownlearning workbooks. Beverley Alimo-Metcalfeand Juliette Alban-Metcalfe’s chapter on‘Leading and managing high performingteams’ also recommends that the NHSembrace a more contemporary understand-ing of leadership as a shared social activitythat ‘emerges through collaborative relation-ships’. They encourage hospital leaders tolook upon their role not as leaders inputtinginto their team, but as the outcome of teammembers working together.

The chapter contributed by Chris Clegg etal., which is focused on ‘Work design for com-passionate care and patient safety’ likewisewarns against top-down inspections and auditsafter the event. Instead, Clegg et al. detail anumber of recommendations to ensure thatstaff are empowered and trusted to act whenthings go wrong. These include ensuring thatward layouts support daily care roles by allow-ing a clear ‘line of sight’ to patients to enableeffective monitoring and response, and devel-oping a national framework for change whichis agreed upon at the local ward level.

Rosalind Searle and Alison Legood’s chap-ter on ‘Improving trust board effectiveness andgovernance’ similarly taps into the theme ofcollective leadership, advising hospital boardsto diversify and become more inclusive byensuring greater involvement of clinicians andwomen. Their chapter emphasises the need forboards to improve the behavioural style of theirmembers so that they become more ‘develop-mental’, sharing knowledge, being open andresponsive to error detection, and modellingthe required behaviours of staff lower down inthe hospital.

In addition to this theme of collective leader-ship, many of the report’s chapters also indicatethe value of drawing upon a synthesis of psycho-logical evidence and expertise when seeking to

implement culture change. BarbaraWren’s chapter, in particular, on‘Managing staff experience toimprove organisational culture’describes interventions which drawon occupational, health and clinicalpsychology theoretical frameworks,and considers the conscious andunconscious processes that influ-

ence the current culture in healthcare. In herarticle she proposes that implementing changerequires taking a systemic perspective whendesigning interventions at role, team and organ-isational level. She discusses the vital role for psy-chology in helping organisations understandand manage anxiety in order to choose appro-priate and well positioned intervention strate-gies, and the benefit of drawing on a range ofpsychological frameworks to help organisationsmanage meaning, create safety and addresscomplexity in a reality based way. Joanna Fitzger-

…towardscollective andparticipativeleadership…


Implementing NHS culture change

ald’s chapter too employs a model of psycholog-ical imperatives in the workplace to describehow ‘Cultures of transparency and openness’(CTO) can be created, arguing that the extentto which a CTO can be built and sustained isdirectly linked to the degree of ‘psychologicalsafety’ in any system.

Thus, OPIPP’s report contains a diverserange of chapters, each exploring differentaspects of organisational culture – from theboards to the wards of hospitals – which mustbe addressed simultaneously in order to createan NHS that is patient-centred and safetyfocused. The chapters are united in their aimof employing occupational psychology evi-dence and expertise to understand theseprocesses of organisational culture change andprovide practical suggestions for those who areresponsible for instigating transformation.

Author(s)Grace Everest, Policy Researcher, Occupa-tional Psychology in Public PolicyDr Joanna Fitzgerald, Warwick BusinessSchool, University of WarwickLouisa Tate, Chair, Policy Researcher,Occupational Psychology in Public Policy;[email protected]

Implementing NHS Culture Change:Contributions from occupational psychology

Full list of chapters:

n Fiona Patterson, Lara Zibarras &Helena Murray: Values-basedRecruitment for Patient-Centred Care

n Barbara Wren: Managing StaffExperience to Improve OrganisationalCulture

n Chris Clegg, Lucy Bolton, Ryan Offuttand Matthew Davis: Work Design forCompassionate Care

n Beverly Alimo-Metcalfe & JulietteAlban-Metcalfe: Leading and ManagingHigh Performing Teams.

n Rosalind Searle, Alison Legood & KevinTeoh: Trust Boards and Governance:Composition and Behavioural Styles

n Michal Tombs-Katz: Fostering aContinuous Learning Culture in theNHS: The role of leadership

n Joanna Wilde: Building Cultures ofOpenness and Transparency

n Michael Wellin: Managing CultureChange in the NHS: An Overview

EMDR Training for Psychologists EMDR is successful in treating Post-Traumatic Stress Disorder and many other clinical conditions in which

adverse life events are a significant component. Add this effective, NICE and World Health Organisation recommended, evidence-based therapy to your existing portfolio of clinical skills.

Four-part courses fully accredited by EMDR Europe

PART 1 DATES BRISTOL EDINBURGH LONDON

22-23 January 2015 26-27 March 2015

25-26 September 2014 20-21 November 2014

16-17 October 2014 8-9 January 2015

2-3 July 2015 1-2 October 2015

PART 4 Practice Update & Supervision Day

(Open to any one who has previously completed EMDR Training) BRISTOL EDINBURGH LONDON

27 November 2015 16 October 2015

4 March 2015 1 July 2015

EMDR Works Ltd.


Compassion: If you stand in the light youcast a shadow1. What is compassion?IF WE ARE trying to teach compassion we mustfirst truly understand what compassion is. Com-passion means to suffer with others and have adesire to alleviate that suffering. Compassionhas been defined by Gilbert (2005) as follows:

Compassion (which is an element of loving-kind-ness) involves being open to the suffering of selfand others, in a non-defensive and non-judge-mental way. Compassion also involves a desire torelieve suffering, cognitions related to under-standing the causes of suffering, and behaviours-acting with compassion. Hence, it is from acombination of motives, emotions, thoughts andbehaviours that compassion emerges.

From this understanding of compassionGilbert has developed a therapeutic approach,compassion-focused therapy. In addition, Bal-latt and Campling (2011) have put forwardtheir model for ‘intelligent kindness’ in health-care on the basis that intellectually and emo-tionally we recognise others as our kin, andrecognise and wish to alleviate their suffering.

If in your work with a person who is sufferingyou are left only feeling good about yourselfbecause of your good deeds and you are not hurta little, maybe you were not being compassionateat all. The ability of people to suffer with anotheror recognise them as their kin will vary both for anindividual over time as their circumstanceschange, and between people. If we want compas-sionate services we need to select people who cansuffer with others, recognise their shared human-ity, and create and maintain organisations thatenable them to do so and act to alleviate suffering.

2. Everything has its shadowAccording to the work of Jung (1959) every-one, every team and every organisation has ashadow, containing aspects that it con-sciously does not want to identify with. Everyword used to express a quality has itsantonym. For compassionate the antonymsare: hardhearted, unfeeling, indifferent andmerciless. Individuals, teams and organisa-tions who aim to be compassionate may holdthese antonym qualities in their shadows. Forexample, in healthcare settings another per-son’s vulnerability may be ignored, or treatedwith indifferent, or in hardhearted way. Thismay be the consequence of the schemas thehealthcare professional developed in child-hood modelled by their parents’ behavioursto internalise the belief that to show vulnera-bility is wrong. The professional’s careerchoice to join a caring profession may stillcontain this shadow.

3. A normal distribution?Compassion can be understood as both a traitand a state that offers an evolutionary advan-tage (Goetz et al., 2010). But as a trait, is itnormally distributed in the general popula-tion? And if so, are members of the caringprofessions at the more compassionate end ofthe distribution? As a state, what are the fac-tors that effect it? These are questions await-ing further empirical attention.

If we could establish a way of measuringcompassion in real time, might we find thatthe mean value for compassion within a popu-lation shifts towards or away from the compas-sionate end of the distribution as the result ofdemands placed upon the system by externalforces such as the level of workload?

Compassion, organisations and leadershipStuart Whomsley

Caring for others in an organised way requires practitioners of all disciplines to be compassionate, organisationsto be efficient, and leaders to be both. This is complex and many thousands of words have been written about theissues connected to these requirements, particularly over the last two years. The following is an attempt to distilsome of the main issues into a summary of psychologically relevant points.


Compassion, organisations and leadership

4. Recommendationsn Research the distribution of an

operationalised measure of compassion inthe general population. Is it normallydistributed? Research the factors thatincrease or reduce compassion in thegeneral population and specifically in thecaring professions.

n Research the distribution ofcompassionateness in the generalpopulation. (Is it normally distributed?)And research the factors that increase or reduce compassion in the general population.

n Recruit people who are able to suffer withothers and desire to alleviate suffering.Create organisations that minimise thesuffering imposed on staff by it, allowingthem to suffer with their clients and notbe distracted by organisation inducedgrief. Create organisations that enablestaff to alleviate their clients’ suffering.

Organisations: Hitting the targets but missing the point1. Safe and certainOrganisations, like individuals, operate ondimensions of how safe and how certain theyare. Life is, at best, a state of safe uncertainty(Mason, 1993). Organisations may find them-selves as uncertain and unsafe whilst striving forthe rarely obtainable position of safe certainty.In such circumstances risk assessments and pro-tocols become defence mechanisms ratherthan useful tools for clients and clinicians.

2. Mind the gap –Management and cliniciansPoor communication is highlighted again andagain in most enquiries into serious incidents.It is dangerous when there is disconnection incommunication between the culture of man-agement and the culture of clinicians. In suchcircumstances, each may think that they arecommunicating and meeting the other’sneeds, but in reality they are not. The goals towhich they are working are not the same.

3. Who do you serve?One of the considerations for members of anorganisation is: Who do you serve? Is it the

Trust, is it the service users and carers, is it thecommissioners, is it the Care Quality Commis-sion and Monitor, is it the NHS, is it all of these?

These multiple masters can lead to confu-sion and further increase the gap betweenmanagement and clinicians, between clini-cians and clients. The Francis Report (2013)highlighted the problem of the goals andneeds of the organisation having become toodominant. In the document’s executive sum-mary they reported that in the South Stafford-shire hospitals they had found: ‘A culturefocused on doing the system’s business notthat of the patients’ (2013, p.4). A clinician’sprimary duty of care should be to their client.This may bring the clinician into conflict withmanagement. However, this needs not be neg-ative conflict if it leads to open and honest dia-logue from their respective positions.

4. Recommendationsn Create organisations that embody safe

uncertainty; that change is inevitable butthat the organisation is safe.

n Acknowledge the different needs ofmanagement and clinical cultures andthat the development of compromise andconsensus positions between the two isneeded. Create an ongoing dialoguebetween the two with opinion flowing topdown and bottom up so that grandrationalist plans are not implementedthat do not take account of empirical andlived experience feedback. This shouldreduce the chances of disconnectionbetween organisational objectives andpatient-focused care.

n Have clarity about the multiplestakeholders, for both clinicians andmanagement, in order to appreciateexplicitly how the demands of each doesor does not fit with their values.

Leadership: Getting the right people,role models and training them well1 Who buys a ticket?The Francis Report (2013) highlighted theimportance of leadership. In the executive sum-mary it stated that: ‘It is a truism that organisa-tional culture is informed by the nature of itsleadership.’ (2013, p.64). So who constitutes the


Stuart Whomsley

leadership of an organisation is crucial. How-ever, do the right people come forward offeringto be leaders? Do the right people get chosen tobe leaders? Should trait models of personality beused in leader selection to make sure that theright people are chosen? The later has beenadvocated for by researchers in the area, such asNg et al. (2008). Recently, attention has turnedto a trait theory based concept of the triadic per-sonality type, which has significant componentsof narcissism, psychopathy and Machiavellian-ism. It has been suggested that people with thistype of personality are increasingly thriving inthe public sector (James, 2013) as governmentpolicies of the last thirty five years have shiftedthe culture of the public sector from one basedon service and duty towards one based on com-petitive business models.

