Counselling Psychology Practice in Differing Contexts

The NHS

The Prison Service

Independent Practice

Employee Assistance

Counselling Psychologist within the Children, Young People and Families Therapy Team (CYPFT) at the Medical Foundation for the Care of Victims of Torture

University Student Support and Advisory Service

Working in adult mental health in the Improving Access to Psychological Therapies Service (IAPT) within an NHS setting, presents many possibilities for applied psychologists to improve the lives of clients.

Traditionally clients accessed psychology services through their GP or a secondary care referral. This changed with the introduction of a stepped care model in which clients can access services in the traditional way or by contacting the self referral phone line to request psychological help. Their call is screened by a primary care mental heath worker who refers the case to psychologist if they have any concerns. IAPT services are also available within community settings and they receive referrals from a wide range of professionals for client groups that previously would not have accessed services.

As a clinician in this service, I provide an assessment service for clients who present with common mental health problems and those that have more complex problems. I offer clients individually tailored psychological formulations within the context of a collaborative, caring and trusting therapeutic relationship. I offer from six and up to twenty sessions of therapy, primarily using CBT principles as a framework for guiding interventions. I have knowledge of a wide range of psychological theories and interventions so I am not restricted to one therapy model.

My role includes providing specialist supervision to low (primary care mental heath workers) and high intensity (generally CBT therapists) workers, ensuring safe and competent practice. I consult colleagues who work in specialist services such as the personality disorders service about clients with whom I am working and those that may need an onward referral.

I provide a consultation service to GPs and other healthcare professional disseminating psychological knowledge and information about our services. It is varied and interesting work which requires stamina and resilience.

Deputy Head of HMP Send - Pia Sinha

I qualified as a Counselling Psychologist in 2000 and started my career as a psychologist working in HMP Holloway. I worked predominantly with women who had a history of self-harm and violence. Through this work I was exposed to the world of ‘Personality Disorder’ and this became somewhat of a specialism. I continued to develop my career along this specialism and in 2004 started working with male offenders in HMP Wandsworth. My work with violence, emotional distress and trauma led me to take on a more strategic role within prison management as Head of Safer Prisons. Through this role, I was able to influence and manage change not only at the individual level through the provision of 1:1 and group interventions, but also systemically. My wider remit was to enable perception change around self-injury and the reasons behind institutional violence in the hope of reducing crisis through ethical and compassionate practice.

Through this exposure, I saw parallels and transferrable skills i.e. the organisation as a chaotic, distressed and challenging entity. This sparked an interest in applying counselling psychology skills and theory in an organisational context. To this end, I had an opportunity to apply for a fast track scheme that trained me to function as a Senior Operational Governor within the service. It has been a positive decision for me and I don’t feel that my skills have become obsolete in the slightest. In many ways it has given me insight into how psychologist can be perceived in the wider operational context and what we need to do to market ourselves more effectively. The range of skills we can offer and the usefulness of our experience can be invaluable for the organisation and we do little justice to ourselves by limiting ourselves to clinical work and being precious about the remit of our tasks.

I am currently Deputy Head of Send which is a prison for women, it largely focuses on the resettlement of women who are about to finish long term sentences, it has the only therapeutic community in the female estate and is psychologically and socially progressive. I feel that it is an ideal place to continue to mesh my newly learned skills as Operational Governor with existing skills as a psychologist.

Many counselling psychologists have an independent practice for part of the time but there are many advantages in a full-time practice. It offers flexibility of days and hours, there are few organisational constraints, a choice of supervisor or consultant and no threat of redundancy or imposed changes. I have diversity in my practice being a psychotherapist for between 12 and 20 people, supervisor for other therapists in private practice, an addiction service, and a solicitor/mediator as well as providing consultancy to Rolls Royce and British Aerospace in the past on staff support and counselling. My approach is individually tailored to my preferred style of therapy and I see adults, children and couples.

This has allowed me to develop my expertise through doing a research PhD in my own time, engage in professional roles and duties which have given me greater awareness of wider issues, and write a book and publish articles. I also practice as an expert in child protection cases which has allowed me to work in legal settings. I work from my home having an office there, but some people might find that isolating and set up joint practices or networks. I enjoy contact with others through volunteering for a national charity. I had to learn business skills such as contracting, financial management and work out how to get referrals by being known rather than large-scale advertising. Independent practice suits me because I do what I find satisfying, have time to reflect and think and work at trying to find ways to make a difference.

