Month: March 2016

On doing therapy in untherapeutic places

I have been in healthcare for ten years. In that time I have worked in, amongst others, Georgian manor houses, secure wards, prisons, prefab sheds, swanky neurology hospital wings, low-secure units, converted Victorian houses, purpose-built units and the dilapidated dungeon of a Victorian asylum. I won’t lie: none has been ideal. Even purpose-built places have industrial decor and, being a Freudian at heart, as well as being a bit soft, I think therapeutic spaces should be comforting. When I have some say over where I see patients – i.e. when I am slightly more important than I currently am (not very, frankly, however much I like to fool myself) – I will have decent squashy armchairs rather than fire-retardant polysomethingorother, rugs, NICE paintings on the wall rather than a job lot from IKEA and pots and pots of tea on the go. I like my creature comforts and frankly I think patients deserve to be seen in an environment which is pleasant. ‘Functional’ is fine at the dentist. It is not, in my view, when it comes to therapy. Infrastructure is important.

And so, when I saw this, yesterday, I had several responses, and very few of them were positive:

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Therapy has always occurred in untherapeutic places. Therapy in prison? We’ve been doing it for years. It’s a challenge, really, because prison is not a nice place and it’s probably not great for your mental health. I have never been on a psychiatric ward and found it comforting. I think it’s a shame – people on wards are often ill and frightened and although they need to be safe they also need to feel safe. I know what makes me feel safe and I don’t think many psychiatric wards would provide it. When I deputy-managed a hostel for women with mental health problems and offending histories I quickly assumed control of all things decor- and DIY-related. I believed that these women deserved to live somewhere that felt like a home. I chose all the furniture when a room was redecorated. I ordered stuff that matched; decent curtains; a nice rug. I made sure the mattress was comfortable and that the bedding was coordinated with the paint. These women had done things which made them outsiders and I wanted them to live somewhere that felt better than hospital or prison; I wanted this hostel to feel like a home, as much as it could. My acid test has always been ‘would it be good enough for my sister?’; lots of the places I have worked have not been, but I tried my best to make this good enough. 

These are all superficial, of course, but the point is the same: how do you do good work in difficult environments? As a rule – in my experience at least – therapy looks at what you can change, because, not to put too fine a point on it, you cannot change what you cannot change. I cannot magically make a ward nice but maybe I can try to make your experience of being there a bit less unpleasant. So my take is always ‘what can we do to get you where you want to be, and how can we try to make it a success?’ But these are interesting times and now psychologists are expected to do therapy in Job Centres and Immigration Removal Centres and I find it deeply unsettling.

Now on the one hand, I am always banging on about the need for psychologically-informed thinking in a range of institutions. Policy affects lives and a thorough understanding of the consequences of government decisions on the existence of the electorate is crucial. There is too little psychological thinking around and frankly it’s got us into a bit of a mess. So, on the face of it, perhaps it makes sense to have psychology in JCs and IRCs. But I wrestle with it. And it’s not entirely clear in my own head yet, but these are some of the reasons I wrestle with it:

‘Rapid turnover of detainees’: Guys, therapy is not as simple as prescribing a pill. I’m not a GP; I can’t sort you out in ten minutes. Maybe I can’t sort you out at all, but I’d really rather we both had the luxury of time to discover whether that’s the case or not. Once, I worked on a stroke ward. I liked it. I did assessments and some intervention and some family work. But turnover was so high that sometimes I would be halfway through an assessment only to discover that the person had been discharged. What does this mean? It means my assessment is incomplete. It means I’ve put you through half an assessment and I can’t even write a proper report outlining all the ways you need some help. It’s disappointing for me and unfair on my patient. And in a job like this it would be endless, and disheartening. And it’s one thing to do neuropsych testing and have to leave it halfway; it’s quite another to do a therapy assessment and leave it halfway. Tell me your trauma and your pain and your fear, but only tell me half of it. Let’s open up the can of worms even though we know we won’t be able to stem the flow. Let me hear half your story and build up some kind of connection and then walk out of your life. Let me break rule one of therapy; the one about a safe and secure relationship. Let me retraumatize you. 

You will see my point, I think.

Next: ‘Stepped-care approach’: Stepped care is great, when there is an a actual care pathway. But if you’re about to be shipped off to another part of the world how can I make recommendations for ongoing care? I can’t assume there will be the infrastructure or the clinicians or the money or the skills to provide what you need. You can’t provide stepped care without a staircase. And a staircase with woodworm isn’t a staircase. It’s a disaster waiting to happen.

Next: An Immigration Removal Centre. It will be full of immigrants. Why might they be immigrants? Because I do not read tabloids, I do not think it’s because they want a big telly and a gorgeous partner. I think about poverty and war and torture, because in my line of work I have to think about poverty and war and torture because I come across them all so much. So we might have some complex, traumatized people. ‘Brief intervention’? For traumatized people who may be terrified that they are about to be returned to their tormentors? Shut up. Seriously. If you think that is appropriate I can’t even be bothered to talk to you. You might think that’s unreasonable, and maybe it is, but I’m a psychologist, not an angel. 

Incidentally, and not to be a cynic here – I take Oscar’s definition of a cynic as Gospel and I know the value of many things, thank you very much – several people ‘in the biz’ have suggested that really, this is about managing immediate risk to make sure nothing ‘untoward’ happens whilst frightened and desperate people are held in these centres, and that really therapy is much less of a focus. I couldn’t possibly comment.

But there’s something more fundamental here. I know that the system I work in – the NHS – is flawed. It is deeply imperfect and sometimes it does not support people as well as it could. But I think its intentions are good and I think it retains values I believe in. So I work within it, trying to do my best not to do harm. But the thing is that some environments are so tainted that I don’t know if psychologists should touch them with a bargepole. Surely working in an IRC is akin to saying ‘IRCs are fine, or at least good enough for me to associate myself with them’? You know a person by the company they keep; you judge a person by the institutions they are associated with. There are institutions so disreputable that I would not be associated with them whatever they offered me. It’s about value and ethics and principles. And I know it’s easy for me to say – I have a job, which is more than many can say. But psychologists rarely have to fight for jobs; we are highly employable. I don’t want to legitimise bad practices and bad policy; all we truly have is our integrity and frankly I think it’s worth fighting for. For me, to accept a job like that makes you to vulnerable to corruption. Because good people can work in bad place but it takes an extraordinary person to work in a bad place and not be tainted by the dirt.

We should be fighting inhuman and oppressive practice. We should be standing outside Job Centres and IRCs, waving placards and denouncing current practice. We should be helping policymakers think more psychologically to provide supportive environments. We should not be propping unethical institutions up with the aim of ‘making them better’, because, frankly, it takes more than one psychologist to right a rotten system. Denounce that which is bad; model that which is good. Do not get sucked into bad systems. It rarely ends well, in my experience. After all, dear reader, the road to hell is paved with good intentions and few of us are truly incorruptible.

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