2. Who does the leader want to be?When polls are conducted or academics con-sulted to find out who are considered to begreat leaders, the people rated at the topoften include: Julius Caesar, Mao, Castro,Churchill, Washington and Ghandi. See, forexample, Industry Leader Magazine (2012).These grand, heroic and usually male figuresmight not be the best for people to modelthemselves on.

In addition, the very act of being a leader cancorrupt and lead to what Owen and Davidson(2009) termed ‘hubris syndrome’, which theysee in Thatcher, G.W. Bush and Blair, where thedesire for power became all consuming. Thismay also link to the triadic personality cluster.

3. Do we train our leaders well?The training that we have offer clinical psychol-ogists in leadership needs to compare favourablyto other professions. Psychiatrists are trained tolead and expected to do so. Clinical psychologytraining courses have improved this aspect oftraining in recent years. Clinical psychologists inleadership roles need to be effective to becomegood role models for the next generation.

4. Recommendationsn Take care in the selection of leaders and

use evidence-based selection procedures.n Set up a resource of exemplars of good

leadership that are more appropriate for

the average person in a healthcare settingrather than grand, heroic figures. Providegood governance in organisations toguard against hubris. The leader mustplay by the rules.

n Provide quality training in leadership andfollowership for clinical psychologists at alllevels. This training could include thestudy of the big models of leadership,such as servant and host leadership, inaddition to leadership styles for specificcontexts, such as being authoritative orcoaching, in order to help them find theirown authentic personal style. In addition,rather than trying to produce genericleaders it may be better to produceleaders for different tasks and contexts.

AuthorDr Stuart Whomsley, Cambridgeshire andPeterborough Foundation Trust; [email protected]

ReferencesAlain, P. (2012). Leadership and ten great leaders

from history. Industry Leader Magazine, 15 April.Retrieved 1 August 2014 from www.industryleader-smagazine.com/leadership-and-10-great-leaders-from-history

Ballatt, J. & Campling, P. (2011). Intelligent Kindness: Reform-ing the culture of healthcare. London: RCPsych Publishing.


Gilbert, P. (2005). Compassion: Conceptualisations,Research and Use in Psychotherapy. Hove: Routledge.

Goetz, J., Ketner, D. & Simons-Thomas, E. (2010).Compassion: An evolutionary analysis and empiri-cal review. Psychological Bulletin, 136(3), 351–374.

James, O. (2013). Office Politics. London: Vermillion. Jung, C.G. (1959). The Archetypes and the collective

unconscious. In H. Read, M. Fordham, G. Adler, W.McGuire (Eds.) The Collected Works of C.G. Jung (Vol-ume 9, Part 1). Princeton, NJ: Princeton University.

Mason, B. (1993). Towards positions of safe uncer-tainty. Human Systems: Journal of Systemic Consulta-tion &: Management, 4. p.189–200.

Ng, K.-Y., Ang, S., & Chan, K.-Y. (2008). Personality andleader effectiveness: A moderated mediation model ofleadership self-efficacy, job demands, and job auton-omy. Journal of Applied Psychology, 93(4), 733–743.

Owen, D. & Davidson, J. (2009). Hubris syndrome: Anacquired personality disorder? A study of US Pres-idents and UK Prime Ministers over the last 100years. Brain, 132(5), 1396–1406.


THIS PIECE by Lydia Davis (2013)reminds me of what can’t be seen, spokenabout or heard. One can turn a blind eye

to things knowingly or unknowingly, as facingthem can be uncomfortable. Adjustment totransitions can be unsettling, as it requiresrelinquishing places of familiarity and facingof survival anxieties. Embracing the loss ofwhat is known and connecting with change isoften challenging, although this may offeropportunities for development and growth.Our paths are often determined by thechoices we make at such transitional points.

Turning of a blind eye (Steiner, 1993) isnot uncommon in organisations. Reviews likethe Francis report (2013) and the report intothe abuse at Winterbourne View (DH, 2012)point out malpractice whichorganisations fail to notice. Gold-man (2008) uses a similar case ofleadership negligence at SkyWavesAerospace International to pointout the consequences of a cultureof ‘no emotions allowed’. Suchreports are important markers forwhat can go wrong in organisa-tions and how this could arisefrom compromised capacity tohold compassion and care inmind. This paper intends to consider factorssuch as containment, empowerment, respon-sible autonomy and internalised accountabil-ity to facilitate a culture of compassion. Itbriefly examines dynamics, which impact such

attributes in individuals and groups. Thescope of reflective organisations, where lead-ers invest in containing structures andprocesses is discussed. Although the focus ofthe paper is on healthcare, issues explored arerelevant to wider settings, as compassion andstaff well-being is relevant to all organisations.

Compassion and care in organisations Capacity to provide care requires a state ofmind which has an ability to hold both oneselfand others in mind. Engaging with ourselvesin a caring role is as important as engagingwith the care needs of clients. This interplaybetween self and other is explored well in Fon-agy and Bateman’s (2006) work on ‘mentalis-ing’. It attends to mental states (beliefs, wishes,

feelings and thoughts) whichdetermine what we do. Theydescribe mentalising as ‘the keysocial-cognitive capacity that hasallowed human beings to createeffective social groups’. It is ‘a per-ceiving and interpreting behaviouras conjoined with intentional men-tal state’ (Allen, 2012). The con-cept is widely used in clinicalsettings and is linked with con-cepts such as empathy, psychologi-

cal mindedness, and ‘the third position’.Mentalising requires attention to the inten-tional mental state of others whom we are withphysically, psychologically and emotionally.We can all lose this capacity temporarily when

Developing a culture of compassion: Can't or won'tAmra S. Rao

We are sitting with our old mother in the nursing home.‘Of course I’m lonesome for your kids. But it’s not like being in a strange place where you don’t know anymore.’She smiles, trying to reassure us. ‘There are plenty of people here from good old Willy.’She adds. ‘Of course, a lot of them can’t talk’. She pauses, and goes on: ‘A lot of them can’t see’.She looks at us through her thick-lensed glasses. We know she can’t see anything but light and shadow.‘I’m the last of the Mohicans, as they say’.The Last of the Mohicans, Lydia Davis (2013)

…compromisedcapacity to hold

compassion and care in mind.


Amra S. Rao

we disconnect with the awareness that othershave a ‘mind’ and treat them as physicalobjects (Fonagy & Bateman, 2006). This workon mentalising provides a helpful frameworkto add to the understanding of compassionand how this is compromised in groups andorganisations.

Individuals and groups under pressure andfaced with anxieties can experience a border-line state of mind where capacity to symboliseand have sufficient distance from the physicalreality to pay attention to mental representa-tion is lost. Attempts to under-stand difficulties are oftenconcrete, assumptive and lackingreference to internal states of one-self and others to understandbehaviour. Others cease to exist ashaving a ‘mind’ representing feel-ings, desires, intentions, thoughtsand needs. Such processes can occur at indi-vidual and group level bringing complexdynamics associated with In and Out groups.This compromises the ability to hold a focusedcompassionate vision, which can attend tomultiple perspectives including self, othersand the wider context.

Compassionate organisations – what comes in the wayIndividuals bring life experiences to work,which, combined with working conditions,impact on their ways of relatedness with thetask and their teams. Ability to mentalise isfacilitated by conditions which help to processand contain work-related challenges and anx-ieties. Such anxieties often arise through con-tact with task and need for collaboration withothers (Krantz, 2001). Menzies Lyth’s work(1988) is centred on anxieties associated withthe nature of the task and how organisationsdevelop systems/defences to manage them.She examined nursing environments andhighlighted how anxieties associated withdependency, survival and personal limits toprovide care can be dealt with by rigid adher-ence to procedures. This can happen at thecost of creative thinking and human contactwith patients, as such anxieties can feelunbearable. Whilst errors and incidents inorganisations allow space to review practices,

anxieties at such times are often pronouncedand can get in the way of reflective learning, asexploration of ‘why’ and ‘how’, and looking atthe impact of the incident on staff and widersystem is often challenging.

Organisations need structures and processesto deliver their tasks safely and effectively. Sys-tems such as strategic vision, policies andforums to communicate and discuss workrelated matters are required to provide neces-sary conditions for the work to be done. Prob-lems arise when these systems impinge on

capacity to think and mentalise,which is essential to inform practiceand learn from experience.

Reports such as Francis’inquiry provide useful insightinto how systems can struggle tonotice matters of concern and ormay choose to turn a blind eye

(Steiner, 1993). Findings on failure to careare not surprising to many of us, as publicservices capacity to contain and sustain aculture of reliable dependency has beenunder enormous pressures in recent years.The NHS has faced fierce financial pres-sures within a context of increased publicexpectations and awareness, enhanced serv-ice users’ voice and advances in health andsocial media technology. This, combinedwith the quality agenda and evidence basedpractice, has influenced many recent driversfor change. The pace of change in manyservices has been rapid. Cuts, redundancies,restructuring, lower staff/customer ratio,pressures surrounding an adequate skillmix, performance targets and stressed workenvironment are familiar challenges tomany public health workers. Although man-agement of change is often marked asimportant, the time and effort required topay attention to system dynamics makes thiswork challenging. A collusive displacementof responsibility can compound this furtherwhen such work is handed over to the other,at the cost of increased vulnerability.

This poses the question of whether wecan’t or won’t play our part in developing aculture of care, which requires a compassion-ate mind. In my view, attention to relationshipbetween container and contained is impor-

A collusivedisplacement

ofresponsibility…


Developing a culture of compassion: Can't or won't

tant to understanding what comes in the wayof embracing this challenge and facilitating aculture of collective compassion. We need tolook at users of services and the workforce, asboth need to be treated with dignity andrespect. Research carried out by the NationalNursing Research Unit at King’s College Lon-don (Maben et al., 2012) showed that levels ofsatisfaction and well-being among NHS staffhave a direct impact on patients’ experiencesof healthcare. It highlights that investing instaff well-being is important for the nursingworkforce but also for quality of care overall.These findings echo those of the Boormanreport, the independent NHS Health and Well-being Review (2009).

Safety and containment at workAttention to staff well-being and containmentis paramount to develop a culture of care andenhance users’ experience. Whilst staffsupport and training initiatives are impor-tant, organisations require a broader perspec-tive to develop a work framework which iscontaining and addresses sources of anxietiesand conflict in the workplace.This is essential to foster condi-tions for a mentalising and com-passionate workplace.

The nature of the work taskplays a vital part in generatinganxieties in staff groups, irre-spective of the setting. Acknowl-edgement and processing ofthese anxieties is important toattend to anti-task behaviour. In human serv-ice organisations, this is often compoundedby what individuals bring to work as well asby group dynamics. Such processes, along-side assumptions one makes about the pri-mary task, can come in the way of the work.In my experience clarity about the primarytask (Rice, 1948) is what often gets lost inorganisations where investment in person-alised relations and ambition takes over.Lawrence and Robinson (1975) brings atten-tion to assumptions at the workplace askingleaders to notice ‘what actually goes on’.They highlight the distinction between whatwe ought to be doing, what we believe to bedoing, and how we actually behave. It is

important for leaders and groups to staycurious about the variations in ‘task in mind’as well as ‘organisation in mind’. Staff canhave a different vision and purpose in mindin connecting with their role, which requiresexploration to facilitate re-engagement withthe task.