My role as a Team Leader at an Employee Assistance company involved managing and supporting a team of 8 counselling psychologists, counsellors and psychotherapists in addition to case managing a portfolio of client companies. As a Team Leader, I was responsible for:

• overseeing my team’s delivery of assessments and solution focused therapy (average of 6-8 sessions) for a variety of mental health issues including carrying out assessments and therapy myself
• providing supervision
• facilitating group discussions with the Clinical Director on complex cases and continued monitoring of these cases
• ensuring staff training and continuous professional development
• organising recruitment, interviewing and induction training for new staff
• carrying out audits on our clinical documentation process
  

In my role as a Case Manager, I was responsible for:

• overseeing all cases under my client companies from initial referral to closing
• managing and consulting on specialist referrals from the relevant Occupational Health and Human Resources departments including sourcing practitioners to provide specialist psychological and psychiatric assessments, onsite trauma support and conflict resolution management
• reviewing the paperwork on all initial counselling and psychology assessments and closing reports
• consulting with our external affiliate practitioners on any cases of clinical concern including complex cases and those considered high risk
• delivering presentations, training and launches to current and prospective client companies on what we offer as a service
• co-facilitating clinical meetings to discuss and formulate appropriate treatment plan and/or onward referral to more specialist services for cases not meeting the service criteria

I work at the Medical Foundation, which is a non-government organisation providing multi-level care and support (legal, financial, educational, social and therapeutic) to victims of torture. The vast majority of the clients at the Medical Foundation are asylum seekers and refugees. I work within a multidisciplinary team consisting of about 20 professionals: systemic family therapists, social workers, interpreters, a paediatrician, an art therapist and a music therapist. The asylum seekers and refugees can self-refer to the Medical Foundation or are referred through NHS primary and secondary care. They are assessed and then referred to the Adult Therapy Team or to the CYPFT, the team I work in. The clients referred to the CYPFT can be families (both parents or one-parent families or couples without children) and unaccompanied minors.

As the only counselling psychologist in the CYPFT team, I bring the scientist-practitioner framework to the team, in that I will connect the clinical work to the theory and I am often the one representing the team at conferences and various training institutions regarding work with asylum seekers and refugees. Since I have just completed a PhD in positive psychology and refugee care I have the role of educating the team in the relevant research and the application of my PhD findings in our clinical work.

I most often work therapeutically without another CYPFT therapist involved. I have a regular client-base of five to ten families, whom I will meet with on a weekly or fortnightly basis. Very often I will work on an individual basis with several members of the same family and have monthly family sessions with all the members present. There is not limit as to how many sessions I can have with my clients; there have been clients I have been working with for years. We have reviews of therapy every six months. The CYPFT holds weekly meetings which include the observation of a team-member’s clinical work and peer supervision. I will have a session with a family once a month while my colleagues (three family therapists, an interpreter and a paediatrician) will be observing the work through a closed circuit television. The clients are always aware of this and if they do not wish for such a session to take place, there is no one observing. When the observing team is in place, I will go mid- session into the room they are in and get some support and ideas about how to proceed. Sometimes three observers will come into the room I am in with the family, and reflect on their observations. The clients find this process very helpful and it provides me and them with ideas about how to proceed and what to focus on. The other weeks in the month I will be the observer of other therapists’ sessions.

I often work with an interpreter. The interpreter can be a source of cultural information if he/she comes from the same background as the client. This input can inform my practice and alert to me to any cultural assumptions or misinterpretations I may make. I offer the interpreter time to debrief after each session, especially if very traumatic material has been elicited in the session. The interpreter is not trained as a therapist to process material and is more in danger of vicarious traumatisation than I am. Because of the interpreting the session is conducted at a different pace and a different dynamic can be created. It is a challenge including the interpreter in the process, yet not let him/her overtake or influence the therapeutic work. Finally, the interpreter can be helpful in pinpointing the linguistic process of the session: how language is used can often speak volumes about the client’s feelings and the dynamics within the family.

