The Concept of 'Psychological Safety'

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Economy of scale can result in depersonalisation of services.Evidence indicates that sound attachments are both therapeutic andhumane. This article describes the proposed application ofattachment theory, through notions of psychological safety and theprofessional family, to a multidisciplinary clinical service for adultswith learning disabilities.First published in Clinical Psychology Forum 186 pp 50-54 2008

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    The Concept of Psychological Safety: a proposal for aservice philosophy

    In: Clinical Psychology Forum 186 pp 50-54 2008

    Suzanne Conboy-Hill

    Economy of scale can result in depersonalisation of services.

    Evidence indicates that sound attachments are both therapeutic and

    humane. This article describes the proposed application of

    attachment theory, through notions of psychological safety and the

    professional family, to a multidisciplinary clinical service for adults

    with learning disabilities.

    The Guiding Mind in the organisation

    Large organisations have advantages associated with economy of

    scale in providing services but can easily lose sight of the individual

    in the process. When something goes wrong and victims embark on

    litigation, the guiding mind of the organisation is identified on the

    grounds that it is this that influences the culture within which

    employees and customers are kept safe. How much more valuable

    then to begin instead with a positive guiding mind by which to

    explicitly build in safety and well-being. Psychological Safety

    (Seager, 2006) is a concept arising from analytic psychotherapy

    that has the potential to provide the framework by which a positive

    guiding mind for services for vulnerable people can be developed.

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    Health Economics and Therapeutic Practice

    Services of all kinds are under pressure to produce more for less,

    every discipline is being challenged to define its usefulness.

    Certainly there are therapeutic approaches that are more effective

    than others but the effectiveness of the majority is almost always

    underpinned by the relationship itself rather than the specific

    technique being used. Patients want different things from therapy,

    outcomes are not easy to define in complex cases, and sometimes a

    positive outcome for the client looks like something else altogether

    to an observer.

    How then to think about being therapeutic? The concept of object

    attachment suggests that ego strength is formed and maintained by

    the experience of good or bad objects during childhood and that

    later resilience in the face of adversity is dependent not only on

    inner strength but on the consistency of positive childhood

    attachment objects. This means there are two points at which

    psychological safety is threatened, the first when developmental

    conditions do not offer good primary attachment objects, and the

    second when a significant attachment is suddenly lost. Where

    psychological history itself is insecure, the likely effect is almost

    unimaginable.

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    Considering the ways in which mental health services are organised

    and our response to risk, Seager (2006) outlined the typical

    scenario pertaining to suicidal behaviour. People are admitted as

    in-patients until they are deemed well enough to be discharged and

    then returned to their physical and psychological environments.

    That a significant number of such people commit suicide at this

    point (King et al, 2001) seems to be surprising to clinicians and

    often triggers evaluations of risk and responsibility with an

    undercurrent of blame running through the process. That it should

    notbe a surprise emerges from the appreciation that, in discharging

    people at the point of apparent wellness, we simultaneously break

    the significant attachments that have got them there and so leave

    those already vulnerable in a state of such desolation that suicide is

    their only answer.

    The theoretical position is that, for people accessing mental health

    and learning disability services, staff teams comprise the significant

    attachment objects that contribute to maintaining a sense of well-

    being. Seager refers to this as the professional family and

    describes it as comprising the wholeteam from managers to desk

    clerks, senior clinicians to volunteer assistants. The containment

    derived from this family is rooted in the feeling of being held in

    mind, remembered, and known by a consistent and important

    group of people and this is what engenders a sense of safety.

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    The Professional Family, Object Attachment and People with

    Learning Disability

    So how does this affect people with learning disability? Our clients

    have arguably some of the most disrupted childhood and adult

    attachments, unstable emotional environments and devaluing

    experiences of any social group. Many were institutionalised as

    children and grew up in the bleak and unforgiving environment of a

    2000 bed hospital. Today most live in community services which

    are ostensibly better than before but still variable in their capacity

    to provide emotionally nurturing and stable relationships.