Alongside differences in how we connectwith the task and role, group dynamics areoften at play at work. Bion (1948) distin-guished between ‘work groups’ and ‘basisassumption groups’. The tendency towardswork on the primary task is referred to as‘work group mentality’ and tendency toavoid work on the primary task is called‘basic assumption mentality’, where thegroup behaviour is directed at trying tomeet unconscious needs of its members byreducing internal conflicts and managingrelationships. In one of the consultanciesI undertook on change transformation,underlying dynamics around the systemchange were pronounced. The task of sign-posting patients to the right treatment wasshadowed by competition between teams

where rivalrous responses camein the way of engaging with whatwould work for the patient. Expe-rience of suspicion and preoccu-pation with rules and processesled to flight from work and fightwith what felt intolerable. Thegroup remained preoccupiedwith status and hierarchy, stir-ring up unspoken competition

which impacted on decision-making. Simi-lar dynamics were noticeable in a coachingassignment in the finance sector whereflight and fight dynamics were at play as newmanagement remained preoccupied withimplementation of new vision for talentmanagement, inclusion and diversity. Littleattention was paid to engagement with exist-ing employees of the firm to consider theimpact of the management of the new visionon their role, values and understanding ofthe task.

There is wide ranging literature on whatcan facilitate containment and effective work-place functioning. Contributions from the sys-tems psychodynamic approach highlights the

…clarity aboutthe primary

task is what often gets lost…


Amra S. Rao

importance of looking at operational struc-tures and processes as well as below the sur-face issues, including:n Clarity on the primary task (Rice, 1948). n Clarity of roles (Lawrence, 1977).n Clear communication and structures of

authorisation (who decides on primarytask and by what authority?).

n Focus on task orientated activities tomobilise co-operation and valuing ofdifferent contributions.

n Workgroups to contain task-relatedanxieties and impact of work on staff tohelp developing a self-observing stanceto one’s emotions and reactions toothers. Such forums can facilitatedeveloping a capacity to hold ‘the thirdposition’, which is a paramount role inprocessing differences that are feared orseen as threatening.

Change: Opportunity or threatInvitation to change can evoke mixed responsessuch as fear and anticipated hope. As men-tioned earlier, change can often be unsettlingand painful as it requires relinquishing places offamiliarity. Thoughtful management of change,with a balanced outward and inward focus,alongside reflection on learning from past andauthentic connectivity with the organisationalhistory is vital opening up opportunities for cre-ativity and growth. This involves focusing ontasks as well as paying attention to an organisa-tional mind-set encompassing anxieties, con-flicting needs, rivalries, competition andambition. This is nevertheless challenging asthe ability to reflect and mentalise is often com-promised at the time of change.

The importance of a ‘transitional space’to process and grieve in order to open upgrowth can’t be underestimated. Kubler-Ross’(2005) stages of loss reminds us of changesindividuals go through whilst faced with griev-ing of what is no more. This work has beenextended to organisations to understand theprocess of change and its impact on individu-als and groups, indicating that grief, angerand depression associated with the loss needto be embraced to arrive at a meaningful posi-tion where opportunities and growth couldbe considered.

In my organisational and coaching work,I frequently come across the phenomena of‘change fatigue’ and feeling of ‘beingdesigned out’, often indicating a disruptedmourning of loss. This results in burn out andaffects capacity to engage with the ‘third posi-tion’. I notice a particular pattern, whereengagement with the task is minimised bydelivering bare essentials to do the work at thecost of creativity and work satisfaction. Individ-ual conflicts are often pronounced with abdi-cation of both personal authority andresponsibility to look at what is going on.

It is not the scope of this paper to exploresuch dynamics in depth, it is suffice to say thatleaders and mangers need to be observant ofsuch driving and restraining forces at workand consider what needs to be harnessed tofacilitate staff well-being and engagement withthe task. Leaders play a significant part inoffering containment in order to cultivatethoughtful and compassionate care with aclear focus. This requires exploration of workpriorities and adopting a reflective style thatallows looking at work from multiple angles.A recent article in the Harvard Business Review(Golman, 2013) suggests that a leader needsto foster a triangulated focus in order to beeffective. This requires:n A focus on oneself, to have self-awareness

and control to connect with direction.n A focus on others to foster relationships.

This requires cognitive and emotionalempathy as well as an empathic concern –the ability to sense what other peopleneed from you.

n A focus on the world with a focusedstrategy and system awareness.

Moving forward: Can’t or won’tQuestions posed by organisational inquiriesand recommendations are often challengingand require a system-based reflectiveapproach and a responsible commitment toexamine practices. It is vital that organisationsattend to structural and procedural changesas well as having a commitment to addressprocesses to uncover ‘under the surface’issues that affect engagement with the task-focused role assignment. This requires reflec-tion on the part of organisations and the


Developing a culture of compassion: Can't or won't

individuals in them to consider whether theycan’t or won’t. Organisations need to take astep beyond the ordinary and embrace the joyand pain associated with the task of providingcare, as it involves both satisfaction and possi-bility of disappointing oneself and others.This entails a triangulated approach at theheart of interaction between people with afocus on task, role and boundary manage-ment to attend to the self, others and widercontext. Engagement of both leaders and fol-lowers is vital for such an endeavour.

What contributes to ‘we can’t and won’t’requires the collective attention of both staffand leaders to hold responsible autonomyand internalised accountability. There is riskof collusive displacement and abdication ofresponsibility resulting in a collective flightfrom the challenge of bringing our individualcontribution. Whilst leaders hold responsibil-ity to set up containing structures, a stance ofdependency on the other can disconnect usfrom what role we can individually play. Man-aging survival anxieties and holding compas-

sion in mind in market of fierce competition,job cuts and fast changing global and politicalworld is not going to be easy. A combinedeffort to develop a sense of enquiry is neededas well as capacity to hold mentalising underpressure, alongside provision of safety forstaff, for the process of learning to unfold.Provision of a protected space for reflection toaddress the impact of work is vital for develop-ing organisations’ social-cognitive capacity.This can help to develop the capacity to beopen, take risks and challenge to connect withresponsible accountability towards oneself,others and the organisational task. Thisrequires courage and resilience on the part ofindividuals, groups and organisations.

AuthorDr Amra S. Rao, Consultant Clinical Psycholo-gist/HPC Registered Practitioner Psycholo-gist/Lead, Borough Wide Psychological Services& Specialist Services Psychology, Newham Local-ity Complex Care, East London FoundationTrust; [email protected]

Figure 1: Triagulated approach to foster compassionate menalising organsations

Other

Self

Fellowship

Authorisation

Boundary

RoleTask

Driving

forces

Retraining

forces

Widercontext


Amra S. Rao

Allen, J.G. ( 2012). Restoring Mentalizing in AttachmentRelationship: Treating Trauma with Plain Old Therapy.Arlington, VA: American Psychiatric Association.

Bateman, A. & Fonagy, P. (2006). Mentalization-basedTreatment for Borderline Personality Disorder: A Practi-cal Guide. Oxford: Oxford University Press.

Bion, W.R. (1948). Experiences in groups. HumanRelations, I–IV, 1948–1951.

Boorman, S. (2009). NHS Health and Well-being Review.London: Department of Health.

Davis, L. (2013). Can’t and Won’t. Colchester: HamishHamilton.

Department of Health (2012). Transforming Care: Anational response to Winterbourne View Hospital.Department of Health Review: Final Report. London:Author.


Goldman, A. (2008). Leadership negligence and mal-practice: emotional toxicity at SkyWaves AerospaceInternational. In N.M. Ashkanasy, W.J. Zerbe &Charmine E.J. Hartel (Eds.) Emotions, Ethics andDecision-Making (Research on Emotion in Organiza-tions, Volume 4). Bingley: Emerald Group Publish-ing Limited (pp.207–224).

Krantz, J. (2011). Dilemmas of Organizational Change: A SystemsPsychodynamic Perspective. Unpublished manuscript.

Lawrence, G. (1977). Management development…some ideas, images and realities. In A.D. Colman &M.H. Geller (Eds.) (1985) Group Relations Reader 2.Portland, OR: A.K. Rice Institute.

Maben, J., Peccei, R., Adams, M., Robert, G., Richard-son, A., Murrells, T. & Morrow E. (2012). Patients’Experiences of Care and the Influence of Staff Motiva-tion, Affect and Well-being. NIHR Service Delivery andOrganisation programme Final report. London:National Institute for Health Research.

Menzies Lyth, I.E.P. (1988). The functioning of socialsystems as a defence against anxiety: A report on astudy of a nursing service of a general hospital. InL.I. Menzies (Ed.) Containing Anxiety in Institutions.London: Free Association Books.

Rice, A.K. (1958). Productivity and Social Organisation:The Ahmedabad experiment. London: Tavistock Pub-lications. New York: Garland.

Steiner, J. (1985). Turning a blind eye: the cover up forOedipus. International Review of Psychoanalysis, 12,161–172.

Steiner, J. (1993). Psychic Retreats: Pathological organiza-tions in psychotic, neurotic and borderline patients. Lon-don: Routledge.

References

Division of Clinical Psychology

Facebook pageThe DCP now has a Facebook page.To get all the latest updates from the Division go to:www.facebook.com/divisionofclinicalpsychology


THE INTEREST in the quality of compas-sion in health and social care has expandedin the last few years and has been awarded

unprecedented importance following the Fran-cis inquiry report (2013). It has been reportedthat patients are more likely to talk more abouttheir experiences and symptoms following care-giver compassion (Firth-Cozens et al., 2009).Thus, the ability of healthcare staff to be com-passionate may aid the cultivation of the thera-peutic relationship, which is one of thebest-known predictors of favourable outcomesof therapy (Norcross, 2011). Thisarticle focuses on the current workand initiatives at the National Psy-chosis Unit (NPU) to promote com-passionate care among the team.

The NPU is a specialist, 23 bedin-patient unit for people diag-nosed with treatment-resistantschizophrenia. It is a long-stay unit,where the patients are often acutelyunwell and at times incidents of violencetowards staff can be high. Many patients alsoexperience a number of physical health risks(e.g. diabetes, heart conditions), which canrequire a crisis-driven response from staff. Inthe wider context, austerity measures withinthe Trust, sickness rates, and increased targetdriven workloads mean that the staff may be athigh risk of compassion fatigue and burnout.High levels of stress have been documented inNHS mental health nurses (Sherring & Knight,2009) and this is especially relevant in a psychi-atric in-patient ward, where work with complexpatients can be both challenging and distress-ing for staff (Bowers et al., 2011). It is under-

standable that these factors may leave staff in aposition where they are unable to work in thebest interests of the patient (e.g. affectiveattunement to patient; Penn et al., 2004).

Clinical psychologists are well placed toassess, formulate and help manage thesepotential professional and personal chal-lenges. We view compassionate care as a recur-rent task, which requires monitoring andenhanced input when a crisis event occurs toenhance a compassionate perspective leadingto quality care. We are currently doing this via

two strands: reflective practicegroups and team formulation;these will be discussed in turn.