I need to be knowledgeable and flexible at many levels in my work. I need to have a good knowledge of the asylum, refugee and immigration law as well as the relevant institutions in place, such as The Home Office and the UK Border Authority. I also need to be aware of the past and current religious and political affairs of the country my clients come from, since they have all fled their home country because of persecution on political, racial and religious grounds. I need to have a relationship with their solicitor and I have often been asked to write a report to support their case in court or at the Home Office. I may asked to provide evidence in court hearings. I often have to write letters emphasising their emotional needs to their local council in support of their application for healthcare, housing, financial and/ or educational issues. Such issues and concerns very often interfere with the clinical work and the therapeutic process and it has been a struggle for me to be flexible and caring, yet professional whilst maintaining boundaries.

I need to have additional flexibility in terms of the therapeutic approach I work in: Working with families who may have experienced varied levels of trauma, the needs of each member may vary greatly. Also the ages vary. For instance, I will be expected to work utilising the arts within a child-centred play therapy model whilst working with the six year-old daughter of the family who has not experienced direct trauma but has an insecure attachment to her parents; I will work utilising EMDR with the father of the family who experienced direct trauma and suffers from PTSD; I will work in a person-centred manner to process the severe sense of loss and grief the mother feels for losing her homeland and parents; I will work systemically with the couple about the feelings of guilt, resentment, anger and blame between them and I will also teach and discuss parenting skills regarding the relationship with their daughter. Often the social services will need to be involved, so I must be very well educated on Child Protection issues. The number of family members, the amount of time they have been separated from each other, the loss or missing of family members, the loss of status, role and identity within a community, all throw additional dynamics to the therapeutic process.

It is challenging work and vicarious traumatisation is a reality for me. Within the CYPFT team, since I am the only counselling psychologist, it is often a struggle not being engulfed in the systemic therapy framework, since all the other clinicians are systemic therapists. Compared to my colleagues, counselling psychology allows me the flexibility to integrate the theory and interventions of various approaches. This makes me more resilient to the challenges the clients’ circumstances impose on the therapeutic work. This is valued in the CYPFT team and is of great value to me in a work with a client group that has such complex and multi-level needs.
The work at the Medical Foundation for the Care of the Victims of Torture IS very challenging on my skills as a therapist, my resilience as a person and my professionalism. Nevertheless, it is very rewarding because I work with people from literally around the globe; I learn directly about cultures and my mind opens. Moreover, even though I learn of what humans are capable of in terms of damage and pain, I constantly experience the immensity of resilience, growth and perseverance the human psyche is capable of. The clients and inspire me and I often experience a sense of elation for the malleability and strength in people.

Furthermore, working long-term with clients allows me to see them grow and develop, I go with them on their journey of adapting to life in the UK, fighting for their cause and then getting refugee status and developing into people who make a home in the UK, redefine themselves and contribute to society. This journey is often very painful, but it is also exhilarating and it always helps me to put my life into perspective.

Finally, the work at the Medical Foundation and within the multi-disciplinary team allows me to learn and share with fellow professionals. My work is respected and my CPD needs are adhered to. I have had the time to do my PhD and train in supervision, systemic therapy and EMDR whilst working at the Medical Foundation. As said earlier, I practice integrating my skills constantly because my clients vary so much in age, needs and background. It does indeed require vigilant updating of my knowledge regarding legislation, policies and global current affairs but then this contributes to me being a more informed citizen of this world.

My main role within the student counselling services involves assessing and counselling students on a one-to-one basis but I also run group workshops and drop-in sessions as well provide e-mail counselling for students who are taking a year of study abroad. The academic year begins with fresher’s’ week when I will go with other colleagues to different venues on campus welcoming and informing new students about our services. Each term is usually very busy with the final term being an exam period where many students become very anxious and sometimes experience panic attacks. It is during the pre-exam term, than I present exam anxiety workshops and relaxation techniques training. In between time, I may be carrying out administrative duties or liaising with other members of staff at a student’s request. Finally, the Health Centre on campus plays an important role for many of the students seen in counselling where some also have health problems, are taking regular medication, or may need referring on for more specific mental health issues. The Health Centre has a comprehensive mental health team available and regular clinical meetings are held with the core counsellors.