    For people who are developmentally delayed through intellectual

    impairment and impoverished emotional histories, the situation is

    further complicated by the likelihood of impaired wholeness or

    adultness of the personality that is now struggling to cope with un-

    containing social and emotional circumstances. As a consequence,

    some people may need complex therapeutic support in order to

    build the trust necessary to forming positive attachments, others

    may not understand what positive attachments are and need

    experience of positive dependency within a secure therapeutic

    relationship to begin to construct such notions.

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    What is clear is that the professional family has a role over and

    above the individual clinical remit of its members. As Seager says,

    referring to suicide, When we define safety in terms of attachment

    and containment it is clear that it is . misleading and . dangerous

    to split off our own role and the part played by other relationships in

    the total care system .

    Psychoanalytic thinking describes suicide as the ultimate act of

    someone who feels at the complete mercy of one or more bad

    objects and/or bereft of attachment to any sufficiently good

    object. People who feel worthless, disconnected, unloved and un-

    valued are at greatest risk of successful suicide attempts.

    For people with learning disability, the tragedy is that what often

    keeps people alive is their own inability to escape the surveillance

    that pervades their lives. The dreadful conclusion is that people

    with some of the fewest resources are condemned to live in the

    deepest misery through being unable orchestrate their own end.

    One man, his voice shrieking his distress, left a messageon our answerphone to say that he had tried drinkingbleach to no effect and so now he was going to eat loadsand loads of chocolate. Funny? Momentarily. Tragic canthere be any doubt?

    Why he thought chocolate would kill him, none of us couldsay but when it did not, he hanged himself in a public carpark.

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    Thankfully, most of our clients get through life without such major

    trauma and, because many services do not retire them when they

    reach old age, we travel with them from adolescence to death. This

    gives us both the opportunity and the obligation to put in place a

    service system that is able to address issues of psychological safety.

    Teams comprising a diverse staff group are capable of providing the

    continuity of contact that underpins a service memory of people so

    that they always feel known and remembered. This is also an

    enduring relationship that offers a narrative record bearing witness

    to their lives when often there is no-one else to do so. Making this

    explicit as a service philosophy would positively influence the

    function of the team and so its structure.

    Finding an Evidence Base

    No-one has yet made the concept of psychological safety an explicit

    core value around which to design services so there is no outcome

    research and therefore no direct evidence of its efficacy. What we

    do know is that therapeutic communities have often adhered to a

    model of care that is a less formalised version of psychological

    safety and that this is perceived by patients as more humane than

    the traditional medical models (see Main 1957). We also know that,

    while doctors see their value in terms of a quick diagnosis which

    they believe should cause patients to like them, patients value a

    doctor who gives them time to tell their story, (make themselves

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    known), and only then produces a diagnosis (Feldman 2006). As

    human beings we know that we prefer mostly to visit places where

    we are known than ones where we are always treated as strangers.

    Finally, a recent study (Kennedy and Thomas, 2007) in which a

    mental health team developed a dialectical behaviour therapy (DBT)

    approach to their clients with borderline personality disorder showed

    how this saved an average of 11,962 per patient in emergency and

    inpatient admissions. But was the DBT itself either necessary or

    sufficient? The description of what they did suggests that in fact

    they had developed a mindful and psychologically safe service which

    contained and nurtured those vulnerable adults by giving them

    sustained, non-contingent contacts with people to whom they could

    attach.

    The Proposal

    Brighton & Hove CLDT is a multi-disciplinary service within which

    philosophies of practice vary although all have a core of mindfulness

    that is not necessarily made explicit. This proposal, to establish a

    commitment to providing a psychologically safe environment in

    which vulnerable adults can make secure attachments to members

    of a professional family, is an attempt to place that core within a

    theoretical context. The defining values are these:

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    Psychological safety is about the total service ethos and

    the total experience of the service user.

    Psychological safety is less about containment in

    buildings and institutions than containment in

    relationships.