First, a qualified psychologistfacilitates monthly reflective-prac-tice group sessions. These groupsaim to provide a safe and support-ive space to allow open discussions,where staff are invited to reflect onthe professional and personal chal-

lenges and successes of their work. Researchindicates that nursing staff that are stressed areless likely to show compassion towards them-selves, which is likely to translate to a lack ofcompassion towards patients (Gilbert, 2009).Informal evaluation of our groups to date hasindicated that they provide normalisation ofexperiences, lessen feelings of isolation, andincrease openness to experiences and empa-thy. Staff also acknowledge that there can be apowerful sense of satisfaction gained from suchchallenging work; termed ‘compassion satisfac-tion’ in the literature (Figley, 2002).

Second, psychologists facilitate complexcase discussion meetings fortnightly;

Cultivating compassionate care within the National Psychosis Unit: The use ofpsychological formulation and staffreflective practiceLauren Armstrong, Victoria Bell & Alison McGourty

…We viewcompassionate

care as a recurrent

task…


Lauren Armstrong, Victoria Bell & Alison McGourty

referred to as ‘long handovers’ on the ward.There is emerging evidence that team for-mulation is associated with improvements instaff members’ ability to provide compas-sionate care towards patients (Lown & Man-ning, 2010) – specifically, increasedempathy, confidence and com-passion (Goodrich, 2012). Theaim of long handovers at theNPU is to improve understand-ing of the patient’s history andpresenting difficulties, and facili-tate the development of thera-peutic relationships. Berry andcolleagues (2008) reported thatwithin an in-patient setting teamformulation had a positive effecton staff appraisals of patients’mental health problems and feel-ings towards patients. A previousevaluation of staff feedback from the longhandovers indicated that they are seen asuseful and a good way to learn aboutpatients. However, we have observed thatthe focus can at times be on action pointsabout ‘what to do with someone’(Onwumere, 2012), which is not the mainfocus of such groups.

Given the abovementioned research find-ings, we are interested in whether the long han-dovers develop compassion towards patients,such as a stronger sense of empathy, non-judg-ment, collaborative working, engagement,greater tolerance of patients’ distress, and con-fidence. This will be assessed through a serviceevaluation, which includes a baseline periodand three-month follow-up. Self-report meas-ures of compassion towards others (Pommier& Neff, 2011), compassion satisfaction andcompassion fatigue (Hudnall Stamm, 2009)will be used at these time points. Additionally,a newly devised five-item compassion-based

self-report measure will also be administeredpre/post each long handover to assess changesin staff compassion towards the patient beingdiscussed. Preliminary findings indicate that,whilst the team have relatively high levels ofcompassion, they are also experiencing burn-

out. Initial indications based onresponses to the five-item measuresuggest that the long handoversare an effective way of increasingcompassion towards patients. Fur-ther data collection and analysis isneeded to fully evaluate the effec-tiveness of the long handovers (inpreparation). Research and devel-opment permission was granted bySouth London & Maudsley NHSFoundation Trust. This evaluationwas also designed in collaborationwith the needs of the ward man-

ager and the wider nursing management team,and is in accordance with the six ‘C’s of nurs-ing: care, compassion, competence, communi-cation, courage and commitment – a nationalstrategy from the Chief Nursing Officer forEngland to build a culture of compassionacross the profession of nursing (www.eng-land.nhs.uk/nursingvision/6cslive).

This will be the first evaluation of compas-sionate care at the NPU and it is hoped findingswill highlight the importance of using psycho-logical formulation to develop and nurture astronger sense of self- and other-compassionwithin an in-patient setting. The findings areexpected to be relevant to developing futureresearch within the NPU and wider Trust.

AuthorsLauren Armstrong, Dr Victoria Bell & Dr AlisonMcGourty; National Psychosis Unit, BethlemRoyal Hospital, South London & Maudsley NHSFoundation Trust; [email protected]

Berry, K., Barrowclough, C. & Wearden, A. (2009). Apilot study investigating the use of psychologicalformulations to modify psychiatric staff percep-tions of service users with psychosis. Behaviouraland cognitive psychotherapy, 37, 39–48.

Bowers, L., Nijman, H., Simpson, A. & Jones, J. (2011).The relationship between leadership, teamwork-ing, structure, burnout and attitude to patients on

acute psychiatric wards. Social Psychiatry and Psychi-atric Epidemiology, 46, 143–148.

Figley, C.R. (2002). Compassion fatigue: Psychothera-pist’s chronic lack of self care. Journal of ClinicalPsychology, 58, 1433–1441.

Firth-Cozens, J. & Cornwell, J. (2009). Enabling Compas-sionate Care in Acute Hospital Settings. London: TheKing's Fund.

References

…longhandovers arean effective

way ofincreasing

compassiontowards

patients…


Cultivating compassionate care


Gilbert, P. (2009). The Compassionate Mind: A newapproach to life’s challenges. London: Constable &Robinson.

Goodrich, J. (2012). Supporting hospital staff to pro-vide compassionate care: Do Schwartz CenterRounds work in English hospitals? Journal of theRoyal Society of Medicine, 105, 117–122.

Hudnall Stamm, B. (2009). Professional Quality of Life Scale (ProQOL): Compassion satisfaction andcompassion fatigue (Version 5). Retrieved fromwww.proqol.org.

Lown, M. & Manning, C (2010). The Schwartz CenterRounds: Evaluation of an interdisciplinaryapproach to enhancing patient-centered commu-

nication, teamwork and provider support. AcademicMedicine, 85, 1073–1081.

Norcross, J.C. (Ed.). (2011). Psychotherapy relationships thatwork (2nd edn.). New York: Oxford University Press.

Onwumere, J. (2012). Evaluation of Long Handovers.Unpublished internal report, South London &Maudsley NHS Foundation Trust.

Penn, D.L., Mueser, K.T., Tarrier, N., Gloege, A.,Cather, C., Serrano, D. & Otto, M.W. (2004). Sup-portive therapy for schizophrenia. SchizophreniaBulletin, 30, 101–112.

Pommier, E.A. (2011). The compassion scale. Disserta-tion Abstracts International Section A: Humanities andSocial Sciences, 72, 1174.

Sherring, S. & Knight, D. (2009). An exploration ofburnout among city mental health nurses. BritishJournal of Nursing, 18, 1234–1240.

East Midlands Branch

DCP East Midlands Event & AGM

Best Foot ForwardA showcase for new and established psychological work

New Art Exchange, Gregory Boulevard, Nottingham NG7 6BEFriday 21 November 2014, 9.30am–4.30pm

(Registration from 9.00am. AGM taking place at 1.00pm)The morning session will be an opportunity to hear about recent research undertaken within localservices, mostly trainee projects or service evaluations. Further projects will be displayed as posters.

The afternoon session will open with a keynote speech by John Read, Professor of Clinical Psychology, University of Liverpool followed by Amanda Wild, Principal Clinical Psychologist,Tees Esk & Wear Valleys NHS Foundation Trust, speaking about 'Trauma informed service provision'.

This is a free event and open to all, but places are limited so please book early.

This event is being financially supported by the DCP East Midlands Branch, which has invested in it for the benefit of its members.

To register go to:https://response.questback.com/britishpsychologicalsociety/cy3thznobiAll queries, please e-mail [email protected]

with ‘Best Foot Forward 2014’ in the subject line.


AKEY THEME arising from the Francisinquiry report was that of culture ofcare. This important aspect of service

delivery was targeted by the Directorate ofForensic Mental Health and Learning Disabil-ities (DFMH&LD) of NHS Greater Glasgow &Clyde (NHSGGC) through the decision todevelop of a package of training aimed atenhancing the therapeutic aspects of thesecure environment.

The Francis inquiry report suggested aneed for organisations to provide the ‘right’culture of care. This includes providing staffwith the right training and support appropri-ate to the needs of the patients they are work-ing with, along with recognising the challengesof the job. For staff in forensic clinical settings,this has particular resonance, as the impact ofpatients’ clinical presentations or historiesshould be considered. Aspects of offences theyhave committed can arouse powerful feelingssuch as disgust or fear, which may impact onpatient engagement and interactions. Simi-larly, there is some evidence to suggest thatpatient characteristics may contribute to diffi-culties in providing a wholly therapeutic envi-ronment. These may include psychosis andparticularly personality pathology (Moore,2012). In line with the Francis inquiry report,the ‘forensic matrix’ (2011) outlines the needto make staff aware of the challenges of work-ing with this complex client group and tounderstand the causes of patients’ behaviours.To help address this, a therapeutic milieutraining programme was developed within theDFMH&LD NHSGGC. The development ofthe training package was led by clinical psy-chology, with contributions from other profes-sional groups, and was drawn frompsychological theory and the existing evidencebase. The package of training was supported

by the senior management team and incorpo-rated into the Directorate learning plan, with atarget of training approximately 80 per cent ofstaff within an 18 month period.

The training programme itself wasdesigned to raise awareness of the influenceson patient behaviour, the therapeutic environ-ment and the nature of interventions deliv-ered within the Directorate to promotepatients’ recovery and risk management, alongwith raising awareness of communicationissues and staff-patient interactions. The train-ing was not didactic but encouraged reflectionand discussion. The specific areas covered inthe content of the training included:n Considering what was meant by the term

‘therapeutic milieu’ and whether this wasa ‘rebranding’ of something familiar.

n Thinking about what it was like to be apatient in the forensic mental health settingincluding an introduction to formulation.

n Consideration of how patients’presentations and characteristics can makeus as staff members feel (incorporating theeffect of the environment, reflecting onthe potential for a ‘them and us’ cultureand the impact of this on both staff andpatients, and working with challenging ordifficult behaviours).

n And finally, participants were encouragedto reflect on effective communication andappropriate disclosure, along withpromoting recovery whilst managing risk,seen as two sides of the same coin.

During development of the programme, cur-rent and former in-patients were invited tocomment on the content of the trainingmaterials in order to ensure that their experi-ences of their care and management werereflected. Furthermore, the material was

Therapeutic milieu training in a forensic mental health settingEmma Drysdale & Patricia Mooney


Therapeutic milieu training in a forensic mental health setting

piloted with a multidisciplinary group of pro-fessionals who provided feedback, both onthe content of the training and on delivery.These processes feed into a revision andrefinement of the original materials into theprogramme as it now stands. The model oftraining was to target whole multidisciplinaryteams as a group, in order to help team mem-bers reflect on the individuals under theircare, rather than on more abstract case exam-ples. A monthly training schedule is now inplace for the forthcoming year.

The experience of delivering the trainingwas a positive one, with participants describ-ing the benefit of a multidisciplinaryapproach to the training, and appreciatingthe range of experience and seniorityamongst facilitators and participants. Itappeared from the feedback that partici-pants really valued gaining a better under-standing of patients’ behaviour throughdiscussion about their background and lifeevents, in the context of some psychologicaltheory to support their understanding, suchas attachment theory. As a facilitator, this wasparticularly rewarding, in that participantsremarked that considering formulationhelped them to remember to reflect more onindividual patient’s strengths and interests,

and that this helped with making interac-tions generally more therapeutic. With theroll out of this training the aim is to supportstaff to feel more valued and informed, andsubsequently foster a culture of care thatmeets the needs of the patients in forensicmental health settings. Further develop-ments may include reinforcing the key mes-sages of the training through the use ofreflective sessions for staff, and also provid-ing fora for patients to reflect on their ownexperiences of the therapeutic milieu, andfor this to be incorporated into ward plans.

