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Getting Mucky With It, And Quite Right Too.

As I give talks or workshops within clinical psychology, on lived experience of mental health problems as mental health professionals, and invite others to think about the implications of that on the mental health scene (training, NHS Mental Health Trusts, professional bodies, on the 'them/us' split in mental health services), the questions arising make it clear there is much work to be done in an area that feels painful, silent and nebulous. 

Painful: because questions feel fearfully contracted around fitness to practice issues, due to being terrified that the experience of mental health problems, past or present, means you are 100% immediately unfit to practice.

Silent: because despite us all being in the mental health business, which aims to open up conversations to destigmatise mental health problems, it seems as if tumbleweed has taken up residence in the corridors because as a professional helping others, you are not allowed to breakdown in the midst of challenging life experiences. This would be shameful as you are supposed to help others and be forever containing, so, it needs to be hidden.

Nebulous: because thats the lack of clarity that happens when things are painful and silent. Ways to understand capacity fluctuations, the normality of that, how to value your own lived experience, what to do and where to go for support and advice in crisis (that only exists informally through mentors, peers and individual supervisors...If you have a good enough relationship with them)  

What are the question themes? Something like this (not exhaustive): 

  • What are the limits of confidentiality around sharing? Also, it's a small world, what is shared, because it seems that others can get spoken about? 

  • What does it mean to be in therapy whilst training or qualified? And what if you haven't said that you are in therapy? What responsibility does your own therapist have to your training or practice? Is therapy understood to be something that enhances your capacity to practice or not? (this seems specific to clinical psychology where therapy is not mandated).

  • Is it understood that being told "you can leave the room" can actually carry the message of "the deeper feelings that you are connecting with are not allowed / you shouldn't have them / they belong outside or othered where vulnerability is ...what are you doing in here?".

To what extent can we help each other as trainees when we hear of difficulties and how can we make asking for help from others feel easier?

How do we approach course staff who feel so full with all their work/who we don't get on with/who don't share our views when we are struggling or want to share in general.

  • What counts as lived experience of mental health problems? How much? How severe? When - now or before?

  • Where is nuanced conversation around capacity and the impacts on it? Why isn't there much guidance around the core competency of capacity work during training? We learn to formulate with others, could formulation help us understand our own capacity better over time or in difficult times?

  • What does 'fit for practice' actually mean and why don't we talk about it in the context of understanding ourselves as human beings who can struggle from time to time? Why is it hushed and difficult and worrying? 

In a world where clinical psychology says it develops practitioners who can 'practice' at all levels of a system, how do we keep alive the value of our bredth of skills when resting from direct clinical work? There seems to be a full and top star weighting on direct clinical intervention work as the main defining aspect of who we are as a professional. Is it technically more useful to breakdown later on in your career when you are probably doing less clinical work and more strategy or management? (an edge of humour coming on here, but ...). 

Why is the HCPC such a remote, ghostly figure that seems to take on the role of a punitive superego, rather than something we can consult with to understand what they understand about being human? 

  •  How do you manage being able to talk about these worries and be a trainee who is actively assessed and actively developing competencies? Where does capacity differ from competency? It feels over-conflated and impacted on by stigma (that you must be 100% incompetent if you have slightly less capacity).

There are a lot of questions, but I think this is excellent. Questions themselves take time to come up, you have to live in something a little first, and people are beginning to 'live in' this issue.

There is a thought, or maybe a wish, that comes from all sorts of places, that as a mental health professional you must be forever fully containing of all possible presentations at all times...this seems like a very difficult idea, because it can be an idealisation and can entrench professionals into forever thinking that they are 'not allowed' to break down. In reality, people choose specialisms in line with their preferences and, sometimes, as to what fits around their own tendernesses - that is knowing yourself and good practice. When training through all placements, there is this idea that you should be able to 'do it all'. Yes, you need to meet competency in placements, but when you qualify you then have choice about where you would like to spend your time that fits with you more personally...which may change as you get to know the scene, and yourself, more as time goes by. 

In my mind, we already have have the skills and tools to help formulate a pathway through these questions,  for example, we train assiduously in being clear about the limits of confidentiality with clients - so we know well there shouldn't be unnecessary sharing within the profession and how to do that.

And this kind of challenging and thinking is not the remit of our trainees alone, it is a full systemic issue with responsibikity for opening up conversatuons, and sharing where personally wished, at all levels of our mental health profession.

There will be excellent and helpful conversations that have happened around these issues when in difficulty, but they seem secret, and that is simply not helping people because it is not overtly addressing fears. We need role models in authority to stand up and cast some light for others to follow (bearing in mind Alex Haslam's Identity Leadership model).

 I'm increasingly of the mindset that clinical psychology has not been doing itself any favours in the fact that these conversations feel so difficult, despite having a hand full of aces when it comes to how to think through these things (seemingly for others but not for ourselves). Fears feel too high, needlessly so, and is it not our stock in trade to put fears on the table and talk about them?  

Lets go back to the silent tumbleweed. In my opinion, it's there because historically (perhaps I can't say historically yet...) having had mental health problems carries stigma and fear, and that is ripe ground for the powerful pervasion of silence. However, there is also another silence; when visiting clinical psychology trainings, what I am not hearing are examples of how lived experience in trainees has been openly valued and entwined in teaching (dare I say in2gr8ted). There is no way in the time that I have been doing this, that I can be any fair gauge of that. It could be that this happens and what is being brought to me are the fears that otherwise feel less speakable, but it is telling in it's absence. 

In the context of all the thinking at large about co-production in mental health services, in my opinion it will be a good day when I join mental health professionals and I hear something like

 'Hi, I'm Natalie and we had CPD training today about all the reasons that someone's past  trauma has made them feel the way they do now. We covered the models and the research, and I wanted, and felt enabled, to share an aspect that had really helped me.' 

One can but hope.

Dr Natalie Kemp

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