    The greatest risk to psychological safety for all human

    beings is to be forgotten and not held in mind.

    In practice this is a promise to service-users that they will be

    thought about in an empathic way by at least one other person in

    whom there is at least a basic level of trust and with whom there is

    reasonably regular contact, and that they will have connections to

    and continuity with other human beings, objects and places in a

    way that affords a sense of belonging, identity, shared meaning and

    purpose.

    The aim is to provide that security for adults whose impaired

    intellectual function causes them to be life-long recipients of

    services.

    Cost implications

    Attitude change costs little and, if initiated by the team itself, should

    lead to an improved service culture that actively values mutual

    support and collaboration.

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    Work load implications

    There is no reason to assume that this would be labour intensive,

    rather it is about rethinking the meaning of therapeutic contact and

    professional roles. It has been our experience that, when placed in

    the context of trust and proper supervision, some of the most

    therapeutic experiences for clients have been delivered by pre-

    clinical assistant psychologists working as volunteers.

    Seager (2006) makes the point that everyone, from manager to

    cleaner is part of this family and responsible for the ethos. In our

    service, the secretarial team exemplifies the model; not only do

    they welcome people with a warm smile and a cup of tea but they

    interface with distraught or angry clients and carers on the phone or

    in person and the ease with which we as clinicians can then follow

    up these matters is testimony to their capacity to contain and

    defuse under difficult circumstances.

    As Seager (2006) says, therapy is much more than the formal

    therapy session, it is the culture of the service itself that allows for

    a style and mode of contact that meets the needs of the client and

    that the client finds therapeutic. The fact that so many of our

    clients also need a form of adult parenting to enable them to carve

    out a lifestyle that brings them joy and affection, risk and

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    excitement, and the stability to benefit from these lends strength to

    the argument that our provision must be flexible and containing

    enough to enable this.

    Our CLDT, as a multi-professional, multi-agency resource, is ideally

    placed to drive these principles into the heart of the local learning

    disability provision. Fingers crossed then

    Affilation

    Sussex Partnership Trust

    Address

    Dr Suzanne Conboy-Hill, Consultant Clinical Psychologist for people

    with learning disabilities. Sussex Partnership Trust, 86 Denmark

    Villas, Hove, Sussex, BN3 3TY

    email Suzanne.conboyhill@sussexpartnership.nhs,uk

    The man who committed suicide by hanging hadbeen an inpatient for some months before this,resisting all attempts to discharge him by turningdown the residential options offered. During thistime he rarely complied with treatment, preferring togo fishing during the day and returning to the wardat night.

    But how do we understand treatment in thisinstance? To the ward staff it was being available to

    talk, to join groups, or to engage in occupationaltherapy but to him maybe it was just the sense ofsecurity he derived from being surrounded bypeople who would respond to his emergencies andnot let him harm himself.

    mailto:Suzanne.conboyhill@sussexpartnership.nhs,ukmailto:Suzanne.conboyhill@sussexpartnership.nhs,uk
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    References

    Feldman, S. (2006). What are Patients Looking for? Medscape

    General Medicineonline article. 8,(3) 41.

    Kennedy, F. and Thomas, S. (2007). A DBT service on the Isle of

    Wight. Clinical Psychology Forum.171, 28-32.

    King, E.A., Baldwin, D.S., Sinclair, J.M.A., Baker, N.G., Campbell,

    M.J. & Thompson, C. (2001). The Wessex Recent In-Patient Suicide

    Study.British Journal of Psychiatry.178, 531-536.

    Main, T. (1989). The Ailment. In Main, T. The Ailment and Other

    Psychoanalytic Essays. Free Association Books. London. (Original

    work published 1957).

    Seager, M. (2006). The Concept of Psychological Safety a

    psychoanalytically informed contribution towards safe, sound &

    supportive mental health services. Psychoanalytic Psychotherapy

    20 (4) 266-280.

    Acknowledgment

    With huge thanks to Martin Seager for inspiring and guiding this

    paper.