AuthorDr Emma Drysdale, Consultant Forensic Clin-ical Psychologist; Dr Patricia Mooney, Con-sultant Clinical Psychologist; Directorate ofForensic Mental Health &Learning Disabili-ties, NHS Greater Glasgow & Clyde

ReferencesForensic Network (2011). The Forensic Mental Health

Matrix – A Guide to Delivering Evidence Based Psycho-logical Therapies in Forensic Mental Health Services inScotland. Edinburgh: Scottish Government.

Moore, E. (2012). Personality disorder: Its impact onstaff and the role of supervision. Advances in Psychi-atric Treatment 18, 44–55.

Understanding Psychosis and SchizophreniaWhy people sometimes hear voices, believe things thatothers find strange, or appear out of touch with reality…and what can help.

An overview of the current state of knowledge in thefield, concluding that psychosis can be understood andtreated in the same way as other psychological problemssuch as anxiety or shyness.

Coming soon to the BPS Shop!


IWRITE this from Toronto where I am on acareer break from my post as joint head ofa child psychology service. This is relevant,

firstly because after 20 years in the NHS in ajob I am passionate about, my frustrationswere such that I leapt at the opportunity tohave some time out. Secondly, I have beenafforded the space to reflect on 12 years as amanager – something that never felt possiblewhen I was working, despite the best of inten-tions. Finally, spending time in Canada, I amstruck that there may be things we can learnfrom the culture here.

For the majority of my career I haveworked in a child psychology service wherethe core values have been explicit and haveshaped every aspect of our practice. Thispredates my leadership role, and indeed,was the incentive to take up the mantle.With such a clear rationale and the supportof an equally passionate job share partnerand team, it has been easier perhaps to crys-tallise those values and to spot when theycome under threat.

The values have remained resolutethroughout my experiences of working withhighly distressed children and families, in anumber of core and specialist teams, with anevolving evidence base, and all the turbu-lence, 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 ourunderstanding.

3. That the child and their family are theexperts on their own experience.

4. That children deserve the opportunity to have a normative, contextual anddevelopmental understanding of their distress.

5. That the language we use is very powerfuland must be considered with care.

6. That the least possible contact withprofessional services, the moreempowering the experience that we areour most important resource and need tobe nurtured if we are to nurture those wework with.

7. That we are a scarce resource and have aresponsibility to target our specialist skillsto maximal effect.

It is my assumption that there is nothing par-ticularly controversial in these values, and theywould be commonly held by psychologicallyminded professionals throughout health.Indeed, in my discussions with the vast major-ity of multidisciplinary and managerial col-leagues there is generally consensus regardingthe above; and they can usually be foundembedded in strategic documents that shapeour public services.

Despite this, when it comes to service deliv-ery, much of my career has been spent eitherarguing in their favour or defending themagainst attack. Indeed, I would characterisethe majority of my professional life as a man-ager as ‘swimming against the tide’, which isperhaps why I felt so ready for a break.

Now that I have the time, I am more ableto reflect on the mismatch between what peo-ple clearly believe and how it actually feels onthe ground. Maybe my thoughts can offersome insight into why the atrocities that led tothe Francis inquiry happened, despite usknowing that most people who work in health-care do so because they genuinely do care.I will also argue that psychology, because ofthe nature of our training, is in an advantagedposition to be able to offer some potentialsolutions.

Core values and the NHS: Reflections with the benefit of distanceLiz Gregory


Liz Gregory

Value 1: Every child is unique Only the brave would deny this, yet as clini-cians we are constantly put under pressure toconform to standardised formats and ‘one sizefits all’ solutions. The rationale is obvious – itis simpler, cheaper, ensures consistency,guards against idiosyncratic practice andreduces negligence claims. The risk, ofcourse, is that it has the potential to deperson-alise and even dehumanise the healthcareexperience. The alternative prospect, ofcourse, that every user of the NHS requires acompletely individualised service, is equallyterrifying for us all in health. This is particu-larly in light of the pressure we are under andthe constant message that demand is onlygoing to grow.

I would argue that clinical psychologistsare able to adopt a helpful position in respectof this dichotomy. We start and finish with thepremise that everyone is unique, but equallywe are diligent in our reference to both theevidence base and the clinical experience toensure the most efficient interventions areidentified. We are trained to anticipate thatthe journey will be dynamic,requiring constant adjustment.We trust that it is through a rela-tionship that change will beachieved, and we have many skillsto help us to achieve this.

It is unrealistic to roll out sim-ilar training to all professions butthere are some basic principlesthat can be shared. For example,listening and responding to feed-back, and having the confidenceto change direction in the middle of aprocess. Interview questions such as ‘how willyou know if today’s appointment has beenhelpful?’ can facilitate an individualisedapproach regardless of the endeavour.

Value 2: The family and the systemsaround the child are central to ourunderstandingThis is most relevant to children’s services, ofcourse, but it may have a wider utility. The tra-ditional model of healthcare is very individu-alised – despite often losing sight of theindividual. However, as psychologists we are

trained to understand that everyone existswithin a context, and that this context may bemore or less helpful to the healing process.We have the skills to manage multiple per-spectives, and frequently deliver interventionsindirectly through carers or staff.

These are unfamiliar concepts within themedical model, and yet they have the poten-tial to be highly relevant. For example, fromfamily myths about illness, to the accessibilityof the school toilets, there are an infinitenumber of factors that can interfere with theeffectiveness of treatments. Questions such as‘who is most likely and who is least likely tosupport you in this?’ can help to identifypotential barriers, and psychologists can havea role in containing the commonly held fearof ‘opening a can of worms’.

Value 3: The child and their family arethe experts on their own experienceAs psychologists this is a concept that is cen-tral to our profession, and it is now gaining areal momentum in the general healthcarearena. We are well placed, therefore, to

support the development of userinvolvement and methodologiessuch as co-construction. We canalso have a role in containinganother common anxiety that thiswill generate unrealistic demands.

This reminds me of my ownexperience of an admission to amedical ward 15 years ago. Thegeneral hygiene levels were verypoor, people were left in soiledbeds and I overheard conversa-

tions between staff about ‘difficult patients’.After I had been discharged I mentioned myconcerns to a doctor from a different organi-sation. Despite being one of the most caringand diligent physicians I know, the responsewas that it was that ‘a hospital and not a hotel’.The comment was fuelled, of course, by feel-ing defensive on behalf of overstretched nurs-ing and medical colleagues, and overwhelmedregarding where the line gets drawn. Again,I believe that psychology has something tooffer this dichotomy. We are trained to searchout solutions in ‘all or nothing’ situations,trusting that a middle ground can be found.

…psychologistscan have a rolein containing thecommonly heldfear of ‘openinga can of worms’.


Core values and the NHS

Value 4: Children deserve theopportunity to have a normative,contextual and developmentalunderstanding of their distressValue 5: The language we use is verypowerful and must be considered with careThese values are perhaps most relevant tomental health services. However, again I amminded of a story that suggests a much widerapplication. I worked with a boy referredbecause of ‘extreme behavioural difficulties’.His mother was the victim of severe domesticviolence, often witnessed by the boy. I saw myrole as acknowledging to the mother that herson was presenting her with a challenge, but atthe same time helping her to understand howhis experiences were relevant to his behav-iour. This inevitably implies that choices inher life may have been a contributing factor –a devastating prospect. It is tricky terrain, butcommon ground for child psychologists, andwe were making tentative progress.

In the meantime, in a desperate attempt tohelp a desperate situation, the GP had writtena number of referrals. The mother dulyattended a paediatric clinic with her son andhe was diagnosed with ‘conduct disorder’.This diagnosis simply confirms that the childhas significant behavioural difficulties. How-ever, for the mother a ‘disorder’ implied thatthe problem lay within her child after all and,no doubt relieved that she was not ‘to blame’,she cancelled future appointments with me.The paediatrician also discharged the boy,unaware of the impact of the diagnosis on themother’s understanding of her sons behav-iour. Sadly, I met the boy again a few yearslater in foster care, placed there he told me,because he had a ‘behaviour disorder’.

This story illustrates a number of pointsthat do not need to be hammered home. Theintention, rather, is to suggest that the NHSitself (that’s us), may perpetuate some of its(our) own problems. The model of care cancreate expectations that, in turn, we feelobliged to fulfil. As psychologists, I am cer-tain we have our blind spots too. However,we do bring a systemic understanding thatcan be particularly useful in unpicking someof these tangles. Indeed, we can often be ofmost use to the teams and services we are not

a part of, as we have the opportunity to adopta meta-perspective, looking at them throughfresh eyes.

Value 6: The least possible contact withprofessional services, the moreempowering the experience I would suggest that this value runs counterto the dominant model of ‘care’ in health. Aspsychologists, we are trained to see that thelightest touch necessary results in the mosteffective interventions. I rarely observe this inother disciplines, who often report ‘feelingguilty’ if they haven’t ‘done something’, espe-cially when waiting lists are long. If we couldhelp in shifting this, then we would go a longway towards changing the culture of depend-ency that is currently crippling the NHS.Sharing our frameworks for psychologicalconsultation, along with therapeutic modelssuch as motivational interviewing and solu-tion focused approaches, are powerful toolsin this process.

Value 7: We are our most importantresource and need to be nurtured if weare to nurture those we work withThis is clearly something that the healthservice wants to believe in, and yet time andtime again staff feel undervalued. Trainingbudgets were the first to be cut; posts areheld vacant to ‘save’ the financial bottomline and staff feel under constant pressure toachieve more with less. As psychologists, wecertainly have the tools to help in this area,but there really has to be some investmenthere if staff are to experience it as anythingother than tokenism.

Value 8: We are a scarce resource andhave a responsibility to target ourspecialist skills to maximal effectThis too is an area where I would suggest psy-chology has something to offer the generalhealthcare landscape. Stepped care, consulta-tion and training are all models of service pro-vision that we embrace, alongside ongoingevaluations to ensure our interventions aretargeted effectively. We are passionate aboutearly intervention, and have a track record indeveloping ‘spend to save’ models of care.


Liz Gregory

Now to Canada, and why my experienceshere feel relevant despite no contact, as yet,with health services. It certainly seems to be asofter, warmer and more patient society. Eventhe large metropolis that is Toronto sees itself asa city of neighbourhoods that care. Reference isoften made to Canadian values, and there is astrong sense of identity that includes toleranceand citizenship. I am sure it is not perfect, ofcourse, but it is both palpable, and impressivegiven the enormity and diversity of the country.

At the heart of this paper is the conceptthat if the NHS adopts the right core values,

then decision making, regardless of the sizeand nature of the task, becomes clearer andmore coherent. If, as citizens and employees,we were able to identify the values we are allprepared to sign up to, I am certain that com-mon ground would emerge, and with that atemplate for a model of health care we couldall feel proud of.

AuthorDr Liz Gregory, Joint Head of Child ClinicalPsychology, Aneurin Bevan Health Board

North West England Branch

The DCP North West Branch is proud to invite you to their Annual Conference and AGM

Better Together: Leadership and Commissioning

for Clinical PsychologyHoliday Inn, 1 Higher Bridge St, Bolton BL1 2EW

Thursday 13 November 2014, 9.30am–4.30pm(Registration from 8.45am)

The aim of the day is to promote education, awareness and discussion around theprovision of psychology services in the North West amidst a changing politicaland economic backdrop. This will be facilitated by presentations and workshops.In addition, there will be the opportunity for regional networking and updatesregarding regional Branch activities.

DCP member £35 (£29.17 + VAT) | Society member £80 (£66.67 + VAT)Non-member £115 (£95.83 + VAT). Lunch and refreshments will be provided.

To book or for further details go to:www.kc-jones.co.uk/commissioning

All queries, please e-mail [email protected] with ‘Better Together 2014’ in the subject line.


WE HAVE BEEN aware of the impactof the organisation upon the capacityof NHS staff to care for the sick and

vulnerable ever since MenziesLyth’s study of nurses working in ageneral hospital (Menzies Lyth,1959). The study revealed that theprimary work task of nurses was tobear the fundamental anxiety ofcaring for our loved ones, of fac-ing the emotionally overwhelmingexperience of caring for the sick,the dying and the fearful. For staffcoping with these overwhelmingexperiences, with few psychological tools tohelp make sense of them, the patient becamea series of technical/professional tasks to becompleted. These unconscious defensivestrategies enabled the staff member to emo-tionally distance themselves from the turmoilof caring for the sick. The work role becameabout ‘doing to’ not ‘caring for’.

This sense of ‘doing to’ rather than ‘car-ing for’ appears to be a potential byproductof current organisational change processes.The Mid Staffordshire inquiry, chaired byRobert Francis, revealed that caring for sickpeople became driven by the need to com-plete tasks and protocols, and meet financialand business deadlines (Francis, 2013).Patients’ needs became a potential distrac-tion. Although as professionals we are allresponsible for our own actions, it has

become increasingly clear that the capacityof the organisational system to hold ontogenuine compassionate care for patients,

their families and staff can becompromised by the need toattend to protocols and targets.

All NHS services are under-going threat and change andour work contexts are in a stateof flux and anxiety. The politicalcontext of the NHS is subject towidespread change – the indus-trialisaton of healthcare, the risein chronic health conditions,

the reprioritisation of funding, and increas-ing service splits and competition (Cooper& Lousada, 2005). What does such disrup-tion and change do to staff capacity to thinkabout the clinical needs of vulnerablepatients? Kahn (2005) argues that sustain-ing resilience in caring systems is created bya set of shared unspoken beliefs amongmembers which he describes as the ‘cul-tural skin’. Such skin is made up of thestrength of work relationships, the impor-tance of an emotional working life (engag-ing openly in a process that tolerates howstaff feel about the work and each other),and a sense that the organisational world ismanageable (that work difficulties can befaced and understood). Business prioritiesare taking over our thinking about ourpatient and work relationships and needs.

Preventing organisational fibrillation: Therole of the development of supervision skillsSue Walsh & Liza Monaghan

As clinical psychologists we are aware of the importance of supervision in the development of thoughtful, self-critical, self-aware clinical practice (Scaife, 2009; Milne, 2009; Fleming & Steen, 2011). However, despiteincreasing expectation that this is a mandatory aspect of good professional practice (CQC, 2013) on the groundexperience suggests that: (a) space for supervision is under attack; and (b) those staff who face the most emotionaldisturbance at work receive least supervision/emotional containment in their work (Bowers et. al., 2011). Thispaper aims to restate and reconstruct an argument for the centrality of supervision skills training which moreeffectively takes account of the organisational contexts in which we work currently and outline the developmentof a distance learning course created to meet the training needs of a local workforce.

Our workcontexts are in a state of flux

and anxiety.


Preventing organisational fibrillation

Work systems are created in which thought-ful containment is replaced with fearful-ness. Rushing mindlessly about (theorganisational fibrillation of the title),unable to stop, is replacing ‘thinking about’the vulnerable other. Reflection is beingreplaced by the organisational imperativeto avoid punishment, to tick boxes and tryto keep your job safe.

We need to reaffirm the role of supervi-sion when connection with others becomeshard. We need to prioritise our understand-ing of what happens to staff capacity tothink when they are under constant changeand threat.

Maintaining our supervision structuresand engendering thinking spaces for our-selves and other professionals becomes a cen-tral and moral task. The importance ofembedding learning within and about the sys-tem in the service of patients and staff is acentral aspect of supervisory practice. One ofthe key findings from Francis was that the fail-ure to build a positive work culture andrepeated service re-organisation and disrup-tion directly influenced unfeeling and dan-gerous work practices.

In the context of service disconnectionand fear, the creation of supervision systemsbecome key to holding onto staff capacity tothink and reflect about patient needs. Asclinical psychologists we should be develop-ing supervision skills in ourselves and otherswhich make sense of the needs of the organ-isation, the needs of the staff and the needsof the patient, because all interact to createsystems which care or systems which harm.The reasons for organisationally informedclinical supervision are: organisations arenetworks of relationships, work is an inten-sively emotional experience, psychologicallyharmful processes emerge when systems andteams become fearful and work problemsbecome pathological the more energy isgiven over to managing fear than to think-ing. Supervision is about thinking togetherwith another. Surely it is not beyond our witto be kind and thoughtful about, and with,each other in the context of facing wide-ranging healthcare reforms (Ballatt & Cam-pling, 2011).

Restating the case: Why is supervision so important?Supervision of healthcare staff, especially inthe early years of practice, is widely acceptedas being important for professional develop-ment and to ensure the best possible care forclients. Some professions have long requiredpractitioners to have ongoing supervisionthroughout their careers. High profile reportsabout the failure of professional practice andreflection in the care of vulnerable patientshave recently highlighted the need for thedevelopment of clinical supervision skills(CQC, 2013). Evidence suggests that how staffunderstand and manage the emotional inter-actions between themselves and their patientsimpacts upon their ability to provide serviceusers with effective care at times of crisis(Bradshaw et al., 2007; Maban et al., 2012).Effective supervision provides staff with athoughtful, reflective space to make sense ofwhat is happening between themselves, theclient and the caring system without recourseto hidden and more destructive responses. Tohold onto compassionate working practiceswith our most vulnerable patients, staffrequire compassionate thinking spaces them-selves. Effective supervision thereby enablesthe staff member to better hold in mind theneeds of the patient.

Our experience as clinicians in the NHSsuggests that supervision may be poorlyunderstood and is the first thing to go whenstaff feel busy or overwhelmed. In many NHSsystems it has become corrupted as a tick boxexercise to ensure the completion of annualleave and staff sickness records. Reprioritisingthe development of self-aware, self-reflectiveclinical supervision skills for clinical staffthroughout the NHS needs to be maintainedas a strategic priority.

Development of training courseIn light of this thinking we have developed adistance learning supervision course based atthe University of Sheffield. When developingthe course our aims were threefold: to pro-mote self-reflective and self-critical learning asan underpinning of effective clinical supervi-sion and to thereby enhance the work per-formance of course participants; to create a


Sue Walsh & Liza Monaghan

well-crafted, useful and robust qualificationfor a group of multidisciplinary NHS staff whoare often overlooked; and to embed andextend the learning to support NHS systemsto change/reprioritise the delivery of highquality supervisory relationships in specificneglected work areas. In this way, individuallearning was connected to system change.

The complexity of mental health serviceuser need, distress and challenging behav-iour is most evident in in-patient and com-plex care settings. Our interest in supervisioncoincided with a local Trust’s initiative todevelop training for staff in these settingsand this led to the creation of thePostgraduate Certificate in Clini-cal Supervision for In-patient andComplex Care Settings by dis-tance learning. As far as we areaware this is the first training pro-gramme nationally which specifi-cally addresses the supervisionneeds of staff working with thisclient group. The underpinningvalues of the initiative were toprovide support for staff carryingout difficult emotional work (a restorativefunction), to ensure that workers are stayingwithin ethical and professional boundaries (anormative function), and to help the devel-opment of knowledge and skills in the work-force (a formative function). Participantswho have enrolled on the course to date arefrom nursing, occupational therapy, socialwork and clinical psychology backgrounds.All participants need to be active supervisorsand the majority to date have been in leader-ship or management positions (e.g. wardmanagers). At the same time, learning at anorganisational level was maintained by thecreation of a reference group of senior staffwithin the local NHS Trust, which has helpedto shape the development of the course andsupport it’s impact within the organisation.

The course is run with an emphasis onapplied adult learning and course materialsare tailored to meet the needs of a multidisci-plinary workforce. It is aimed at working prac-titioners and is therefore multi-modal;combining face-to-face teaching, web-basedlearning and regular tutorials. The assessed

coursework combines a focus on day-to-daypractice with the integration of existing skillswithin an online community.

Learning to dateWe are now on our second intake of thecourse and have conducted a small-scale eval-uation informed by a Return on Investment(ROI) framework with our first intake.Although based on small numbers (nine peo-ple completed), results suggest positive andsignificant individual learning with concomi-tant impact on clinical practice. Staff whohave attended the course report returning to

their areas of work with enthusi-asm, and new skills to influencechanges at ward level and beyond.Staff are reporting that they feelthey have the skills to change sys-tems and are working up plans ineach of their areas (wards andteams) to develop supervision sys-tems and processes. The evalua-tion is ongoing with our secondcohort beginning May 2014.

One of our key learning pointshas been the importance of support for staffwithin their organisation. In addition to practi-cal support (e.g. in the form of study leave,access to Learning Beyond Registration fund-ing) our view is that learning across professionsand the organisation has taken place becausethe course is supported and embedded withinan NHS reference group. This vehicle hasenabled a rethink of wider Trust supervision sys-tems and processes to take place. The referencegroup is a multidisciplinary forum that activelyreviews the efficacy of the course in meetingTrust goals as well as providing a forum towiden the organisational impact of the develop-ment of supervisory skills. This supports partici-pants to raise the question of ‘what needs tochange in order to embed learning and devel-opment in the culture of my organisation?’

Having a course that provides academicdepth has emphasised the importance of thedelivery of thoughtful and self-aware supervi-sion, and is encouraging others in small stepsto see such learning as providing a set of nec-essary skills to do the job of caring for highlydistressed patients. This educational initiative

…enabled arethink of

wider Trustsupervisionsystems andprocesses totake place.


Preventing organisational fibrillation

is in effect reprioritising the centrality of thecaring relationship; one in which both patientand staff feel safe.

SummaryIt is argued that effective, well-informedsupervisors are crucial to the development ofsafe reflective practice and therefore themanagement of patient risk (Bond & Hol-land, 2010; Hawkins & Shohet, 2012). Clini-cal supervision is a mandatory aspect ofmental health professional practice and isone aspect of the regulatory process for pro-fessional registration. However, clinicalsupervision has often been conflated withmanagerial tasks and reflective space is some-times difficult to prioritise in busy and highrisk environments. The aims of the Postgrad-

uate Certificate in Clinical Supervision for In-patient and Complex Care staff by distancelearning are to deliver high quality clinicalsupervisory training and to provide a clini-cally useful skills development opportunityfor multidisciplinary NHS staff who work withthe highest levels of patient distress. Prima-rily, maintaining the priority of clinical super-vision can only take place if we, as clinicalpsychologists ensure that the systems inwhich we work continue to prioritise bothclinical and organisational thinking spaces inthe face of a business imperative.

AuthorsSue Walsh & Liza Monaghan, Joint Directorsof Clinical Practice, Clinical Psychology Unit,University of Sheffield

Ballatt, J. & Campling, P. (2011). Intelligent Kindness:Reforming the culture of healthcare. London: RoyalCollege of Psychiatrists.

Bond, M. & Holland, S. (2010). Skills of Clinical Supervi-sion for Nurses: A practical guide for supervisees, clinicalsupervisors and managers. Open Univesity Press –McGraw-Hill: Berkshire.

Bradshaw, T., Butterworth, A. & Mairs, H. (2007). Doesstructured clinical supervision during psychosocialintervention education enhance outcome for men-tal health nurses and the service users they workwith? Journal of Psychiatric and Mental Health Nurs-ing, 14, 4–12.

Cooper, A. & Lousada, J. (2005). Borderline Welfare: Feel-ing and fear of feeling in modern welfare. London:Karnac Books.

Care Quality Commission (2013). Supporting informa-tion and guidance: Supporting effective clinical super-vision.


Hawkins, R. & Shohet, R. (2012). Supervision in the Help-ing Professions (4th edn.) Milton Keynes: Open Uni-versity Press.

Kahn, W.A. (2005). Holding Fast: The struggle to createresilient caregiving organisations. Hove: BrunnerRoutledge.

Maben, J., Peccei, R., Adams, M., Robert, G., Richard-son, A., Murrells, T. & Morrow E. (2012). Patients’Experiences of Care and the Influence of Staff Motiva-tion, Affect and Well-being. NIHR Service Delivery andOrganisation programme Final report. London:National Institute for Health Research.

Menzies Lyth, I.E.P. (1959). The functioning of socialsystems as a defense against anxiety: A report on astudy of the nursing service of a general hospital.Human Relations, 13, 95–121.

References

DCP CPD workshopsFind out about the latest DCP CPD workshops on the BPS Learning Centre

www.bps.org.uk/findcpd


IT HAS BEEN an especially active time forfaculties since the summer break. On25 September the DCP Leadership and

Management Faculty held its annual confer-ence in York, where they continued their workon ‘A comprehensive model of psychologicalservices provision from primary care to com-plex presentations and populations’. The fac-ulty are working on some innovative andcreative ways to represent this in imaginativediagrams currently titled: ‘The River’, ‘TheStreet’ and ‘The Flower’. This is still a work inprogress, but it promises great things.

As part of this event copies of the Faculty-led publication National Mental Health, Well-being and Psychological Therapies – The role ofclinical psychology: A briefing paper for NHS Com-missioners were distributed. Copies of this arealso available from the Society’s online shop(http://shop.bps.org.uk/national-mental-health-well-being-and-psychological-therapies-the-role-of-clinical-psychology-a-briefing-paper-for-nhs-commissioners.html).

IN A FURTHER positive development byDCP Faculties that should lead to betterservice user and carer focused compassion-

ate services, Thursday 4 November will alsosee the Psychosis and Complex Mental HealthFaculty build upon their successful and sellout ‘Developing the Narrative’ event from lastyear with this year’s ‘Developing the Narrative2: Putting the new narrative into practice’. Itwill be held at the Society’s London office onTabernacle Street, London.

In the morning there will be a series ofpresentations on how people are developingthe narrative in innovative ways. Sheena Fos-ter, experienced campaigner for the rightsof carers, will present with Faculty Chair,Isabel Clark, on mutual understanding.

Lucy Johnstone, formulation guru, will givea talk on how formulations can be used asan alternative to diagnosis. Russel Razzaque,mindfulness and open dialogue researcher,will explain how the Open Dialogueapproach is a way to take clinical work in anew direction, and Katie Mottram and KatieField from the Spiritual Crisis Network willpresent an alternative way to understandand work, with some of the experiencesassociated with psychosis.

The afternoon will feature a series of work-shops by the morning’s presenters. In addition,there will be workshops by Carol Valenejad,trauma specialist, on ‘Making research ideas areality’; by Hugh Middleton, psychiatrist andProfessor of Sociology and Social Policy, and

Clinical Psychology News

Leadership and Management Faculty get comprehensive and creative

Psychosis Faculty continue developing the narrative


Clinical Psychology News

colleagues Duncan Double, Carl Beuster andSelma Ibrahim, on ‘Sharing clinical and statu-tory responsibility to promote recovery’; and byCharlie Heriot-Maitland, psychosis and com-passion researcher, who will present on ‘Howwe can learn lessons from the anomalous expe-riences of non-clinical groups’.

After tea, the New Paradigm Alliance willexplain who they are and what they plan todo, and share their manifesto with attendees.Finally, there will be the Faculty’s AGM.

Isabel Clark, the outgoing chair of the Fac-ulty, described the event thus:

‘Our aim in this conference is to move the“beyond diagnosis” debate on in a practicalfashion, by showcasing clinical examples ofhow it can be done, and forging an alliancewith other professionals, service users and car-ers to change the thinking around mentalhealth within services and for the wider public.’

To book, go to: https://response.quest-back.com/britishpsychologicalsociety/pcmhannual14. The event is free to all faculty membersand a lunch is provided. Any queries please con-tact [email protected] with‘PCMH Narrative 2’ in the subject line.

Send us your news!Please send your news stories to:[email protected]

Stuart WhomsleyDCP PR & Communications Lead

Now available on the BPS Shop

Safeguarding and Promotingthe Welfare of ChildrenThis recently revised position paper outlinesthe professional practice framework for allChartered psychologists in relation tosafeguarding children and young people.

http://shop.bps.org.uk/publications/briefing-papers-and-reports/safeguarding-and-promoting-the-welfare-of-children-position-paper.html


FORMULATION is a ‘core competency’for clinical psychologists in the UK, andcorrespondingly, Johnstone and Dallos’

text, now in its second edition, has become acornerstone of British clinical psychologist’sthinking and training.

This latest version adds chapters on ‘per-sonal construct formulation’, and formulatingin teams, and in health-care settings. Theselatter two will be particularly invaluable forthe real-life application of psychology. What’sthe use of rethinking health and mentalhealth problems if it is only done by one pro-fessional among many? These chapters arealso bracingly practical, dealing with many ofthe everyday essentials of helping a wholeteam to reach a working understanding ofservice users (and openly acknowledging thismay not always be possible).

A final chapter deals with the controversiesrelated to psychological formulation. John-stone here addresses the question of whetherformulation is ‘evidence based’, concludingfrankly that it is not. Though she is quite rightto raise the question of empirical validation(a problem which surprisingly few researchershave taken on, maybe because of the concep-tual difficulty it presents), there may be other

ways to skin the validity cat. Psychological for-mulation is (as Johnstone is careful to pointout) a process for drawing inferences about aperson’s psychology. Cannot such inferencesbe in themselves more or less valid, depend-ing on the manner in which they are drawnand the premises from which they begin?

Johnstone approvingly cites Gillian But-ler’s statement that a formulation is a set of‘hypotheses to be tested’, but this notionneeds to be further built in to the way wemake our formulations. If I could change thisbook in one significant way, it would be byintegrating more detail on the use of ‘riskyprediction and refutation’ as a form ofhypothesis building in formulation, consistentwith the ‘local clinical scientist’ model(Stricker & Trierweiler, 1995).

Another key issue in the text is the distinc-tion between ‘usefulness’ and ‘truth’. John-stone suggests formulation should concernitself with the former, whereas diagnosisaspires to the latter. I think formulation canbe more ambitious. Presumably there is a factof the matter about any given individual’s

Book review

Formulation inPsychology andPsychotherapy:Making sense ofpeople’s problems(2nd Edition)Edited by Lucy Johnstone

& Rudi Dallos

Routledge, 2013, 320pp.Reviewed by Huw Green


Book review

problems, which the clinician can more or lessaccurately capture in words. Is there somebenefit to be gleaned from constructing sto-ries that ignore veracity, or is it more likely (asthis reviewer suspects) that ‘truth’ tends tobring ‘usefulness’ along with it, such that themore we know about a particular individual(and they about themselves), the more ablewe are to help them?

This is an immensely useful book; practi-cal, creative and still unique in its particularcoverage of psychological models. Perhapsonly Tracy Eells’ Handbook of Psychotherapy Case

Formulation (2010) covers more territory in asingle volume, but that big book lacks John-stone and Dallos’ volume’s specificity for a UKhealth service context.

ReferencesEells, T. (2010). Handbook of Psychotherapy Case Formula-

tion (2nd edn.) New York: Guildford. Johnstone, L. & Dallos, R. (2014). Formulation in Psy-

chology and Psychotherapy: Making sense of peo-ple’s problems. Hove: Routledge.

Stricker, G. & Trierweiler, S.J. (1995). The Local Clin-ical Scientist: A Bridge Between Science and Prac-tice. American Psychologist, 50(12), 995–1002.

London Branch

Clinical PerfectionismRoz Shafran Professor of Translational Psychology at University College London andfounder of the Charlie Waller Institute of Evidence-Based Psychological Treatment

BPS London Office, 30 Tabernacle Street, London EC2A 4UEThursday 27 November 2014, 10.00am–4.30pm (registration from 9.30)

‘Clinical perfectionism’ is a highly specific construct which can often pose problems inroutine therapeutic practice. The core psychopathology of clinical perfectionism is an overevaluation of achievement and striving that causes significant adverse consequences. It isimplicated in the maintenance of psychopathology, in particular eating disorders, anxietydisorders and depression.

Professor Roz Shafran will provide a cognitive-behavioural analysis of clinical perfectionismand the factors that contribute to its maintenance. Relevant research literature and currentevidence-base for interventions will be provided. By the end of the day, participants willlearn how to assess clinical perfectionism and determine when it may warrant a specificintervention. They will also be familiar with relevant cognitive-behavioural strategies. Theworkshop will be interactive and include both experiential and didactic teaching and videos.Participants will have a chance to discuss their own cases.

This is a free event for DCP members only. Places are limited, so please book early.

This event is being financially supported by the DCP London Branch, which has invested in it for the benefit of its members.

To register go to:https://response.questback.com/britishpsychologicalsociety/qvbq7huuvz

All queries, please e-mail [email protected] with ‘Clinical Perfectionism 2014’ in the subject line.


Manchester DCP Executive Committee meetingThe recent DCP Executive meeting in Manchester was all about steer-ing a progressive course and keeping us on track to build the more coherent and influential pro-fessional organisation that we so obviously need.

The headlines from the Manchester meeting include:n establishing for the first time a UK-wide database for clinical psychology;n signing off and rolling out our new strategies for Experts by Experience

and for Equality and Diversity;n a new plan to engage and bring trainees into membership;n concrete steps to improve our media profile;n the next stage of our work on classification;n strengthening our links with the English Care Quality Commission;n the priorities for the new, soon to be appointed, England policy officer;n planning for this year’s Glasgow 14 conference, and next year’s 50 Years of Clinical

Psychology conference, and celebration in London and throughout the country; andn building cross-nation and cross-divisional momentum on Francis, Winterbourne and Andrews.Details of the agenda, draft minutes and associated papers can be accessed on the DCP website(www.bps.org.uk/dcp).

Devolution and the lack of coherent English structuresThe Division and the Society in general are relatively well organised in Northern Ireland and Scot-land, and are getting stronger in Wales. All three have their own DCP executive committees andrelationships with their own governmental bodies. In England, we mirror Westminster, in that wedon’t have an English executive. We also have the same problem and tensions around the fact thatEngland is so much bigger than the other three nations. London and our North West branches,for example, both have more DCP members than the entire combined membership of Scotland,Northern Ireland and Wales. Given the new devolved decision making, the scale of the job cutsand dislocation of health and social care in England, we have been working hard to strengthenour English branch structures and our links with training courses and heads of psychology and areon course for setting up an English Executive group. This may sound bureaucratic and compli-cated, but we need effective political structures in all four nations as soon as possible.

Preventing the closure of one of our training courses in the West MidlandsWorking closely with the local heads of psychology and training courses, we have managed to pre-vent further cuts to training commissions in the West Midlands. The training commissioninggroup there has used savings from cutting clinical psychology training places to fund a pro-gramme of psychological therapy skills training across NHS adult mental health services. We allo-cated additional funding to our West Midlands branch to produce detailed and up-to-date NHSand independent sector workforce data. We demonstrated the flawed nature of the data and work-force modelling that underpinned it. The majority of West Midlands trainees currently don’t evengo into adult mental health jobs. If the second round of planned cuts had gone ahead a wholetraining course would have been lost. We now need to try and get the original cuts reversed. This

Notes from the ChairRichard Pemberton


Richard Pemberton

also highlights how we need to re-establish our role as a core senior clinical profession acrosshealthcare generally, rather than identify overly on a narrow role in adult mental health as psy-chological therapists.

The West Midlands work has been helpful to East of England branch members who have alsohad to respond to threats to commissioned training places. Alison Longwill, who did thedetailed work for the West Midlands, is helping us pull together a national database across allcare groups and a system for regularly updating it. Her full West Midlands report and can beaccessed on the DCP website (www.bps.org.uk/networks-and-communities/member-networks/division-clinical-psychology/resources).

A comprehensive psychological services modelWe don’t just need quality workforce data – we also need a shared vision for the future psychologyand therapy workforce. The recent Leadership and Management Faculty event in York started topaint this picture. The West Midlands work also helpfully highlights the impact of the loss of lead-ership posts on professional governance, safety and access to psychological services.

Postponed elections and the SocietyJamie Hacker Hughes, the Society’s President Elect, attended part of the Executive meeting. Heis a clinical psychologist and ex-chair of the Campaign for a Royal College of Psychology. His visitwas timely as we are still under the moratorium that the Trustees have imposed on our recom-pense arrangements. These enable us to recompense employers for some of the time electedmembers spend on DCP and Society business. The record of our agreement with the Society andtrustees about these arrangements back in 2006 cannot be found. Graham Turpin kept the docu-mentation we submitted at that time and which produced the recompense arrangements we haveenjoyed since then. The trustees have instigated an urgent review of these arrangements and theirpolicy. If you are on our main e-mail list you will have received a separate notification about this.If you haven’t, the details of our recent submission to the trustees and the interesting history canbe found on the DCP website (www.bps.org.uk/dcp). This is not as ‘Alice in Wonderland’ as it mayseem. The trustees are understandably keen to reduce internal fragmentation and increase theinfluence of the Society. It is, for example, unsatisfactory that the DCP Faculty for Children, YoungPeople and their Families and the Division of Educational and Child Psychology are not workingtogether within a joined up BPS child and family evidence policy and practice strategy. It is also,for example, problematic that English home branches have no common terms of reference. Wehave been developing our branches across all four nations in a way that explicitly attempts to linkup practitioner psychologist groups but in reality the current laissez faire set up is often distinctlyHeath Robinson. Jamie Hacker Hughes is leading a review of membership sub-structures in theSociety and we will be contributing to this.

The worst case scenario is that we lose our ability to recompense key posts, and as a conse-quence the ability to build a professional and effective clinical psychology operation. The best casescenario is that our efforts are complemented and strengthened by sitting within Society processesand structures that take us all forward. In the short term we have had to postpone the electionsfor some of our key leadership positions and will be asking the current post holders to say in placeuntil we are clear what we are able to offer people who put themselves forward for election. Apolo-gies for this unexpected and highly unsatisfactory state of affairs.

FrancisAs highlighted in this special edition of Clinical Psychology Forum we have been working closely withother divisions on our contribution to the issues raised in the Francis Report. We’ve had excellentFrancis linked events in all four nations. Many thanks to Al Beck and Andrew Hider, and to Jo Hem-mingfield and the Leadership and Management Faculty, who have kept going against a number of


Notes from the Chair

strong headwinds to get this together. Issues of quality governance, leadership, staff well-being andservice user involvement have always been integral to the profession so we are well placed to shapethe debate and improve practice. Thanks also to Beth Parry Jones, DCP Wales Chair, and the WelshDCP Francis team for their work on the Francis and Andrews Cardiff conference, which hasattracted substantial cross-disciplinary interest in Wales (www.bps.org.uk/events/post-francis-and-andrews-psychological-approaches-advancing-compassionate-healthcare-delivery-wales).

WhistleblowingI have personal experience of the risks and heavy pressures of whistleblowing. It is rarely easy orstraightforward to challenge poor or abusive practice. This can be especially hard in particularorganisation cultures. We know many health and social care organisations can easily lapse into toauthoritarianism and a culture of bullying. This Care Quality Commission independent reportinto their own well documented problems is well worth reading (www.cqc.org.uk/content/cqc-publishes-independent-report-bullying-and-harassment-order-learn-lessons-and-make). TheBritish Psychological Society has produced its own position paper on whistleblowing in responseto Francis’ consultation on Whistleblowing in the NHS: Independent review (www.bps.org.uk/bpslegacy/cp?frmAction=details&paperID=1347&RegionID=0&iYear=0&open=). It helpfullydetails the literature but doesn’t suggest how we can increase support to members who are strug-gling to get their concerns about the practice of colleagues or services properly addressed. Weneed to have our own ‘duty of candour’ debate. Your professional body is here to offer adviceabout just these sort of matters and you should feel free to contact any of the divisions’ officersas listed on the inside back cover of CPF.

The theme of compassion care will also feature next month at our Glasgow Annual Confer-ence. Paul Gilbert is giving a keynote and public lecture. If you haven’t already had a look at theprogramme you can access it on the main BPS website (www.bps.org.uk/dcp2014). Come andjoin us.

Last but by no means least, on 27 November we have organised a high profile London launchof our Understanding Psychosis and Schizophrenia report. Anne Cooke and the group who haveworked so hard to produce it should get a medal. It sets a new standard for the quality of our pub-lications, but also for the way we publicly promote our work and contribution. Details of thelaunch event and the document can also be found on the BPS site (www.bps.org.uk/networks-and-communities/member-networks/division-clinical-psychology/understanding-psychosis-and-sc).

Richard [email protected]@socratext

to advertise inThe PsychologistPlease contact:

Ben Nelmes020 7880 6244

[email protected]

Division of Clinical Psychology ContactsNational OfficersChair Richard Pemberton – [email protected]

Honorary Treasurer Steven Coles – [email protected]

Director, Membership Services Unit Cath Burley – [email protected]

Director, Professional Standards Unit Stephen Weatherhead – [email protected]

Director, Policy Unit England Position vacant

PR & Communications Lead Stuart Whomsley – [email protected]

Chair, Conference Committee Anja Wittowski – [email protected]

Dougal Hare – [email protected]

Interim Leadership Group contact c/o Helen Barnett – [email protected]

Service Area LeadsAdult – vacant

Child Andrew Rogers and Jaime Craig – [email protected]

Clinical Health Angela Busittil – [email protected]

Learning Disabilities People with Intellectual Disabilities – [email protected]

Older People Rebecca Dow – [email protected]

Devolved NationsScotland: Ruth [email protected]

Wales: Beth [email protected]

Northern Ireland: Ciaran [email protected]

English Branch ChairsEast of England: Sue [email protected]

East Midlands: Mary O’[email protected]

London: Zenobia [email protected]

North West: Lee Harkness & Kathryn [email protected]

South Central: Vacant

South East Coast: Clara [email protected]

South West: Annie [email protected]

West Midlands: Pam [email protected]

Yorkshire & Humber: Simon [email protected]

Pre-Qualification GroupAnita [email protected]

Faculty ChairsChildren, Young People & Their Families:Andrew Rogers and Jaime [email protected]

Psychology of Older People: Rebecca [email protected]

Learning Disabilities: Karen [email protected]

HIV & Sexual Health: Alex [email protected]

Psychosis & Complex Mental Health: Isabel [email protected]

Addictions: Ryan [email protected]

Clinical Health Psychology: Dorothy [email protected]

Eating Disorders: Nicholas [email protected]

Forensic: Kerry [email protected]

Oncology & Palliative: Inigo [email protected]

Leadership & Management: Esther Cohen [email protected]

Holistic: Jane [email protected]

Perinatal: Pauline [email protected]

ContentsRegulars1 Foreword

Jamie Hacker Hughes3 Editorial – Clinical psychology: Keeping the human in healthcare

Andrew Hider, Alison Beck & Richard Pemberton5 Ethics column – The governance and influence of clinical psychology:

Professional ethics and the Francis reportTony Wainwright

10 DCP Experts by Experience Column – Courage to tackle the real issuesJoanne Hemmingfield

12 DCP Pre-Qualification Group Column –Seeing an in-patient dementia ward through curious eyes – A trainee’s experienceRachael Edge

68 Clinical Psychology News70 Book review – Formulation in Psychology and Psychotherapy: Making sense of people’s

problems (2nd Edition) Edited by Lucy Johnstone & Rudi DallosReviewed by Huw Green

72 Notes from the ChairRichard Pemberton

Articles15 Cure the NHS

Julie Bailey17 Psychological responsibility

Derek Mowbray22 Schwartz Rounds: An intervention with potential to simultaneously improve staff

experience and organisational cultureBarbara Wren

26 Introducing Schwartz Center Rounds into a Welsh NHS Health Board: Six months in – A reflection on the process and experience to dateDebbie Rees-Adams & Louise Hughes

28 Military metaphors and mental health – Francis and psychiatric systemsAndrew Hider

34 Staff stress, change and the NHSAlison Beck

38 DCP political influence: Strategy and tactics to influence national policyJohn Hanna

43 Implementing NHS culture change: Contributions from occupational psychologyGrace Everest, Joanna Fitzgerald & Louisa Tate

46 Compassion, organisations and leadershipStuart Whomsley

49 Developing a culture of compassion: Can't or won'tAmra S. Rao

55 Cultivating compassionate care within the National Psychosis Unit: The use of psychological formulation and staff reflective practiceLauren Armstrong, Victoria Bell & Alison McGourty

58 Therapeutic milieu training in a forensic mental health settingEmma Drysdale & Patricia Mooney

60 Core values and the NHS: Reflections with the benefit of distanceLiz Gregory

64 Preventing organisational fibrillation: The role of the development of supervision skillsSue Walsh & Liza Monaghan

clinical psychology forum - british psychological society network… · clinical psychology forum...

Documents